Identifying Long-Term Morbidities and Health Trajectories After Prolonged Mechanical Ventilation in Children Using State All Payer Claims Data

Physical Activity Monitoring in Children in the 1-Year After 3 or More Days of Invasive Ventilation: Feasibility of Using Accelerometers

OBJECTIVES

To measure physical activity in a cohort of children who survived greater than or equal to 3 days of invasive ventilation.

DESIGN

Prospective cohort study (2018-2021).

SETTING

Quaternary children's hospital PICU.

PATIENTS

Children (2-17 yr old) without a preexisting tracheostomy who were ambulatory pre-illness and received greater than or equal to 3 days of invasive ventilation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We measured duration and intensity of physical activity using hip- (< 6 yr old) or wrist- (≥ 6 yr old) worn ActiGraph GT3XP-BTLE accelerometers (ActiGraph, Pensacola, FL) for 7 days at three timepoints: hospital discharge, 3 months, and 12 months post-discharge. We measured duration of moderate or vigorous physical activity (MVPA) and nonsedentary activity, both characterized as percent of total awake wear time and total minutes per day. We categorized participants based on when they first attained a "high activity" day defined as greater than or equal to 60 minutes of MVPA or a day with percent of MVPA in the top quartile of all days measured. We evaluated 55 children of whom 43 (78%) had data from greater than or equal to 1 timepoint including 19 (35%) with data from all timepoints. Maximum daily MVPA increased across the three post-discharge timepoints (median, 16.0 min [interquartile range (IQR), 8.0-42.8 min], 48.3 min [27.8-94.3 min], and 68.4 min [34.7-111.0 min], respectively) as did maximum daily percent of awake wear time in MVPA (median, 4.3% [IQR, 2.8-9.0%], 10.1% [5.7-14.4%], and 11.1% [7.1-17.5%], respectively). Of the 43 participants, 27 achieved a high activity day: nine of 43 during the hospital discharge period, 14 of 43 during the 3 months post-discharge period, and four of 43 during the 12 months post-discharge period; 16 of 43 did not demonstrate high activity during the post-discharge year.

CONCLUSIONS

In the 1-year after PICU discharge measuring physical activity with accelerometers in children 2-17 years old is feasible. Furthermore, demonstration of variable recovery trajectories in our pilot cohort suggests it has potential to be an outcome measure in clinical trials.

Artificial Intelligence in the Management of Patients with Respiratory Failure Requiring Mechanical Ventilation: A Scoping Review

Background: Mechanical ventilation (MV) is one of the most frequently used organ replacement modalities in the intensive care unit (ICU). Artificial intelligence (AI) presents substantial potential in optimizing mechanical ventilation management. The utility of AI in MV lies in its ability to harness extensive data from electronic monitoring systems, facilitating personalized care tailored to individual patient needs. This scoping review aimed to consolidate and evaluate the existing evidence for the application of AI in managing respiratory failure among patients necessitating MV. Methods: The literature search was conducted in PubMed, Scopus, and the Cochrane Library. Studies investigating the utilization of AI in patients undergoing MV, including observational and randomized controlled trials, were selected. Results: Overall, 152 articles were screened, and 37 were included in the analysis. We categorized the goals of AI in the included studies into the following groups: (1) prediction of requirement in MV; (2) prediction of outcomes in MV; (3) prediction of weaning from MV; (4) prediction of hypoxemia after extubation; (5) prediction models for MV-associated severe acute kidney injury; (6) identification of long-term outcomes after prolonged MV; (7) prediction of survival. Conclusions: AI has been studied in a wide variety of patients with respiratory failure requiring MV. Common applications of AI in MV included the assessment of the performance of ML for mortality prediction in patients with respiratory failure, prediction and identification of the most appropriate time for extubation, detection of patient-ventilator asynchrony, ineffective expiration, and the prediction of the severity of the respiratory failure.

A systematic review of dexmedetomidine pharmacology in pediatric patients

Dexmedetomidine is a centrally acting alpha-2 agonist used for initiation and maintenance of procedural sedation and mechanical ventilation in adult and pediatric settings. It is commonly used in both pediatric and neonatal intensive care units. Dexmedetomidine requires extensive titration, and patients can be over or under-sedated during titration, leading to adverse events such as hypotension and bradycardia, or inadequate sedation, which can result in self-extubation. There is a critical need to identify factors that contribute to variation in metabolism, clearance, and downstream targets of dexmedetomidine so that individualized pediatric dosing regimens can be developed. This review is focused on dexmedetomidine pharmacokinetics and pharmacodynamics in the pediatric population and dexmedetomidine-related pharmacogenes in both adults and children. We found that the strongest predictors of dexmedetomidine pharmacokinetics were age and size. Multiple pharmacogenes of significance have been identified, including ADRA2A, UGT2B10, UGT1A4, CYP1A2, CYP2A6, and CYP2D6. Evidence is weak for the correlation of these individual polymorphic genes with dexmedetomidine pharmacokinetics/dynamics, though there may be a polygenetic influence on pharmacologic response. This review provides a comprehensive overview of the genomic data gathered to date. We aim to summarize current pharmacologic studies regarding dexmedetomidine use and pharmacology in pediatric patients.

