Noninvasive Ventilation for Pediatric Acute Respiratory Distress Syndrome: Experience From the 2016/2017 Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Prospective Cohort Study

The Prevalence and Outcome of Acute Hypoxemic Respiratory Failure (PANDORA) Study in Mechanically Ventilated Children: Prospective Multicenter Epidemiology in Spain, 2019-2021

OBJECTIVES

To describe the epidemiology and outcome of children with acute hypoxemic respiratory failure (AHRF) and/or pediatric acute respiratory distress syndrome (PARDS).

DESIGN

Prospective, observational study in six nonconsecutive 2-month blocks form October 2019 to September 2021.

SETTING

A network of 22 PICUs in Spain.

PATIENTS

Consecutive children (7 d to 15 yr old) with a diagnosis of AHRF, defined by Pao2/Fio2 ratio less than or equal to 300 mm Hg, who needed invasive mechanical ventilation (IMV) using positive end-expiratory pressure (PEEP) greater than or equal to 5 cm H2O and Fio2 greater than or equal to 0.3.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcomes were AHRF prevalence and PICU mortality. The secondary outcomes were the prevalence of IMV with PARDS (IMV-PARDS) and the use of adjunctive therapies. There were 6545 PICU admissions: 1374 (21%) underwent IMV and 181 (2.8%) had AHRF. Ninety-one patients (1.4% of PICU admissions, 6.6% of IMV cases, and 50.3% of AHRF cases) met the Second Pediatric Acute Lung Injury Consensus Conference IMV-PARDS criteria. At baseline, mean (± sd) tidal volume was 7.4 ± 1.8 mL/kg ideal body weight, PEEP 8.4 ± 3.1 cm H2O, Fio2 0.68 ± 0.23, and plateau pressure 25.7 ± 6.3 cm H2O. Unlike patients with PARDS, adjunctive therapies were used infrequently in non-PARDS AHRF patients. AHRF patients without PARDS had more ventilator-free days than PARDS patients (16.4 ± 9.4 vs. 11.2 ± 10.5; p = 0.002). All-cause PICU mortality in AHRF cases was higher in PARDS vs. non-PARDS patients (30.8% [95% CI, 21.5-41.3] vs. (14.4% [95% CI, 7.9-23.4]; p = 0.01).

CONCLUSIONS

In our 2019-2021 PICU population, the prevalence of AHRF is 2.8% of IMV cases. Of such patients, the prevalence of PARDS was 50.3%, and there was a 30.8% mortality, which was higher than in cases of AHRF without PARDS.

Invasive Respiratory Support in Critical Pediatric Asthma

In the United States and Canada, severe asthma requiring mechanical ventilation has declined over the past decade reflecting a rise in noninvasive therapies. When aggressive noninvasive therapies fail, endotracheal intubation and mechanical ventilation are lifesaving and should be planned for in advance. As speed is important, the most experienced practitioner should intubate and rapid correction of hypercarbia and respiratory acidosis should be avoided. An elevated minute ventilation may cause pulmonary hyperinflation leading to air-leak syndrome and/or hemodynamic instability. Patients with severe air flow obstruction in asthma typically have near-normal respiratory system compliance. Therefore, an increase in plateau pressure (Pplat) usually reflects dynamic hyperinflation. A suggested upper limit for Pplat is 25-30 cm H2O. Intrinsic PEEP (PEEPi) is measured with an expiratory hold and is valuable in that PEEP set on the ventilator can be lower than PEEPi. A reasonable ventilation strategy involving low ventilator rates and PEEP without quick correction of blood gases should be adopted. Alternative modalities to conventional mechanical ventilation are limited and unless very experienced with high-frequency oscillatory ventilation, the risk likely outweighs benefit. Heliox may be beneficial but cannot be delivered by every ventilator and this varies by manufacturer. Inhaled anesthetics are direct bronchodilators and likely beneficial but as no conventional ICU ventilator can deliver them, close cooperation with Anesthesiology is needed. Extracorporeal membrane oxygenation (ECMO) is a rescue therapy that is particularly useful in cases of severe air-leak syndrome. As with mechanical ventilation, ECMO does not reverse the asthma disease process but allows support of the patient until there is improvement with other therapies. Most children who die experience cardiac arrest prior to hospitalization. Otherwise, most mechanically ventilated children survive to hospital discharge but there is a suggestion of additional mortality from asthma in the following decade.

