Outcome of children with neuromuscular disease admitted to paediatric intensive care

[Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]

The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.

Characteristics and Outcomes of Young Adult Patients with Severe Sepsis Admitted to Pediatric Intensive Care Units Versus Medical/Surgical Intensive Care Units

Purpose: Young adults receive severe sepsis treatment across pediatric and adult care settings. However, little is known about young adult sepsis outcome differences in pediatric versus adult hospital settings. Material and Methods: Using Truven MarketScan database from 2010-2015, we compared in-hospital mortality and hospital length of stay in young adults ages 18-26 treated for severe sepsis in Pediatric Intensive Care Units (PICUs) versus Medical ICUs (MICUs)/Surgical ICUs (SICUs) using logistic regression models and accelerated time failure models, respectively. Comorbidities were identified using Complex Chronic Conditions (CCC) and Charlson Comorbidity Index (CCI). Results: Of the 18 900 young adults hospitalized with severe sepsis, 163 (0.9%) were treated in the PICU and 952 (5.0%) in the MICU/SICU. PICU patients were more likely to have a comorbid condition compared to MICU/SICU patients. Compared to PICU patients, MICU/SICU patients had a lower odds of in-hospital mortality after adjusting for age, sex, Medicaid status, and comorbidities (adjusting for CCC, odds ratio [OR]: 0.50, 95% CI 0.29-0.89; adjusting for CCI, OR: 0.51, 95% CI 0.29-0.94). There was no difference in adjusted length of stay for young adults with severe sepsis (adjusting for CCC, Event Time Ratio [ETR]: 1.14, 95% CI 0.94-1.38; adjusting for CCI, ETR: 1.09, 95% CI 0.90-1.33). Conclusions: Young adults with severe sepsis experience higher adjusted odds of mortality when treated in PICUs versus MICU/SICUs. However, there was no difference in length of stay. Variation in mortality is likely due to significant differences in the patient populations, including comorbidity status.

Initial multicenter experience with ventricular assist devices in children and young adults with muscular dystrophy: An ACTION registry analysis

PURPOSE

Cardiac disease results in significant morbidity and mortality in patients with muscular dystrophy (MD). Single centers have reported their ventricular assist device (VAD) experience in specific MDs and in limited numbers. This study sought to describe the outcomes associated with VAD therapy in an unselected population across multiple centers.

METHODS

We examined outcomes of patients with MD and dilated cardiomyopathy implanted with a VAD at Advanced Cardiac Therapies Improving Outcomes Network (ACTION) centers from 9/2012 to 9/2020.

RESULTS

A total of 19 VADs were implanted in 18 patients across 12 sites. The majority of patients had dystrophinopathy (66%) and the median age at implant was 17.2 years (range 11.7-29.5). Eleven patients were non-ambulatory (61%) and 6 (33%) were on respiratory support pre-VAD. Five (28%) patients were implanted as a bridge to transplant, 4 of whom survived to transplant. Of 13 patients implanted as bridge to decision or destination therapy, 77% were alive at 1 year and 69% at 2 years. The overall frequencies of positive outcome (transplanted or alive on device) at 1 year and 2 years were 84% and 78%, respectively. Two patients suffered a stroke, 2 developed sepsis, 1 required tracheostomy, and 1 experienced severe right heart failure requiring right-sided VAD.

CONCLUSIONS

This study demonstrates the potential utility of VAD therapies in patients with muscular dystrophy. Further research is needed to further improve outcomes and better determine which patients may benefit most from VAD therapy in terms of survival and quality of life.

Population-Level Analysis of Appropriateness of End-of-Life Care for Children with Neurologic Conditions

OBJECTIVE

The objective of this study was to measure the appropriateness of end-of-life care for children who died with neurologic conditions.

STUDY DESIGN

Based on linked routinely collected databases, we conducted a population-level decedent retrospective cohort study of children with neurologic conditions who died in Belgium between 2010 and 2017. We measured a set of 22 face-validated quality indicators. The set concerns 12 indicators of potentially appropriate end-of-life care (eg, specialized comfort medication, physician contact, continuous care) and 10 indicators of potentially inappropriate end-of-life care (eg, diagnostic tests, phlebotomy). We performed ANOVA for predictors (age, sex, disease category, nationality, having siblings, year of death) for scales of appropriate and inappropriate care.