Recovery Trajectories in Children Requiring 3 or More Days of Invasive Ventilation

OBJECTIVES

To characterize health-related quality of life (HRQL) and functional recovery trajectories and risk factors for prolonged impairments among critically ill children receiving greater than or equal to 3 days of invasive ventilation.

DESIGN

Prospective cohort study.

SETTING

Quaternary children's hospital PICU.

PATIENTS

Children without a preexisting tracheostomy who received greater than or equal to 3 days of invasive ventilation, survived hospitalization, and completed greater than or equal to 1 postdischarge data collection.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We evaluated 144 children measuring HRQL using proxy-report Pediatric Quality of Life Inventory and functional status using the Functional Status Scale (FSS) reflecting preillness baseline, PICU and hospital discharge, and 1, 3, 6, and 12 months after hospital discharge. They had a median age of 5.3 years (interquartile range, 1.1-13.0 yr), 58 (40%) were female, 45 (31%) had a complex chronic condition, and 110 (76%) had normal preillness FSS scores. Respiratory failure etiologies included lung disease ( n = 49; 34%), neurologic failure ( n = 23; 16%), and septic shock ( n = 22; 15%). At 1-month postdischarge, 68 of 122 (56%) reported worsened HRQL and 35 (29%) had a new functional impairment compared with preillness baseline. This improved at 3 months to 54 (46%) and 24 (20%), respectively, and remained stable through the remaining 9 months of follow-up. We used interaction forests to evaluate relative variable importance including pairwise interactions and found that therapy consultation within 3 days of intubation was associated with better HRQL recovery in older patients and those with better preillness physical HRQL. During the postdischarge year, 76 patients (53%) had an emergency department visit or hospitalization, and 62 (43%) newly received physical, occupational, or speech therapy.

CONCLUSIONS

Impairments in HRQL and functional status as well as health resource use were common among children with acute respiratory failure. Early therapy consultation was a modifiable characteristic associated with shorter duration of worsened HRQL in older patients.

Respiratory culture growth and 3-years lung health outcomes in children with bronchopulmonary dysplasia and tracheostomies

BACKGROUND

While bacteria identification on respiratory cultures is associated with poor short-term outcomes in children with bronchopulmonary dysplasia (BPD) and tracheostomies, the influence on longer-term respiratory support needs remains unknown.

OBJECTIVE

To determine if respiratory culture growth of pathogenic organisms is associated with ongoing need for respiratory support, decannulation, and death at 3 years posttracheostomy placement in children with BPD and tracheostomies.

METHODS

This single center, retrospective cohort study included infants and children with BPD and tracheostomies placed 2010-2018 and ≥1 respiratory culture obtained in 36 months posttracheostomy. Primary predictor was any pathogen identified on respiratory culture. Additional predictors were any Pseudomonas aeruginosa and chronic P. aeruginosa identification. Outcomes included continued use of respiratory support (e.g., oxygen, positive pressure), decannulation, and death at 3 years posttracheostomy. We used Poisson regression models to examine the relationship between respiratory organisms and outcomes, controlling for patient-level covariates and within-patient clustering.

RESULTS

Among 170 children, 59.4% had a pathogen identified, 28.8% ever had P. aeruginosa, and 3.5% had chronic P. aeruginosa. At 3 years, 33.1% of alive children required ongoing respiratory support and 24.8% achieved decannulation; 18.9% were deceased. In adjusted analysis, any pathogen and P. aeruginosa were not associated with ongoing respiratory support or mortality. However, P. aeruginosa was associated with decreased decannulation probability (adjusted risk ratio 0.48, 95% CI 0.23-0.98). Chronic P. aeruginosa was associated with lower survival probability.

CONCLUSION

Our findings suggest that respiratory pathogens including P. aeruginosa may not promote long-term respiratory dysfunction, but identification of P. aeruginosa may delay decannulation.

Failed Extubation in Neonates After Cardiac Surgery: A Single-Center, Retrospective Study

OBJECTIVES

To describe factors associated with failed extubation (FE) in neonates following cardiovascular surgery, and the relationship with clinical outcomes.

