Acute respiratory failure in infants and children with bronchiolitis, pneumonitis and status astmaticus

The development of pediatric critical care medicine at The Children's Hospital of Philadelphia: an interview with Dr. John J. 'Jack' Downes

Dr. John J. 'Jack' Downes (1930-), the anesthesiologist-in-chief at The Children's Hospital of Philadelphia (1972-1996), has made numerous contributions to pediatric anesthesia and critical care medicine through a broad spectrum of research on chronic respiratory failure, status asthmaticus, postoperative risks of apnea in premature infants, and home-assisted mechanical ventilation. However, his defining moment was in January 1967, when The Children's Hospital of Philadelphia inaugurated its pediatric intensive care unit--the first of its kind in North America. During his tenure, he and his colleagues trained an entire generation of pediatric anesthesiologists and intensivists and set a standard of care and professionalism that continues to the present day. Based on an interview with Dr. Downes, this article reviews a career that advanced pediatric anesthesia and critical care medicine and describes the development of that first pediatric intensive care unit at The Children's Hospital of Philadelphia.

Severe ventilatory failure in asthma in children. Experience of 13 episodes over 6 years

During the 6-year period from 1 October 1971 to 30 September 1977, 13 (about 1%) of 1225 admissions to hospital with asthma developed severe ventilatory failure (peak arterial PCO 2 greater than 8 kPa). Mean age was 4.1 years (2.3--7.9), and on average each patient had been admitted to hospital on 5 occasions during the preceding year. 11 gave a family history of asthma or a personal history of associated allergies. A viral upper respiratory tract infection was the commonest precipitant of wheeze, and in 7 patients the duration of wheeziness before admission to hospital was 12 hours or less. Six (0.5%) patients were treated by mechanical ventilation and all survived. The changing patterns of management during the study period are reviewed.

Acute respiratory failure in bronchiolitis and pneumonia in infancy. Modes of presentation and treatment

The modes of presentation and the management of acute respiratory failure in 11 infants with severe lower respiratory tract infections (due to respiratory syncytial virus in eight) are described. Progressive respiratory difficulties leading to exhaustion, peripheral circulatory collapse, recurrent apnoeic attacks, or generalized convulsions were the main clinical presentations resulting in severe ventilatory failure. In nine infants preventilation carbon dioxide tensions exceeded 65 mm Hg. It seems likely that the use of intermittent positive-pressure ventilation in these patients contributed to the low mortality rate, less than 0.5%, from such illnesses during the 15-month study period.

Virological findings and blood gas tensions in acute lower respiratory tract infections in children

Sequential blood gas tensions and pH have been measured in 84 children selected from 486 admitted to hospital during a 15-month period with acute lower respiratory tract infections. Of those selected 73 were treated conservatively and 11 by intermittent positive-pressure ventilation; one infant in the latter group died. Respiratory syncytial virus (R.S.V.) was isolated from 24 out of 62 patients studied and the main pathogen in the most severely affected infants. Statistical analysis showed that age and R.S.V. infection were independent determinants of severity, as reflected by a peak Pco(2) measurement at the height of the illness (age, P < 0.01; R.S.V. 0.05 > P > 0.01).