RESULTS

Between 2010 and 2017, 139 children with neurologic conditions died in Belgium. For potentially appropriate care, in the last 30 days, 76% of children received clinical care, 55% had continuous care relationships, 17% had contact with a general physician, 8% of children received specialized comfort medication, and 14% received care from a palliative care team. For potentially inappropriate care, in the last 14 days, 45% had blood drawn and 27% were admitted to intensive care unit.

CONCLUSIONS

Our study found indications of appropriate as well as inappropriate end-of-life care for children who died with neurologic conditions. These findings reveal a substantial margin for potential quality improvement, in regard to palliative care provision, multidisciplinary care, financial support, specialized comfort medication, clinical follow-up, general physician contact, diagnostics, and blood drawing.

Risk Factors of Readmission to Pediatric Intensive Care Unit Within 1 Year: A Case-Control Study

BACKGROUND

Research on pediatric intensive care unit (PICU) readmission is lacking in China. This study was conducted to describe the risk factors associated with PICU readmission within 1 year after PICU discharge.

METHODS

This retrospective case-control study included patients aged from 1 month to 16 years who were discharged between January 2018 and May 2020. The case group included readmitted patients with two or more PICU admissions within 1 year during the study period. The control group included survivors with only one PICU admission during the same study period, and the controls were matched on age and sex. Demographic and clinical variables were collected from the electronic administrative database. Risk factors were analyzed by univariate and multivariate analyses.

RESULTS

From January 2018 to May 2020, 2,529 patients were discharged from the PICU, and 103 (4.07%) were readmitted within 1 year. In the univariate analysis, PICU readmission within 1 year was associated with lower weight, the presence of chronic conditions, a higher StrongKids score on admission, length of PICU stay of more than 2 weeks, the presence of dysfunction at discharge, sedation medications use, vasopressor use, and invasive mechanical ventilation in the first PICU stay. Patients had a higher StrongKids score as a surrogate for increased risk of malnutrition. In the multivariate analysis, the factors most significantly associated with PICU readmission within 1 year were the presence of chronic conditions, a higher StrongKids score on admission, and length of PICU stay of more than 2 weeks in the first PICU stay. In the subgroup analysis, compared with the control group, the factors most significantly associated with readmission within 48 h of discharge were the presence of chronic conditions, a higher StrongKids score on admission, and vasopressor use during the first PICU stay. The mortality rate was 8.74% (9/103) in patients with PICU readmission. The overall PICU mortality rate was 7.39% (201/2,721) during the study period.

CONCLUSIONS

Patients with chronic conditions, a higher StrongKids score on admission, and length of PICU stay of more than 2 weeks were at much higher risk for PICU readmission within 1 year. Patients with vasopressor use during the first PICU hospitalization were more likely to be readmitted within 48 h of discharge.

All You Need Is Evidence: What We Know About Pneumonia in Children With Neuromuscular Diseases

Neuromuscular diseases may involve all major respiratory muscles groups including inspiratory, expiratory, and bulbar muscles. Respiratory complications are the major cause of morbidity and mortality. Pneumonia represents a frequent cause of morbidity in children with neuromuscular disease. The aim of this review is to collect knowledge about pneumonia in children with neuromuscular diseases. Pneumonia usually follows viral respiratory infections of the upper respiratory tract, due to the combination of an increased amount of nasal and oral secretions and an impairment of the cough efficiency and of the clearance of secretions due to the muscle weakness, further compromised by the infection itself. The accumulation of bronchial secretions leads to atelectasis and promote bacterial infection. Moreover, dysfunction of swallowing mechanism exposes these children to the risk of developing aspiration pneumonia. However, etiology of viral and bacterial respiratory infection in these patients is still poorly studied.

Ethical decision-making for children with neuromuscular disorders in the COVID-19 crisis

The sudden appearance and proliferation of coronavirus disease 2019 has forced societies and governmental authorities across the world to confront the possibility of resource constraints when critical care facilities are overwhelmed by the sheer numbers of grievously ill patients. As governments and health care systems develop and update policies and guidelines regarding the allocation of resources, patients and families affected by chronic disabilities, including many neuromuscular disorders that affect children and young adults, have become alarmed at the possibility that they may be determined to have less favorable prognoses due to their underlying diagnoses and thus be assigned to lower priority groups. It is important for health care workers, policymakers, and government officials to be aware that the long-term prognoses for children and young adults with neuromuscular disorders are often more promising than previously believed due to a better understanding of the natural history of these diseases, benefits of multidisciplinary supportive care, and novel molecular therapies that can dramatically improve the disease course. Although the realities of a global pandemic have the potential to require a shift from our usual, highly individualistic standards of care to crisis standards of care, shifting priorities should nonetheless be informed by good facts. Resource allocation guidelines with the potential to affect children and young adults with neuromuscular disorders should take into account the known trajectory of acute respiratory illness in this population and rely primarily on contemporary long-term outcome data.