Kittredge Lecture: Determining Noninvasive Ventilation Failure in Pediatric Patients

Noninvasive ventilation is a standard therapy to treat respiratory distress in children and its successful use has been shown to shorten stay. However, with its application there are risks for adverse events, and therapy failure has been linked to prolonged time on invasive mechanical ventilation, increased stay, and mortality. It is essential for respiratory therapists to understand the factors contributing to noninvasive ventilation failure and what is known on how to predict which children will fail noninvasive ventilation from the existing literature.

Pediatric pulmonology year in review-Pediatric pulmonary critical care

Pediatric pulmonary critical care literature has continued to grow in recent years. Our aim in this review is to narrowly focus on publications providing clinically-relevant advances in pediatric pulmonary critical care in 2023.

Pediatric Acute Respiratory Distress Syndrome Severity and Health-Related Quality of Life Outcomes: Single-Center Retrospective Cohort, 2011-2017

OBJECTIVES

To determine factors associated with health-related quality of life (HRQL) decline among pediatric acute respiratory distress syndrome (PARDS) survivors.

DESIGN

Retrospective cohort study.

SETTING

Academic children's hospital.

PATIENTS

Three hundred fifteen children 1 month to 18 years old with an unplanned PICU admission from December 2011 to February 2017 enrolled in the hospital's Outcomes Assessment Program.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Pre-admission baseline and median 6-week post-discharge HRQL were assessed using the Pediatric Quality of Life Inventory or the Functional Status II-R. Patients meeting retrospectively applied Second Pediatric Acute Lung Injury Consensus Conference criteria for PARDS were identified, and PARDS severity was classified using binary (mild/moderate, severe) and trichotomous (mild, moderate, severe) categorization for noninvasive ventilation and invasive mechanical ventilation (IMV). PARDS occurred in 41 of 315 children (13.0%). Clinically important HRQL decline (≥ 4.5 points) occurred in 17 of 41 patients (41.5%) with PARDS and 64 of 274 without PARDS (23.4%). On multivariable generalized linear regression adjusted for age, baseline Pediatric Overall Performance Category, maximum nonrespiratory Pediatric Logistic Organ Dysfunction score, diagnosis, length of stay, and time to follow-up, PARDS was associated with HRQL decline (adjusted relative risk [aRR], 1.70; 95% CI, 1.03-2.77). Four-hour and maximum PARDS severity were the only factors associated with HRQL decline. HRQL decline occurred in five of 18 patients with mild PARDS at 4 hours, five of 13 with moderate PARDS (aRR 2.35 vs. no PARDS [95% CI, 1.01-5.50]), and seven of ten with severe PARDS (aRR 2.56 vs. no PARDS [95% CI, 1.45-4.53]). The area under the receiver operating characteristic curve for discrimination of HRQL decline for IMV patients was 0.79 (95% CI, 0.66-0.91) for binary and 0.80 (95% CI, 0.69-0.93) for trichotomous severity categorization.

CONCLUSIONS

HRQL decline is common among children surviving PARDS, and risk of decline is associated with PARDS severity. HRQL decline from baseline may be an efficient and clinically meaningful endpoint to incorporate into PARDS clinical trials.

Current Advances and Gaps in Knowledge on Personalizing Masks for Noninvasive Respiratory Support

Noninvasive respiratory support delivered through a face mask has become a cornerstone treatment for adults and children with acute or chronic respiratory failure. However, an imperfect mask fit by using commercially available interfaces is frequently encountered, which may result in patient discomfort and treatment inefficiency or failure. To overcome this challenge, over the past decade, increasing attention has been given to the development of personalized face masks, which are custom-made to address the specific facial dimensions of an individual patient. With this scoping review, we aim to provide a comprehensive overview of the current advances and gaps in knowledge with regard to the personalization masks for CPAP and NIV. We performed a systematic search of the literature and identified and summarized a total of 23 studies. Most studies included were involved in the development of nasal masks. Studies that targeted adult respiratory care mainly focused on chronic (home) ventilation and included some clinical testing in a relevant subject population. In contrast, pediatric studies focused mostly on respiratory support in the acute setting, whereas testing was limited to bench or case studies only. Most studies were positive with regard to the performance (ie, comfort, level of air leak, and mask pressure applied to the skin) of personalized masks in bench testing or in human, healthy or patient, subjects. Advances in the field of 3-dimensional scanning and soft material printing were identified, but important gaps in knowledge remain. In particular, more insight into cushion materials, headgear design, clinical feasibility, and cost-effectiveness is needed before definite recommendations can be made with regard to implementation of large-scale clinical programs that personalize noninvasive respiratory support masks for adults and children.

What's new in pediatric critical care?

