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Seliem W, Sultan AM. Does heliox administered by low-flow nasal cannula improve respiratory distress in infants with respiratory syncytial virus acute bronchiolitis? A randomised controlled trial. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.anpede.2018.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Hopster K, Duffee LR, Hopster-Iversen CCS, Driessen B. Efficacy of an alveolar recruitment maneuver for improving gas exchange and pulmonary mechanics in anesthetized horses ventilated with oxygen or a helium-oxygen mixture. Am J Vet Res 2018; 79:1021-1027. [DOI: 10.2460/ajvr.79.10.1021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Seliem W, Sultan AM. [Does heliox administered by low-flow nasal cannula improve respiratory distress in infants with respiratory syncytial virus acute bronchiolitis? A randomized controlled trial]. An Pediatr (Barc) 2018; 90:3-9. [PMID: 29627312 DOI: 10.1016/j.anpedi.2018.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 01/18/2018] [Accepted: 01/19/2018] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES The aim of our study is to evaluate whether the use of heliox (79:21) delivered through a low flow nasal cannula would improve respiratory distress in infants with acute bronchiolitis caused by respiratory syncytial virus. METHODS We have conducted a prospective randomized controlled study. All patients fulfilled inclusion criteria were randomized to either heliox (79:21) or air via NC at 2 L/min for a continuous 24hours. Measurements were taken at baseline, after 2hours and at the end of the 24hours. RESULTS We have included 104 patients into our study. The MCA-S did not show any significant difference between the two groups after 2hours 4.3 vs. 4.1 (P =.78), or at 24hours after 4.2 vs. 4.3 (P =.89). No difference was found in the proportion of participants progressed to MV, n-CPAP or oxygen via nasal cannula (RR 1.0, 0.86 and 0.89) (P= 1.0, .77 and .73). There was no notable reduction in length of treatment in Heliox group 2.42 days vs. 2.79 days in air group P =.65. The in oxygen saturation, PaO2, and PaCO2 did not to have any statistical difference between the two studied groups after 2hours and 24hours of treatment. CONCLUSION Our data showed absence of any beneficial effect of heliox in a concentration (79:21) delivered through low flow nasal cannula in terms of respiratory distress improvement in infants with RSV acute bronchiolitis.
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Affiliation(s)
- Wael Seliem
- Facultad de Medicina, Universidad de El Mansura, El Mansura, Egipto; Departamento de Pediatría, Hospital Infantil Universitario de El Mansura, El Mansura, Egipto.
| | - Amira M Sultan
- Facultad de Medicina, Universidad de El Mansura, El Mansura, Egipto; Departamento de Microbiología Clínica e Inmunología, Hospital Infantil Universitario de El Mansura, El Mansura, Egipto
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Heliox delivered by high flow nasal cannula improves oxygenation in infants with respiratory syncytial virus acute bronchiolitis. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2018. [DOI: 10.1016/j.jpedp.2017.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Heliox delivered by high flow nasal cannula improves oxygenation in infants with respiratory syncytial virus acute bronchiolitis. J Pediatr (Rio J) 2018; 94:56-61. [PMID: 28506664 DOI: 10.1016/j.jped.2017.04.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 01/26/2017] [Accepted: 01/31/2017] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The objective of this study is to evaluate the hypothesis that use of heliox would result in improvement of gas exchange when used with high flow nasal cannula in infants with RSV acute bronchiolitis. METHODS All patients that met the inclusion criteria were randomized to either heliox (70:30) or air-oxygen mixture 30% via high flow nasal cannula at 8L/min for a continuous 24h. Measurements were taken at baseline, after 2h, and at the end of the 24h. RESULTS This prospective study included 48 patients. After 2h of treatment with heliox, the oxygen saturation and PaO2 significantly improved when compared with the air-oxygen group, 98.3% vs. 92.9%, 62.0mmHg vs. 43.6mmHg (p=0.04 and 0.01), respectively. Furthermore, PaO2/FiO2 ratio was significantly higher in the heliox group when compared with the air-oxygen group, 206.7 vs. 145.3. Nevertheless, CO2 showed better elimination when heliox was used, without significance. MWCA score dropped significantly in the heliox group, 2.2 points vs. 4.0 points in air-oxygen (p=0.04), 2h after starting the therapy. CONCLUSION Transient improvement of oxygenation in infants with RSV acute bronchiolitis during the initial phase of the therapy is associated with heliox when provided with HFNC, may provide a precious time for other therapeutic agents to work or for the disease to resolve naturally, avoiding other aggressive interventions.