DESIGN

Retrospective cohort study.

SETTING

Twenty-bed pediatric cardiac ICU (PCICU) in an academic tertiary care children's hospital.

PATIENTS

Neonates admitted to the PCICU following cardiac surgery between July 2015 and June 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients who experienced FE were compared with patients who were successfully extubated. Variables associated with FE ( p < 0.05) from univariate analysis were considered for inclusion in multivariable logistic regression. Univariate associations of FE with clinical outcomes were also examined. Of 240 patients, 40 (17%) experienced FE. Univariate analyses revealed associations of FE with upper airway (UA) abnormality (25% vs 8%, p = 0.003) and delayed sternal closure (50% vs 24%, p = 0.001). There were weaker associations of FE with hypoplastic left heart syndrome (25% vs 13%, p = 0.04), postoperative ventilation greater than 7 days (33% vs 15%, p = 0.01), Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category 5 operations (38% vs 21%, p = 0.02), and respiratory rate during spontaneous breathing trial (median 42 vs 37 breaths/min, p = 0.01). In multivariable analysis, UA abnormalities (adjusted odds ratio [AOR] 3.5; 95% CI, 1.4-9.0), postoperative ventilation greater than 7 days (AOR 2.3; 95% CI, 1.0-5.2), and STAT category 5 operations (AOR 2.4; 95% CI, 1.1-5.2) were independently associated with FE. FE was also associated with unplanned reoperation/reintervention during hospital course (38% vs 22%, p = 0.04), longer hospitalization (median 29 vs 16.5 d, p < 0.0001), and in-hospital mortality (13% vs 3%, p = 0.02).

CONCLUSIONS

FE in neonates occurs relatively commonly following cardiac surgery and is associated with adverse clinical outcomes. Additional data are needed to further optimize periextubation decision-making in patients with multiple clinical factors associated with FE.

Outcomes of Children Surviving Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

OBJECTIVES

To summarize the evidence for the Second Pediatric Acute Lung Injury Consensus Conference-2 (PALICC-2) recommendations for assessment of outcomes among patients surviving pediatric acute respiratory distress syndrome (PARDS).

DATA SOURCES

MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost).

STUDY SELECTION

We conducted a scoping review to identify studies evaluating outcomes following PARDS. We included studies of survivors of PARDS, acute respiratory failure with a high proportion of PARDS patients, or other critical illnesses if PARDS-specific outcomes could be extracted.

DATA EXTRACTION

Title/abstract review, full-text review, and data extraction using a standardized data collection form.

DATA SYNTHESIS

The Grading of Recommendations Assessment, Development and Evaluation approach was used to identify and summarize evidence and develop recommendations. Of 8,037 abstracts screened, we identified 20 articles for inclusion. Morbidity following PARDS was common and affected multiple domains of pulmonary and nonpulmonary function. There was insufficient evidence to generate any evidence-based recommendations. We generated eight good practice statements and five research statements. A panel of 52 experts discussed each proposed good practice statement and research statement, and the agreement rate was measured with an online voting process. Good practice statements describe the approach to clinical outcome assessment, assessment of pulmonary outcomes of children surviving PARDS, and assessment of nonpulmonary outcomes of children surviving PARDS including health-related quality of life and physical, neurocognitive, emotional, family, and social functioning. The five research statements relate to assessment of patient preillness status, use of postdischarge endpoints for clinical trials, the association between short-term and longer term outcomes, the trajectory of recovery following PARDS, and practices to optimize follow-up.

CONCLUSIONS

There is increasing evidence that children are at risk for impairments across a range of pulmonary and nonpulmonary health domains following hospitalization for PARDS. The results of this extensive scoping review and consensus conference involving experts in PARDS research, clinical care, and outcomes assessment provide guidance to clinicians and researchers on postdischarge follow-up to optimize the long-term health of patients surviving PARDS.

Unplanned Admissions, Emergency Department Visits, and Epilepsy After Critical Neurological Illness Requiring Prolonged Mechanical Ventilation in Children

Background and Purpose

Long-term outcomes after pediatric neurocritical illness are poorly characterized. This study aims to characterize the frequency and risk factors for post-discharge unplanned health resource use in a pediatric neurocritical care population using insurance claims data.

Methods

Retrospective cohort study evaluating children who survived a hospitalization for an acute neurologic illness or injury requiring mechanical ventilation for >72 hours and had insurance eligibility in Colorado's All Payers Claims database. Insurance claims identified unplanned readmissions and emergency department [ED] visits during the post-discharge year. For patients without pre-existing epilepsy/seizures, we evaluated for post-ICU epilepsy identified by claim(s) for a maintenance anti-seizure medication during months 6-12 post-discharge. Multivariable logistic regression identified factors associated with each outcome.