Combined noninvasive ventilation and mechanical insufflator-exsufflator for acute respiratory failure in patients with neuromuscular disease: effectiveness and outcome predictors

Background:

To determine the effectiveness of combined noninvasive ventilation (NIV) and mechanical insufflator-exsufflator (MI-E) for acute respiratory failure (ARF) in patients with neuromuscular disease (NMD), and outcome predictors.

Methods:

A prospectively observational study of patients with ARF was conducted in a pediatric intensive care unit (PICU). All received combined NIV/MI-E during PICU stays between 2007 and 2017. Pertinent clinical variables of heart rate (HR), respiratory rate (RR), pH, PaCO₂, and PaO₂/FiO₂ ratio were collected at baseline and at 2 h, 4-8 h, and 12-24 h after initiating use of NIV/MI-E. Treatment success was defined as avoiding intubation.

Results:

A total of 62 ARF episodes in 56 patients with NMD (median age, 13 years) were enrolled. The most frequent underlying NMD was spinal muscular atrophy (32/62, 52%). ARF was primarily due to pneumonia (65%). The treatment success rate was 86%. PICU stay and hospitalization were shorter in the success group (9.4 ± 6.1 vs. 21.9 ± 13.9 days and 16.3 ± 7.8 vs. 33.6 ± 17.9 days, respectively; both p < 0.05). HR, RR, pH, and PaCO₂ showed a progressive improvement, particularly after 4 h following successful NIV/MI-E treatment. RR decrease at 4 h, and pH increase and PaCO₂ decrease at 4-8 h might predict success of NIV/MI-E treatment. The multivariate analysis identified PaCO₂ at 4-8 h of 58.0 mmHg as an outcome predictor of NIV/MI-E treatment.

Conclusions:

Applying combined NIV/MI-E in the acute care setting is an efficient means of averting intubation in NMD patients with ARF. Clinical features within 8 h of the institution may predict treatment outcome.

The reviews of this paper are available via the supplemental material section.

Noninvasive Ventilation and Mechanical Insufflator-Exsufflator for Acute Respiratory Failure in Children With Neuromuscular Disorders

Children with neuromuscular disorder (NMD) usually have pulmonary involvement characterized by weakened respiratory muscles, insufficient coughing, and inability to clear airway secretions. When suffering from community-acquired pneumonia, these patients are more likely to develop acute respiratory failure (ARF). Therefore, recurrent pneumonias leading to acute on chronic respiratory failure accounts for a common cause of mortality in children with NMD. For many years, noninvasive ventilation (NIV) has been regarded as a life-prolonging tool and has been used as the preferred intervention for treating chronic hypoventilation in patients with advanced NMD. However, an increasing number of studies have proposed the utility of NIV as first-line management for acute on chronic respiratory failure in NMD patients. The benefits of NIV support in acute settings include avoiding invasive mechanical ventilation, shorter intensive care unit or hospital stays, facilitation of extubation, and improved overall survival. As the difficulty in clearing respiratory secretions is considered a significant risk factor attributing to NIV failure, combined coughing assistance of mechanical insufflator-exsufflator (MI-E) with NIV has been recommended the treatment of acute neuromuscular respiratory failure. Several recent studies have demonstrated the feasibility and effectiveness of combined NIV and MI-E in treating ARF of children with NMD in acute care settings. However, to date, only one randomized controlled study has investigated the efficacy of NIV in childhood ARF, but subjects with underlying NMD were excluded. It reflects the need for more studies to elaborate evidence-based practice, especially the combined NIV and MI-E use in children with acute neuromuscular respiratory failure. In this article, we will review the feasibility, effectiveness, predictors of outcome, and perspectives of novel applications of combined NIV and MI-E in the treatment of ARF in NMD children.