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Kim YI, Pareek R, Murphy R, Harrison L, Farrell E, Cook R, DeVincenzo J. The antiviral effects of RSV fusion inhibitor, MDT-637, on clinical isolates, vs its achievable concentrations in the human respiratory tract and comparison to ribavirin. Influenza Other Respir Viruses 2017; 11:525-530. [PMID: 28990339 PMCID: PMC5705693 DOI: 10.1111/irv.12503] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2017] [Indexed: 11/30/2022] Open
Abstract
Background Respiratory syncytial virus (RSV) viral load and disease severity associate, and the timing of viral load and disease run in parallel. An antiviral must be broadly effective against the natural spectrum of RSV genotypes and must attain concentrations capable of inhibiting viral replication within the human respiratory tract. Objectives We evaluated a novel RSV fusion inhibitor, MDT‐637, and compared it with ribavirin for therapeutic effect in vitro to identify relative therapeutic doses achievable in humans. Method MDT‐637 and ribavirin were co‐incubated with RSV in HEp‐2 cells. Quantitative PCR assessed viral concentrations; 50% inhibitory concentrations (IC50) were compared to achievable human MDT‐637 and ribavirin peak and trough concentrations. Results and conclusions The IC50 for MDT‐637 and ribavirin (against RSV‐A Long) was 1.42 and 16 973 ng/mL, respectively. The ratio of achievable peak respiratory secretion concentration to IC50 was 6041‐fold for MDT‐637 and 25‐fold for aerosolized ribavirin. The ratio of trough concentration to IC50 was 1481‐fold for MDT‐637 and 3.29‐fold for aerosolized ribavirin. Maximal peak and trough levels of oral or intravenous ribavirin were significantly lower than their IC50s. We also measured MDT‐637 IC50s in 3 lab strains and 4 clinical strains. The IC50s ranged from 0.36 to 3.4 ng/mL. Achievable human MDT‐637 concentrations in respiratory secretions exceed the IC50s by factors from hundreds to thousands of times greater than does ribavirin. Furthermore, MDT‐637 has broad in vitro antiviral activity on clinical strains of different RSV genotypes and clades. Together, these data imply that MDT‐637 may produce a superior clinical effect compared to ribavirin on natural RSV infections.
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Affiliation(s)
- Young-In Kim
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA.,Children's Foundation Research Institute at Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Rajat Pareek
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA.,Children's Foundation Research Institute at Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Ryan Murphy
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA.,College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Lisa Harrison
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA.,Children's Foundation Research Institute at Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Eric Farrell
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Robert Cook
- Teva Global Respiratory R&D, Teva Pharmaceuticals, Monmouth Junction, NJ, USA
| | - John DeVincenzo
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA.,Children's Foundation Research Institute at Le Bonheur Children's Hospital, Memphis, TN, USA.,College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Microbiology, Immunology, and Biochemistry, University of Tennessee Health Science Center, Memphis, TN, USA
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7
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Abstract
BACKGROUND Bronchiolitis is the leading cause of hospitalisation among infants in high-income countries. Acute viral bronchiolitis is associated with airway obstruction and turbulent gas flow. Heliox, a mixture of oxygen and the inert gas helium, may improve gas flow through high-resistance airways and decrease the work of breathing. In this review, we selected trials that objectively assessed the effect of the addition of heliox to standard medical care for acute bronchiolitis. OBJECTIVES To assess heliox inhalation therapy in addition to standard medical care for acute bronchiolitis in infants with respiratory distress, as measured by clinical endpoints (in particular the rate of endotracheal intubation, the rate of emergency department discharge, the length of treatment for respiratory distress) and pulmonary function testing (mainly clinical respiratory scores). SEARCH METHODS We searched CENTRAL (2015, Issue 2), MEDLINE (1966 to March week 3, 2015), EMBASE (1974 to March 2015), LILACS (1982 to March 2015) and the National Institutes of Health (NIH) website (May 2009). SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs of heliox in infants with acute bronchiolitis. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed trial quality. MAIN RESULTS We included seven trials involving 447 infants younger than two years with respiratory distress secondary to viral bronchiolitis. All children were recruited from a paediatric intensive care unit (PICU; 378 infants), except in one trial (emergency department; 69 infants). All children were younger than two (under nine months in two trials and under three months in one trial). Positive tests for respiratory syncytial virus (RSV) were required for inclusion in five trials. The two other trials were carried out in the bronchiolitis seasons. Seven different protocols were used for inhalation therapy with heliox.When heliox was used in the PICU, we observed no significant reduction in the rate of intubation: risk ratio (RR) 2.73 (95% confidence interval (CI) 0.96 to 7.75, four trials, 408 infants, low quality evidence). When heliox inhalation was used in the emergency department, we observed no increase in the rate of discharge: RR 0.51 (95% CI 0.17 to 1.55, one trial, 69 infants, moderate quality evidence).There was no decrease in the length of treatment for respiratory distress: mean difference (MD) -0.19 days (95% CI -0.56 to 0.19, two trials, 320 infants, moderate quality evidence). However, in the subgroup of infants who were started on nasal continuous positive airway pressure (nCPAP) right from the start, because of severe respiratory distress, heliox therapy reduced the length of treatment: MD -0.76 days (95% CI -1.45 to -0.08, one trial, 21 infants, low quality evidence). No adverse events related to heliox inhalation were reported.We found that infants treated with heliox inhalation had a significantly lower mean clinical respiratory score in the first hour after starting treatment when compared to those treated with air or oxygen inhalation: MD -1.04 (95% CI -1.60 to -0.48, four trials, 138 infants, moderate quality evidence). This outcome had statistical heterogeneity, which remained even after removing the study using a standard high-concentration reservoir mask. Several factors may explain this heterogeneity, including first the limited number of patients in each trial, and the wide differences in the baseline severity of disease between studies, with the modified Wood Clinical Asthma Score (m-WCAS) in infants treated with heliox ranging from less than two to more than seven. AUTHORS' CONCLUSIONS Current evidence suggests that the addition of heliox therapy may significantly reduce a clinical score evaluating respiratory distress in the first hour after starting treatment in infants with acute RSV bronchiolitis. We noticed this beneficial effect regardless of which heliox inhalation protocol was used. Nevertheless, there was no reduction in the rate of intubation, in the rate of emergency department discharge, or in the length of treatment for respiratory distress. Heliox could reduce the length of treatment in infants requiring CPAP for severe respiratory distress. Further studies with homogeneous logistics in their heliox application are needed. Inclusion criteria must include a clinical severity score that reflects severe respiratory distress to avoid inclusion of children with mild bronchiolitis who may not benefit from heliox inhalation. Such studies would provide the necessary information as to the appropriate place for heliox in the therapeutic schedule for severe bronchiolitis.
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Affiliation(s)
- Jean‐Michel Liet
- Hôpital Mère‐Enfant, CHU de NantesPediatric Intensive Care Unit38 Boulevard Jean‐MonnetFaïencerieNantesFrance44093
| | | | - Vineet Gupta
- Moses Cone HospitalPediatric Critical Care Medicine1200 N. Elm StreetGreensboroNCUSA27401
| | - Gilles Cambonie
- Hôpital Arnaud de VilleneuveService de Réanimation Pédiatrique et Néonatale, Pédiatrie II371 av du Doyen Gaston GiraudMontpellier CEDEX 5France34295
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Beurskens CJP, Wösten-van Asperen RM, Preckel B, Juffermans NP. The potential of heliox as a therapy for acute respiratory distress syndrome in adults and children: a descriptive review. Respiration 2015; 89:166-74. [PMID: 25662070 DOI: 10.1159/000369472] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 10/28/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In neonatal respiratory distress syndrome (RDS) and acute RDS (ARDS) mechanical ventilation is often necessary to manage hypoxia, whilst protecting the lungs through lower volume ventilation and permissive hypercapnia. Mechanical ventilation can, however, induce or aggravate the lung injury caused by the respiratory distress. Helium, in a gas mixture with oxygen (heliox), has a low density and can reduce the flow in narrow airways and allow for lower driving pressures. OBJECTIVES The aim of this study was to review preclinical and clinical studies of the use of heliox ventilation in acute lung injury associated with respiratory failure. METHODS A systematic search was executed in the PubMed and EMBASE databases, with search terms referring to ARDS or an acute lung injury condition associated with respiratory failure and the corresponding intervention. RESULTS A total of 576 papers were retrieved. After the majority had been excluded 20 papers remained, of which 6 articles described animal models (3 paediatric; 3 adult animal models) and 14 were clinical studies, of which 12 described paediatric patient populations and 2 adult patient populations. In both paediatric and adult animal models, heliox improved gas exchange while allowing for less invasive ventilation in a wide variety of models using different ventilation modes. Clinical studies show a reduction in the work of breathing during heliox ventilation, with a concomitant increase in pH and decrease in PaCO2 levels compared to oxygen ventilation. CONCLUSIONS Although evidence so far is limited, there may be a rationale for heliox ventilation in ARDS as an intervention to improve ventilation and reduce the work of breathing.