Results

101 children, median age 3.7 years (interquartile range (IQR) .4-11.9), admitted for trauma (57%), hypoxic-ischemic injury (17%) and seizures (15%). During the post-discharge year, 4 (4%) patients died, 26 (26%) were readmitted, and 48 (48%) had an ED visit. Having a pre-existing complex chronic condition was independently associated with readmission and emergency department visit. Admission for trauma was protective against readmission. Of those without pre-existing seizures (n = 86), 25 (29%) developed post-ICU epilepsy. Acute seizures during admission and prolonged ICU stays were independently associated with post-ICU epilepsy.

Conclusions

Survivors of pediatric neurocritical illness are at risk of unplanned healthcare use and post-ICU epilepsy. Critical illness risk factors including prolonged ICU stay and acute seizures may identify cohorts for targeted follow up or interventions to prevent unplanned healthcare use and post-ICU epilepsy.

Prolonged Mechanical Ventilation in Pediatric Trauma Patients in a Combat Zone

OBJECTIVES

It is well known that polytrauma can lead to acute lung injury. Respiratory failure has been previously observed in combat trauma, but not reported in children, who account for over 11% of bed days at deployed Military Treatment Facilities (MTFs) using significant resources. We seek to identify risk factors associated with prolonged mechanical ventilation (PMV) which is important in resource planning and allocation in austere environments.

DESIGN

Retrospective review of prospectively collected data within the United States Department of Defense Trauma Registry.

SETTING

Deployed U.S. MTFs in Iraq and Afghanistan from 2007 to 2016.

PATIENTS

All pediatric subjects who required at least 1 day of mechanical ventilation, excluding patients who died on day 0.

INTERVENTIONS

PMV was defined using the Youden index for mortality. A multivariable logistic regression model was then performed to identify factors associated with PMV.

MEASUREMENTS AND MAIN RESULTS

The Youden index identified greater than or equal to 6 days as the cutoff for PMV. Of the 859 casualties included in the analysis, 154 (17.9%) had PMV. On univariable analysis, age, severe injury to the thorax and skin, 24-hour volume/kg administration of crystalloids, colloids, platelets, plasma, and packed RBCs was associated with PMV. In the multivariable model, odds ratios (95% CI) associated with PMV were crystalloids 1.04 (1.02-1.07), colloids 1.24 (1.04-1.49), platelets 1.03 (1.01-1.05), severe injury to the thorax 2.24 (1.41-3.48), and severe injury to the skin 4.48 (2.72-7.38). Model goodness-of-fit r2 was 0.14.

CONCLUSIONS

In this analysis of factors associated with PMV in pediatric trauma patients in a combat zone, in addition to severe injury to skin and thorax, we found that administration of crystalloids, colloids, and platelets was independently associated with greater odds of PMV. Our findings will help inform resource planning and suggest potential resuscitation strategies for future studies.

Postdischarge health resource use in pediatric survivors of prolonged mechanical ventilation for acute respiratory illness

We aimed to identify characteristics associated with postdischarge health resource use in children without medical complexity who survived an episode of prolonged mechanical ventilation for respiratory illness. We hypothesized that longer durations of mechanical ventilation, noncomplex chronic conditions, and severe acute respiratory distress syndrome (ARDS) would be associated with readmission or an Emergency Department (ED) visit. In this retrospective cohort, we evaluated children without a complex chronic condition who survived a respiratory illness requiring ≥3 days of mechanical ventilation and who had insurance eligibility within the Colorado All Payers Claims Database. We used insurance claims to characterize health resource use and multivariable logistic regression to identify characteristics associated with readmission or an ED visit during the postdischarge year. We evaluated 82 children, median age 12.8 months (interquartile range [IQR]: 4.0-24.1), 20 (24%) with a noncomplex chronic condition and 62 (76%) without any chronic conditions. Bronchiolitis (60%) and pneumonia/aspiration pneumonitis (17%) were the most common etiologies of respiratory failure and 47 (57%) patients had severe ARDS. Forty-six (56%) patients had an ED visit or readmission. Among the 18 readmitted patients, 16/18 (89%) readmissions were for respiratory illness. Forty (49%) patients had ≥2 outpatient pulmonary visits and 45 (55%) filled a pulmonary medication prescription. In analyses controlling for age, illness severity and mechanical ventilation duration, severe ARDS was predictive of ED visit or readmission (odds ratio [OR]: 5.53 [95% confidence interval [CI]: 1.79, 19.09]). Children who survive prolonged mechanical ventilation for respiratory disease experience high rates of postdischarge health resource use, particularly those surviving severe ARDS.