Acute Neuromuscular Disorders in the Pediatric Intensive Care Unit

BACKGROUND

The neuromuscular disorders encountered in the pediatric intensive care unit (PICU) encompass a broad spectrum of pathologies. These include acute disorders (eg, Guillain-Barre syndrome), acute-on-chronic disorders (eg, myasthenia gravis), progressive disorders (eg, muscular dystrophy), and disorders that develop in the PICU (eg, critical illness myopathy/polyneuropathy). Familiarity with the presenting features of these disorders is of paramount importance in facilitating timely diagnosis.

METHODS

We conducted a retrospective review of the medical records of patients admitted to the PICU or Intermediate Care Program (ICP) at a single tertiary children's hospital from 2006 to 2017 with an acute or acute-on-chronic neuromuscular disorder. We did not include patients with a known progressive neuromuscular disorder or critical illness myopathy/polyneuropathy.

RESULTS

Twenty-four patients were admitted to the PICU/ICP with acute or acute-on-chronic neuromuscular disorders. Diagnosis and indication for ICU/ICP admission were Guillain-Barre syndrome (n = 6; respiratory failure: 3, respiratory monitoring: 2, autonomic instability: 1), myasthenia gravis (n = 5; airway clearance: 3, respiratory failure: 2), acute flaccid myelitis (n = 3; respiratory failure: 2, respiratory monitoring: 1), periodic paralysis (n = 3; intravenous potassium replacement), rhabdomyolysis (n = 3; monitoring for electrolyte derangements), infant botulism (n = 2; respiratory failure), chronic demyelinating polyneuropathy (n = 1; respiratory failure), and congenital myasthenic syndrome (n = 1; apnea). No patients were admitted to the PICU/ICP with a diagnosis of tick paralysis, acute intermittent porphyria, or inflammatory myopathy.

CONCLUSIONS

Although acute and acute-on-chronic neuromuscular disorders are encountered relatively rarely in the PICU, familiarity with the presenting features of these disorders is important in facilitating timely diagnosis. This, in turn, enables the institution of effective management strategies, thereby avoiding complications associated with diagnostic delays.

Noninvasive airway approaches for acute neuromuscular respiratory failure in emergency departments

Emerging evidence advocates for noninvasive ventilation (NIV) combined with mechanical in-exsufflation (MIE) as a first-line approach for acute respiratory failure (ARF) in patients with neuromuscular disorders (NMD). To date, most NIV studies of ARF in NMD patients have been performed in intensive care units or in hospital settings. However, the utility of using combined NIV/MIE in the emergency department (ED) settings is unclear. We report on the implementation of NIV/MIE in two children with type II spinal muscular atrophy who presented to the ED with ARF. This is the first report on the feasibility and efficacy of combining NIV/MIE in ED settings for pediatric NMD patients with ARF.

Mechanical insufflation-exsufflation: Practice patterns among respiratory therapists in Ontario

BACKGROUND

The mechanical insufflator-exsufflator (MIE) is effective in assisting cough and in helping to avoid unplanned hospitalizations, tracheostomy and long-term ventilation in patients with neuromuscular disease or spinal cord injury. Despite this, the availability and usage of the device in Canada is unknown.

OBJECTIVE

To investigate practice patterns and availability of the MIE in Ontario hospitals.

METHODS

A cross-sectional, self-administered mail survey was sent to a random sample of 400 respiratory therapists practicing in 96 Ontario hospitals.

RESULTS

A total of 114 (28%) completed surveys were returned from 62 (65%) hospitals. Twenty (32%) hospitals had a MIE. The respiratory therapist was the predominant health care provider using the MIE. The device was most commonly used in the intensive care unit, and medical/surgical units in patients with neuromuscular diseases or spinal cord injuries. Optimal pressure spans of 35 cmH2O to 40 cmH2O were used by 54% of respondents. Fourteen of the 20 hospitals with an MIE had policies or guidelines in place, and four of these hospitals had established staff competencies. Measurements of peak cough flow, maximal inspiratory/expiratory pressure and vital capacity were reported to be infrequently performed.

CONCLUSIONS

The present study demonstrated that the MIE device is not widely available in Ontario hospitals and there are variations in how the devices are applied, possibly resulting in suboptimal therapy. A comprehensive educational program about MIE devices that incorporates best practices and a practical component is recommended for current providers as well as for inclusion in student curricula.

Withdrawal of ventilatory support outside the intensive care unit: guidance for practice

OBJECTIVE

To review the work of one tertiary paediatric palliative care service in facilitating planned withdrawal of ventilatory support outside the intensive care setting, with the purpose of developing local guidance for practice.