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Affiliation(s)
- Charlotte J P Beurskens
- Laboratory of Experimental Intensive Care and Anaesthesiology, University of Amsterdam, Amsterdam, The Netherlands
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Bronchiolitis. PEDIATRIC AND NEONATAL MECHANICAL VENTILATION 2015. [PMCID: PMC7122073 DOI: 10.1007/978-3-642-01219-8_50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Everyone on the planet is exposed to respiratory syncytial virus (RSV) infection by the age of 2 years. Most infants admitted to the pediatric intensive care unit (PICU) for respiratory support during this infection are previously healthy, but their principal risk for needing PICU treatment is young age. That is, if you are born in October/November in the northern hemisphere, then your first winter exposure to RSV is likely to be when you are less than 4 months of age and vulnerable because of poor respiratory mechanical reserve (Alonso et al. 2007). However, if you are born in May/June, then you will be 7–8 months during your first winter exposure to RSV, much bigger and stronger and have more efficient thoracic and diaphragmatic mechanics. In the PICU, the main predictors of severe outcome in previously well infants appear to be young age, presence of apnea, and pulmonary consolidation on admission chest radiograph (Tasker et al. 2000; Lopez Guinea et al. 2007). Taken together, we can say that more severe RSV bronchiolitis in PICU practice is typically a problem of pulmonary consolidation, poor respiratory mechanics, and poor reserve, in the younger infant.
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Chowdhury MM, McKenzie SA, Pearson CC, Carr S, Pao C, Shah AR, Reus E, Eliahoo J, Gordon F, Bland H, Habibi P. Heliox therapy in bronchiolitis: phase III multicenter double-blind randomized controlled trial. Pediatrics 2013; 131:661-9. [PMID: 23509160 DOI: 10.1542/peds.2012-1317] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Supportive care remains the mainstay of therapy in bronchiolitis. Earlier studies suggest that helium-oxygen therapy may be beneficial, but evidence is limited. We aimed to compare efficacy of 2 treatment gases, Heliox and Airox (21% oxygen + 79% helium or nitrogen, respectively), on length of hospital treatment for bronchiolitis. METHODS This was a multicenter randomized blinded controlled trial of 319 bronchiolitic infant subjects randomly assigned to either gas; 281 subjects completed the study (140 Heliox, 141 Airox), whose data was analyzed. Treatment was delivered via facemask (nasal cannula, if the facemask intolerant) ± continuous positive airway pressure (CPAP). Severe bronchiolitics received CPAP from the start. Primary end point was length of treatment (LoT) required to alleviate hypoxia and respiratory distress. Secondary end-points were proportion of subjects needing CPAP; CPAP (LoT); and change in respiratory distress score. RESULTS Analysis by intention to treat (all subjects); median LoT (inter-quartile range, days): Heliox 1.90 (1.08-3.17), Airox 1.87 (1.11-3.34), P = .41. Facemask tolerant subgroup: Heliox 1.46 (0.85-1.95), Airox 2.01 (0.93-2.86), P = .03. Nasal cannula subgroup: Heliox 2.51 (1.21-4.32), Airox 2.81 (1.45-4.78), P = .53. Subgroup started on CPAP: Heliox 1.55 (1.38-2.01), Airox 2.26 (1.84-2.73), P = .02. Proportion of subjects needing CPAP: Heliox 17%, Airox 19%, O.R. 0.87 (0.47-1.60), P = .76. Heliox reduced respiratory distress score after 8 hours (mixed models estimate, -0.1298; P < .001). The effect was greater for facemask compared with nasal cannula (mixed models estimate, 0.093; P = .04). CONCLUSIONS Heliox therapy does not reduce LoT unless given via a tight-fitting facemask or CPAP. Nasal cannula heliox therapy is ineffective.