Pediatric intensive care medicine is a rapidly evolving field of medicine, with recent publication of landmark papers specific for the pediatric population. Progress has been made in modes of mechanical ventilation, including noninvasive ventilation in pediatric ARDS and after extubation failure, with updated guidelines on ventilator liberation. Improved technology and advancements in hemodynamic support allow for better care of our patients with heart disease. Sepsis burden in children remains high and continued efforts are made to improve survival. A nutritional plan with a tailored approach, focusing on individualized needs, could offer benefits for our patients. Sedation practices and guidelines have been updated, focusing on minimizing delirium and facilitating early mobility. This manuscript highlights some of the most recent advances and updates.

Immunocompromised-Associated Pediatric Acute Respiratory Distress Syndrome: Experience From the 2016/2017 Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Prospective Cohort Study

OBJECTIVES

To characterize immunocompromised-associated pediatric acute respiratory distress syndrome (I-PARDS) and contrast it to PARDS.

DESIGN

This is a secondary analysis of the 2016-2017 PARDS incidence and epidemiology (PARDIE) study, a prospective observational, cross-sectional study of children with PARDS.

SETTING

Dataset of 145 PICUs across 27 countries.

PATIENTS

During 10 nonconsecutive weeks (from May 2016 to June 2017), data about immunocompromising conditions (ICCs, defined as malignancy, congenital/acquired immunodeficiency, posttransplantation, or diseases requiring immunosuppression) were collected.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 708 subjects, 105 (14.8%) had ICC. Before the development of I-PARDS, those with ICC were more likely to be hospitalized (70% vs. 35%, p < 0.001), have more at-risk for PARDS ( p = 0.046), and spent more hours at-risk (20 [interquartile range, IQR: 8-46] vs. 11 [IQR: 4-33], [ p = 0.002]). Noninvasive ventilation (NIV) use was more common in those with ICC ( p < 0.001). Of those diagnosed with PARDS on NIV ( n = 161), children with ICC were more likely to be subsequently intubated ( n = 28/40 [70%] vs n = 53/121 [44%], p = 0.004). Severe PARDS was more common (32% vs 23%, p < 0.001) in I-PARDS. Oxygenation indices were higher at diagnosis and had less improvement over the first 3 days of PARDS ( p < 0.001). Children with I-PARDS had greater nonpulmonary organ dysfunction. Adjusting for Pediatric Risk of Mortality IV and oxygenation index, children with I-PARDS had a higher severity of illness-adjusted PICU mortality (adjusted hazard ratio: 3.0 [95% CI, 1.9-4.7] p < 0.001) and were less likely to be extubated alive within 28 days (subdistribution hazard ratio: 0.47 [95% CI, 0.31-0.71] p < 0.001).

CONCLUSIONS

I-PARDS is a unique subtype of PARDS associated with hospitalization before diagnosis and increased: time at-risk for PARDS, NIV use, hypoxia, nonpulmonary organ dysfunction, and mortality. The opportunity for early detection and intervention seems to exist. Dedicated study in these patients is imperative to determine if targeted interventions will benefit these unique patients with the ultimate goal of improving outcomes.

Sequential respiratory support in septic patients undergoing continuous renal replacement therapy: A study based on MIMIC-III database

Objective

Oxygen and hemodynamic management are important for providing a sufficient adequate oxygen-containing blood to the organs for septic patients. In present study, we aimed to explore the application of sequential respiratory support (SRS) and the association of SRS with the outcome of septic patients who needed continuous renal replacement therapy (CRRT).

Methods

We extracted the medical information of septic patients who received CRRT within 24 h of intensive care unit (ICU) admission from the MIMIC-III v1.4. SRS was defined as receiving firstly oxygen therapy followed by mechanical ventilation (MV) within 24 h of admission to ICU. The propensity score matching (PSM) was performed to compare the differences in clinical characteristics and outcomes of patients with or without SRS. Finally, we developed logistic regression models to analyze the effects of SRS on hospital mortality.

Results

A total of 181 patients entered in this study, and there were 80 patients undergoing MV including SRS group (n = 61) and non-SRS group (n = 19). In the multivariate logistic regression, the value of SRS was associated with the lower risk of hospital mortality adjusted by minimum systolic BP (SBP), maximum lactate, vasopressor use, and sequential organ failure assessment (SOFA) score or Logistic Organ Dysfunction System (LODS) scores within the first 24 h of ICU stay. After PSM adjusted by SBP, maximum lactate, vasopressor use, SOFA, and LODS, there were 31 patients in SRS group with a and 18 cases in non-SRS group, displaying a significantly lower hospital mortality in SRS group than that in patients without SRS (19.4 % vs. 83.3 %, P < 0.001). In addition, age, qSOFA, necessitating the administration of vasopressor, and duration of vasopressor were significantly correlated with the hospital mortality in septic patients undergoing CRRT and SRS.