METHODS

Retrospective 10-year (2003-2012) case note review of intensive care patients whose parents elected to withdraw ventilation in another setting. Demographic and clinical data revealed common themes and specific incidents relevant to local guideline development.

RESULTS

18 children (aged 2 weeks to 16 years) were considered. Three died prior to transfer. Transfer locations included home (5), hospice (8) and other (2). Primary pathologies included malignant, neurological, renal and respiratory diseases. Collaborative working was evidenced in the review including multidisciplinary team meetings with the palliative care team prior to discharge. Planning included development of symptom management plans and emergency care plans in the event of longer than anticipated survival. Transfer of children and management of extubations demonstrated the benefits of planning and recognition that unexpected events occur despite detailed planning. We identified the need for local written guidance supporting healthcare professionals planning and undertaking extubation outside the intensive care setting, addressing the following phases: (i) introduction of withdrawal, (ii) preparation pretransfer, (iii) extubation, (iv) care postextubation and (v) care postdeath.

CONCLUSIONS

Planned withdrawal of ventilatory support outside the intensive care setting is challenging and resource intensive. The development of local collaborations and guidance can enable parents of children dependent on intensive care to consider a preferred place of death for their child, which may be outside the intensive care unit.

Combined noninvasive ventilation and mechanical in-exsufflator in the treatment of pediatric acute neuromuscular respiratory failure

OBJECTIVES

The present study aims to evaluate the efficacy and complications of combined noninvasive ventilation (NIV) and assisted coughing by mechanical in-exsufflator (MIE) for acute respiratory failure (ARF) in children with neuromuscular disease (NMD).

METHODS

A prospective study was conducted in the pediatric intensive care unit. Children with NMD and ARF treated by combined NIV and MIE were included. Treatment success was defined as freedom from tracheal intubation during the hospital stay. Physiologic indices including PaO2 , PaCO2 , pH, and PaO2 /FiO2 were recorded before and 12, 24 hr after the use of NIV/MIE.

RESULTS

Combined NIV/MIE was used in 15 NMD children (mean: 8.1 years, range: 3 months to 18 years) with 16 cases of ARF. There was no mortality in this cohort. Treatment success was achieved in 12 cases (75%), including six cases (38%) demanding "Do Not Intubate." ARF was due to pneumonia, with a mean baseline PaCO2 of 73.2 ± 19.0 mmHg. In the success group, hypercarbia and acidosis improved after use of NIV/MIE for 24 hr (PaCO2 : 71.7 ± 18.6 mmHg vs. 55.8 ± 11.6 mmHg, P < 0.01; pH: 7.29 ± 0.07 vs. 7.38 ± 0.05, P < 0.01). All patients tolerated NIV/MIE well despite transient skin pressure sores in five cases.

CONCLUSIONS

Combined NIV/MIE is a safe and effective approach to rapidly improve physiologic indices and decrease the need for intubation in NMD children with ARF. NIV/MIE provides a good alternative for those refusing intubation.

Sleep disorders in children

Sleep disorders are very common in childhood and are often amenable to simple advice and parental education. Questions about sleep should be an integral part of every paediatric consultation. Children with underlying syndromes or complex medical conditions often have multiple sleep issues. Excessive sleepiness in children requires careful history-taking and consideration of specialised investigation. Obstructive sleep apnoea (OSA) is a common condition in childhood with important health implications. The high prevalence of OSA warrants rigorous attempts to identify children at higher risk and manage them appropriately. Adenotonsillectomy is a highly efficacious therapy for paediatric OSA. A current major issue is to improve ways of distinguishing mild from severe OSA before a child undergoes adenotonsillectomy, as those with more severe disease are at increased risk of postoperative complications and should undergo adenotonsillectomy in a tertiary centre. Children with obesity and other comorbid conditions are at increased risk of persisting OSA despite adenotonsillectomy. Topical (nasal) steroids and/or anti-inflammatory agents have a role in the non-surgical treatment of mild OSA. Continuous positive airway pressure and orthodontic interventions are treatment options for treatment of persisting OSA in children.