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Affiliation(s)
- Mina M Chowdhury
- Department of Pediatrics, Wright Fleming Institute, Imperial College, London, United Kingdom
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Wright M, Mullett CJ, Piedimonte G. Pharmacological management of acute bronchiolitis. Ther Clin Risk Manag 2011; 4:895-903. [PMID: 19209271 PMCID: PMC2621418 DOI: 10.2147/tcrm.s1556] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This article reviews the current knowledge base related to the pharmacological treatments for acute bronchiolitis. Bronchiolitis is a common lower respiratory illness affecting infants worldwide. The mainstays of therapy include airway support, supplemental oxygen, and support of fluids and nutrition. Frequently tried pharmacological interventions, such as ribavirin, nebulized bronchodilators, and systemic corticosteroids, have not been proven to benefit patients with bronchiolitis. Antibiotics do not improve the clinical course of patients with bronchiolitis, and should be used only in those patients with proven concurrent bacterial infection. Exogenous surfactant and heliox therapy also cannot be recommended for routine use, but surfactant replacement holds promise and should be further studied.
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Affiliation(s)
- Melvin Wright
- Department of Pediatrics, West Virginia University School of Medicine, Morgantown, WV, USA
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Wright M, Piedimonte G. Respiratory syncytial virus prevention and therapy: past, present, and future. Pediatr Pulmonol 2011; 46:324-47. [PMID: 21438168 DOI: 10.1002/ppul.21377] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Revised: 08/24/2010] [Accepted: 08/29/2010] [Indexed: 11/06/2022]
Abstract
Respiratory syncytial virus (RSV) is the most common respiratory pathogen in infants and young children worldwide. More than 50 years after its discovery, and despite relentless attempts to identify pharmacological therapies to improve the clinical course and outcomes of this disease, the most effective therapy remains supportive care. Although the quest for a safe and effective vaccine remains unsuccessful, pediatricians practicing during the past decade have been able to protect at least the more vulnerable patients with safe and effective passive prophylaxis. This review summarizes the history, microbiology, epidemiology, pathophysiology, and clinical manifestations of this infection in order to provide the reader with the background information necessary to fully appreciate the many challenges presented by the clinical management of young children with bronchiolitis. The last part of this article attempts an evidence-based review of the pharmacologic strategies currently available and those being evaluated, intentionally omitting highly experimental approaches not yet tested in clinical trials and, therefore, not likely to become available in the foreseeable future.
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Affiliation(s)
- Melvin Wright
- Department of Pediatrics and Pediatric Research Institute, West Virginia University School of Medicine, Morgantown, West Virginia 26506-9214, USA
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Szczapa T, Gadzinowski J. Use of heliox in the management of neonates with meconium aspiration syndrome. Neonatology 2011; 100:265-70. [PMID: 21701217 DOI: 10.1159/000327531] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Accepted: 03/08/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND Helium-oxygen mixture (heliox) ventilation has been known as an alternative treatment in patients with airway obstruction. Because of the physical properties of heliox, mechanical ventilation with this gas mixture may offer advantages in the management of respiratory failure associated with meconium aspiration syndrome (MAS). OBJECTIVES The purpose of this pilot study was to assess the effect of short-term mechanical ventilation with heliox in newborns with MAS on vital signs, oxygenation, acid-base balance and respiratory function parameters. METHODS The study was carried out in newborns with respiratory failure requiring mechanical ventilation due to MAS. Eight patients were ventilated using pressure-controlled synchronized intermittent mandatory ventilation. Parameters of respiratory function, oxygenation, acid-base balance and vital signs were recorded at baseline, then twice during 1 h of heliox ventilation and finally twice during 1 h after switching back to air-oxygen ventilation. RESULTS Mechanical ventilation with heliox did not affect vital signs and the infants' clinical condition remained stable during the study. Heliox ventilation was associated with a nonsignificant increase in tidal volume, minute ventilation and peak expiratory flow rate values. Mechanical ventilation with heliox allowed the use of significantly lower FiO(2), with a significant decrease in alveolar-arterial oxygen tension difference and a decrease in the oxygenation index which was not statistically significant. There was also a significant increase in the PaO(2)/FiO(2) ratio during heliox ventilation. CONCLUSIONS Ventilation with a helium and oxygen mixture had a positive effect on the selected parameters of oxygenation, while its effects on other respiratory parameters were relatively small.