Conclusions

Receiving SRS within the first 24 h upon admission to the ICU was independently associated with the hospital mortality in patient with sepsis undergoing CRRT, and patients who were directly received MV had a high risk of death.

Complicated Falciparum Malarial ARDS Requiring Noninvasive Support

Severe plasmodium falciparum infection can induce respiratory distress and clinical ARDS in children, requiring intensive care admission and respiratory support. We present 3 cases of imported malarial acute respiratory distress syndrome requiring noninvasive ventilation in the pediatric intensive care unit, in the absence of any cerebral involvement. Radiological features and their relationship with severe hematological complications are also illustrated.

Development of personalized non-invasive ventilation masks for critically ill children: a bench study

BACKGROUND

Obtaining a properly fitting non-invasive ventilation (NIV) mask to treat acute respiratory failure is a major challenge, especially in young children and patients with craniofacial abnormalities. Personalization of NIV masks holds promise to improve pediatric NIV efficiency. As current customization methods are relatively time consuming, this study aimed to test the air leak and surface pressure performance of personalized oronasal face masks using 3D printed soft materials. Personalized masks of three different biocompatible materials (silicone and photopolymer resin) were developed and tested on three head models of young children with abnormal facial features during preclinical bench simulation of pediatric NIV. Air leak percentages and facial surface pressures were measured and compared for each mask.

RESULTS

Personalized NIV masks could be successfully produced in under 12 h in a semi-automated 3D production process. During NIV simulation, overall air leak performance and applied surface pressures were acceptable, with leak percentages under 30% and average surface pressure values mostly remaining under normal capillary pressure. There was a small advantage of the masks produced with soft photopolymer resin material.

CONCLUSION

This first, proof-of-concept bench study simulating NIV in children with abnormal facial features, showed that it is possible to obtain biocompatible, personalized oronasal masks with acceptable air leak and facial surface pressure performance using a relatively short, and semi-automated production process. Further research into the clinical value and possibilities for application of personalized NIV masks in critically ill children is needed.

Critical Care Utilization in Children With Cancer: U.S. Pediatric Health Information System Database Cohort 2012-2021

OBJECTIVES

To determine changes in pediatric oncology hospitalizations requiring intensive care over the period 2012-2021.

DESIGN

Retrospective study of hospital admission.

SETTING

Registry data from 36 children's hospitals in the U.S. Pediatric Health Information Systems database.

PATIENTS

Children 18 years or younger admitted to any of 36 hospitals with an oncology diagnosis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were a total of 55,827 unique patients accounted for 281,221 pediatric oncology hospitalizations over the 10-year period, and 16.6% of hospitalizations included admission to the PICU. Hospitalizations and PICU admissions steadily increased over this decade. Between 2012 and 2016, 15.1% of oncology hospitalizations were admitted to the PICU compared with 18.0% from 2017 to 2021 (difference 2.9% [95% CI, 2.6-3.2%] p ≤ 0.0001). Support with invasive mechanical ventilation also increased over time with 3.7% during 2012-2016 compared with 4.1% from 2017 to 2021 (difference 0.4% [95% CI, 0.2-0.5%] p ≤ 0.0001). Similar results were seen with cardiorespiratory life support using extracorporeal membrane oxygenation (difference 0.05% [95% CI, 0.02-0.07%] p = 0.0002), multiple vasoactive agent use (difference 0.3% [95% CI, 0.2-0.4%] p < 0.0001), central line placement (difference 5.3% [95% CI, 5.1-5.6%], p < 0.001), and arterial line placement (difference 0.4% [95% CI, 0.3-0.4%], p < 0.001). Year-on-year case fatality rate was unchanged over time (1.3%), but admission to the PICU during the second 5 years, compared with the first 5 years, was associated with lower odds of mortality (difference 0.7% [95% CI, 0.3-1.1%]) (odds ratio 0.82 [95% CI, 0.75-0.90%] p < 0.001).

CONCLUSIONS

The percentage of pediatric oncology hospitalizations resulting in PICU admission has increased over the past 10 years. Despite the increasing use of PICU admission and markers of acuity, and on comparing 2017-2021 with 2012-2016, there are lower odds of mortality.