Comparison of the immunogenicity of intramuscular versus subcutaneous administration of trivalent inactivated influenza vaccine in individuals with neuromuscular diseases

Individuals with neuromuscular disease show a wide spectrum of muscle pathology. To test the hypothesis that the immune response to trivalent inactivated influenza vaccine is potentially inadequate when given intramuscularly into a fibrosed muscle, this prospective randomized study compared the immunogenicity and safety of the standard intramuscular versus subcutaneous administration of the influenza vaccine in 22 nonambulatory subjects, of whom 10 have been on glucocorticoid therapy. Analysis of hemagglutination inhibition antibody titers showed high prevalence of seroprotection (prevaccination of 82% H1N1, 72% H3N2, 31% B; postvaccination of 100% H1N1, 77% H3N2, 59% B). Geometric mean titer ratios for each antigen showed no significant difference (P > .5) between intramuscular and subcutaneous routes. Seroprotection was not adversely affected by glucocorticoid therapy. Local tolerance was better with subcutaneous route. Larger studies are needed to confirm these preliminary results.

Use of a lung model to assess mechanical in-exsufflator therapy in infants with tracheostomy

BACKGROUND

The mechanical in-exsufflator (MIE) is commonly used to augment cough in patients with neuromuscular disease from infancy to adulthood. Little is known about the alveolar pressures, lung volumes, and expiratory flow rates generated by the MIE when used via tracheostomy tube in infants and children.

METHODS

A high-fidelity mechanical lung model was programmed to simulate infants with tracheostomy tubes. Generated pressures, volumes, and expiratory flows using the MIE device at variable insufflation/exsufflation pressures and times were recorded. The primary measure of interest was maximal expiratory flow (MEF).

RESULTS

Pressure equilibration across the tracheostomy tube did not occur with insufflation time <1 sec. Longer insufflation time significantly increased measured alveolar pressures, lung volume, and MEF until TLC was reached. Longer exsufflation time did not significantly increase MEF. Higher insufflation pressures resulted in greater lung volumes, with >70% vital capacity attained at insufflation pressures as low as 20 cmH2 O. Though higher insufflation pressures resulted in increased expiratory flow rates, more negative exsufflation pressure had a greater absolute impact on MEF.

CONCLUSIONS

Using the MIE via tracheostomy tube in an infant lung model, we found that an insufflation time of >1 sec is required for equilibration of insufflation pressure and alveolar pressure. Longer exsufflation time does not significantly alter MEF. Higher insufflation and exsufflation pressures both increased MEF, but greater exsufflation pressure had more substantial impact.

Children with chronic illness return to their baseline functional status after organ dysfunction on the first day of admission in the pediatric intensive care unit

OBJECTIVE

To determine chronic illness outcomes after admission with multiple organ dysfunction syndrome (MODS) for patients in the pediatric intensive care unit (PICU).

STUDY DESIGN

We evaluated consecutive PICU admissions from 35 US children's hospitals from January 2004-December 2005 in the virtual PICU Performance System database. We excluded hospitals with >10% missing values for MODS variables and patients<1 month or>18 years of age. MODS was identified by laboratory and vital sign values from day of admission with International Pediatric Sepsis Consensus Conference criteria. Chronic illness was identified by secondary diagnoses, classified by modified Delphi method. We evaluated functional outcomes with pediatric overall performance category and pediatric cerebral performance category scores from PICU admission and discharge.

RESULTS

Of 44 693 admissions, 52.1% had a chronic diagnosis. Chronic diagnoses increased MODS at PICU admission (24.6% vs 12.0%, P<.001) and mortality rates (3.7% vs 1.9%, P<.001). Patients with a chronic diagnosis had similar changes in pediatric overall performance category and pediatric cerebral performance category scores from PICU admission to discharge as previously healthy children. However, outcome in different chronic diagnosis categories was variable.

CONCLUSIONS

Chronic illness increased MODS incidence at PICU admission and impacted all-cause PICU mortality rates. Although, in aggregate, children who survive return to baseline functional status, this varies by chronic illness category.

[Use of mechanical ventilation in pediatric patients]

BACKGROUND/AIM

Major aims of mechanical ventilation (MV) in pediatrics mean the contribution to complete recovery of acute disorder or to establishing stability of previously long-term changed health condition. MV is used today in 16-46% of patients treated in pediatric intensive care units. The aim of this paper was to get insight into the presence of the disease and pathologic conditions and outcome of MV regarding previous health condition of pediatric patients.