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Affiliation(s)
- Tomasz Szczapa
- Department of Neonatology, Poznań University of Medical Sciences, Poznań, Poland.
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14
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Abstract
BACKGROUND Acute viral bronchiolitis is associated with airway obstruction and turbulent gas flow. Heliox, a mixture of oxygen and the inert gas helium, may improve gas flow through high-resistance airways and decrease the work of breathing. OBJECTIVES To assess heliox in addition to standard medical care for acute bronchiolitis in infants. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 2), which includes the Cochrane Acute Respiratory Infections (ARI) Group's Specialised Register, MEDLINE (1966 to June 2009), EMBASE (June 2009), LILACS (May 2009) and the NIH web site (May 2009). SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs of heliox in infants with acute bronchiolitis. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed trial quality. We pooled data from individual trials. MAIN RESULTS We included four trials involving 84 infants under two years of age with respiratory distress secondary to bronchiolitis caused by respiratory syncytial virus (RSV) and requiring paediatric intensive care unit (PICU) hospitalisation. We found that infants treated with heliox inhalation had a significantly lower mean clinical respiratory score in the first hour after starting treatment when compared to those treated with air or oxygen inhalation (mean difference (MD) -1.15, 95% confidence interval (CI) -1.98 to -0.33, P = 0.006, n = 69). There was no clinically significant reduction in the rate of intubation (risk ratio (RR) 1.38, 95% CI 0.41 to 4.56, P = 0.60, n = 58), in the need for mechanical ventilation (RR 1.11, 95% CI 0.36 to 3.38, P = 0.86, n = 58), or in the length of stay in a PICU (MD = -0.15 days, 95% CI -0.92 to 0.61, P = 0.69, n = 58). No adverse events related to heliox inhalation were reported. AUTHORS' CONCLUSIONS Current evidence suggests that the addition of heliox therapy may significantly reduce a clinical score evaluating respiratory distress in the first hour after starting treatment in infants with acute RSV bronchiolitis. Nevertheless, there was no reduction in the rate of intubation, in the need for mechanical ventilation, or in the length of PICU stay. Further studies with homogeneous logistics in their heliox application are needed. Such studies would provide necessary information as to the appropriate place for heliox in the therapeutic schedule for severe bronchiolitis.
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Affiliation(s)
- Jean-Michel Liet
- Pediatric Intensive Care Unit, Hôpital Mère-Enfant, CHU de Nantes, 38 Boulevard Jean-Monnet, Faïencerie, Nantes, France, 44093
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González de Dios J, Ochoa Sangrador C. Conferencia de Consenso sobre bronquiolitis aguda (IV): tratamiento de la bronquiolitis aguda. Revisión de la evidencia científica. An Pediatr (Barc) 2010; 72:285.e1-285.e42. [DOI: 10.1016/j.anpedi.2009.12.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Accepted: 12/14/2009] [Indexed: 11/25/2022] Open
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Abstract
Helium-oxygen (heliox) gas mixtures have been studied for over 70 years as an adjunctive therapy for airway obstruction in a variety of respiratory diseases. The medical use of heliox is based on the physical properties of helium as its low density makes it advantageous in promoting more efficient flow through narrowed passages. Clinical evidence of the efficacy of heliox in treating paediatric respiratory diseases is increasing in the medical literature. This article consists of a comprehensive review of the literature investigating the utility of heliox in the treatment of paediatric respiratory disorders, including upper and lower airway obstruction, mechanical ventilation, and aerosol delivery.
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Affiliation(s)
- Marie D Frazier
- Division of Critical Care, Marshall University, Huntington, WV 25701, USA.