METHODS

This retrospective study included 476 pediatric patients (beyond neonatal age) who underwent mechanical ventilation (MV). On the basis of previous health status the patients were classified in two groups: the group A consisted of 157 children with no previous chronic disease leading to MV and the group H comprised of 319 children who received MV due to worsening ofprevious chronic disease.

RESULTS

In both groups of pediatric patients there was significant predominance of younger age patients. Acute and chronic neurological disorders were the most frequent conditions requiring use of MV. Out of a total number (476) of the patients, 178 patients (37.40%) died. In the group A 17 patients (10.9%) died, while in the group H mortality rate was significantly higher (161 or 50.5% patients died; p < 0.01; RR 4.85; CI 3.1-7.6). Total duration time of MV in all the patients was 7 525 days, with 1 345 days (15%) accounted for the group A and 4 567 days (85%) for the group H. Mean MV duration was 7.48 (+/- 9.23) days for the patients in the group A which is significantly shorter in comparison to mean 21.8 (+/- 57.96) days for the group H patients (p < 0.001).

CONCLUSION

These results point out significant contribution of MV to better outcome in pediatric patients with different acute disorders. Clear dominance of chronically ill children requiring mechanical ventilation due to acute worsening of their condition implies new complexity of problems regarding organization of pediatric intensive care and treatment.

Airway clearance in children with neuromuscular weakness

PURPOSE OF REVIEW

Assistance with airway clearance is critical for reducing morbidity and mortality in children with neuromuscular weakness. Several techniques and devices are available to enhance airway clearance in patients with neuromuscular disease. Only recently, however, has assessment of their effectiveness included children. This review highlights the rationale for use of both secretion extraction and mucus mobilization techniques and devices, emphasizing findings in pediatric patients whenever possible.

RECENT FINDINGS

Cough in adults is adequate when peak cough flow exceeds 160 l/min. Similar threshold values in young children have not been established. Those methods that enhance secretion extraction include breath stacking, manual or mechanical insufflation, manually assisted cough, and mechanical insufflation-exsufflation. All are well tolerated in children and can increase peak cough flows, although the greatest increase occurs with mechanical insufflation-exsufflation. Techniques successfully used to help mobilize secretions include high frequency chest wall oscillation and intrapulmonary percussive ventilation. Various modalities can be used successfully alone or in combination.

SUMMARY

Secretion extraction and mobilization techniques are safe, even in infants who require airway clearance assistance. To date, however, criteria specific for children are lacking to determine when such modalities should be used and which ones are most effective.

Paediatric home ventilatory support: the Auckland experience

OBJECTIVES

To examine the trend over time, describe the disease categories treated, intervention success and outcomes of the children treated at home with continuous positive airway pressure (CPAP), non-invasive ventilation (NIV) and ventilation via tracheostomy (invasive ventilatory support, IVS) by the Respiratory Service at the Starship Children's Hospital in Auckland.

METHODS

A retrospective review was undertaken of the Respiratory Service records from November 1991 to February 2004.

RESULTS

Home CPAP, NIV or IVS was initiated in 160 children (89 boys, median age 6 years) in the study period. Sixty-nine (46 boys) remain on support and are still actively managed by the Starship Respiratory Service, of whom 46% live outside the Greater Auckland Region. Despite 42% of children being less than 5 years of age at initiation of therapy, institution of support failed in only 11%. The majority received treatment by non-invasive mask interface (68% (n = 108) CPAP, 29% (n = 47) NIV), with only 3% (n = 5) supported via tracheostomy. The numbers and complexity of support rose over the 12 years. Respiratory support was discontinued in 57% of cases, after a median of 12.5 months (range 3-52 months); in two-thirds, support was no longer required due to an improvement in the medical condition. The most common indication for support in current patients is respiratory parenchymal or airway disease followed by neuromuscular disease. Obesity is not a common indication.

CONCLUSION

This review documents the increasing trend in children receiving respiratory support at home. Future planning and resources are needed to address this growing need.

Acute management of paediatric respiratory failure

Respiratory failure may be defined as failure of the lungs to maintain adequate gas exchange. It may occur as a result of alveolar hypoventilation, diffusion impairment, intrapulmonary shunting or ventilation–perfusion mismatch. Respiratory failure may be associated with hypoxaemia, hypercarbia or both. Hypoxaemia can cause tissue hypoxia and progressive hypercarbia can cause carbon dioxide narcosis. Both of these complications are potentially life threatening. Thus treatment of respiratory failure must aim both to maintain gas exchange and to treat the underlying cause.