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17
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Chidgey SM, Broadley KJ. Respiratory syncytial virus infections: characteristics and treatment. J Pharm Pharmacol 2010; 57:1371-81. [PMID: 16259768 DOI: 10.1211/jpp.57.11.0001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Abstract
In this review, we describe the history, epidemiology and clinical manifestations of infections attributed to respiratory syncytial virus (RSV) in children. At present, no cure exists for RSV infection but commonly employed palliative treatments include oxygen and inhaled β2-adrenoceptor agonists, such as salbutamol, to relieve the wheezing and increased bronchiolar smooth muscle constriction. Adrenaline (epinephrine) has been found to be superior to the selective β2-adrenoceptor agonists. Oral or inhaled corticosteroids should counteract the inflammatory response to RSV infection but their effectiveness is controversial. Inhaled ribavirin is the only licensed antiviral product approved for the treatment of RSV lower respiratory-tract infection in hospitalized children, although its use is now restricted to high-risk infants. Other treatments considered are nasopharyngeal suctioning, surfactant therapy, recombinant human deoxyribonuclease I, heliox (helium:oxygen) and inhaled nitric oxide. Prevention of infection by RSV antibodies is another strategy and, currently, palivizumab is the only safe, effective and convenient preventative treatment for RSV disease in high-risk populations of infants and young children. Its cost-effectiveness, however, has been questioned. Both live attenuated and subunit vaccines against RSV infection have been developed but so far there is no safe and effective vaccine available. Finding effective treatments and prophylactic measures remains a major challenge for the future.
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Affiliation(s)
- Sharon M Chidgey
- Department of Pharmacology, Welsh School of Pharmacy, Cardiff University, King Edward VII Avenue, Cardiff CF10 3XF, UK
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Abstract
Respiratory syncytial virus (RSV) lower respiratory tract disease may present as bronchiolitis, an obstructive lung disease with hyperinflation, or pneumonitis, a restrictive parenchymal disease with diffuse consolidation, a large intrapulmonary shunt and acute respiratory distress syndrome (ARDS). Although a significant proportion of those admitted to hospital will require some form of respiratory support, there have been few randomised studies to determine which is the most beneficial. Studies on the use of continuous positive airway pressure (CPAP), heliox, inhaled nitric oxide, and natural surfactant are reviewed. Current practice regarding ventilator support is largely based on clinical judgment and case reports. Multicentre randomised trials with long-term follow-ups are urgently required.
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Affiliation(s)
- Anne Greenough
- Division of Asthma, Allergy and Lung Biology, King's College London School of Medicine at Guy's, King's College and St. Thomas' Hospitals, London, UK.
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Kneyber MCJ, van Heerde M, Twisk JWR, Plötz FB, Markhors DG. Heliox reduces respiratory system resistance in respiratory syncytial virus induced respiratory failure. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R71. [PMID: 19450268 PMCID: PMC2717432 DOI: 10.1186/cc7880] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2008] [Revised: 04/20/2009] [Accepted: 05/15/2009] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Respiratory syncytial virus (RSV) lower respiratory tract disease is characterised by narrowing of the airways resulting in increased airway resistance, air-trapping and respiratory acidosis. These problems might be overcome using helium-oxygen gas mixture. However, the effect of mechanical ventilation with heliox in these patients is unclear. The objective of this prospective cross-over study was to determine the effects of mechanical ventilation with heliox 60/40 versus conventional gas on respiratory system resistance, air-trapping and CO2 removal. METHODS Mechanically ventilated, sedated and paralyzed infants with proven RSV were enrolled within 24 hours after paediatric intensive care unit (PICU)admission. At T = 0, respiratory system mechanics including respiratory system compliance and resistance, and peak expiratory flow rate were measured with the AVEA ventilator. The measurements were repeated at each interval (after 30 minutes of ventilation with heliox, after 30 minutes of ventilation with nitrox and again after 30 minutes of ventilation with heliox). Indices of gas exchange (ventilation and oxygenation index) were calculated at each interval. Air-trapping (defined by relative change in end-expiratory lung volume) was determined by electrical impedance tomography (EIT) at each interval. RESULTS Thirteen infants were enrolled. In nine, EIT measurements were performed. Mechanical ventilation with heliox significantly decreased respiratory system resistance. This was not accompanied by an improved CO2 elimination, decreased peak expiratory flow rate or decreased end-expiratory lung volume. Importantly, oxygenation remained unaltered throughout the experimental protocol. CONCLUSIONS Respiratory system resistance is significantly decreased by mechanical ventilation with heliox (ISCRTN98152468).
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Affiliation(s)
- Martin C J Kneyber
- Department of Pediatric Intensive Care, VU university medical center, Amsterdam, The Netherlands.
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20
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Iglesias Fernández C, Huidobro Fernández B, Míguez Navarro C, Guerrero Soler M, Vázquez López P, Marañón Pardillo R. [Heliox-driven bronchodilator nebulization in the treatment of infants with bronchiolitis]. An Pediatr (Barc) 2008; 70:40-4. [PMID: 19174118 DOI: 10.1016/j.anpedi.2008.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2007] [Revised: 07/14/2008] [Accepted: 08/02/2008] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Heliox is a helium-oxygen mixture which improves laminar flow and decreases airway resistance and the work of breathing. The aim of this study was to assess the effects of salbutamol or epinephrine nebulization driven by heliox in infants with moderate-to-severe bronchiolitis. MATERIALS AND METHODS This prospective, observational, interventional, controlled and randomized study included ninety-six children who came to our pediatric emergency department with first episode of moderate-to-severe bronchiolitis. The patients were randomized to receive salbutamol or epinephrine nebulized with either oxygen (control group) or heliox (70% helium and 30% oxygen) as the driving gas. Heart rate, respiratory rate, pulse oximetry oxygen saturation and clinical score were measured before and after the treatment period. We also reported hospitalization rates and the number of patients who returned to the emergency department in the following seventy two hours. RESULTS There were no significant differences between both groups. The only statistically significant difference was that, in the heliox group, patients with severe bronchiolitis needed a lower number of nebulizations than infants in the control group. CONCLUSIONS According to our study, heliox-driven salbutamol or epinephrine is not an effective therapy in patients with acute bronchiolitis.
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Affiliation(s)
- C Iglesias Fernández
- Sección de Urgencias de Pediatría, Hospital General Universitario Gregorio Marañón, Madrid, España.
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21
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Molloy EJ, McCallion N, O'Donnell CPF, Davis PG. Heliox for prevention of morbidity and mortality in ventilated newborn infants. Hippokratia 2008. [DOI: 10.1002/14651858.cd007304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Eleanor J Molloy
- National Maternity Hospital; Neonatal Unit; Holles Street Dublin 2 Ireland
| | - Naomi McCallion
- National Maternity Hospital; Neonatal Unit; Holles Street Dublin 2 Ireland
| | - Colm PF O'Donnell
- National Maternity Hospital; Neonatal Unit; Holles Street Dublin 2 Ireland
| | - Peter G Davis
- Royal Women's Hospital; Department of Obstetrics and Gynaecology; 132 Grattan Street Carlton Victoria Australia 3053
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22
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Kissoon N, Rimensberger PC, Bohn D. Ventilation strategies and adjunctive therapy in severe lung disease. Pediatr Clin North Am 2008; 55:709-33, xii. [PMID: 18501762 DOI: 10.1016/j.pcl.2008.02.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Respiratory failure caused by severe lung disease is a common reason for admission to the pediatric and neonatal intensive care units. Efforts to decrease morbidity and mortality have fueled investigations into innovative methods of ventilation, kinder gentler ventilation techniques, pharmacotherapeutic adjuncts, and extracorporeal life support modalities. This article discusses the rationale for and experience with some of these techniques.
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Affiliation(s)
- Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Children's Hospital, Room K4-105, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada.
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23
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Kneyber MCJ, Plötz FB. Respiratory Syncytial Virus (RSV) in the Pediatric Intensive Care Unit. Intensive Care Med 2007. [DOI: 10.1007/978-0-387-49518-7_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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24
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Iglesias Fernández C, López-Herce Cid J, Mencía Bartolomé S, Santiago Lozano MJ, Moral Torrero R, Carrillo Alvarez A. Eficacia del tratamiento con heliox en niños con insuficiencia respiratoria. An Pediatr (Barc) 2007; 66:240-7. [PMID: 17349249 DOI: 10.1157/13099685] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To analyze response to heliox therapy in critically ill infants and children with upper and/or lower airway respiratory insufficiency. PATIENTS AND METHODS Sixty-five patients, aged between 12 days and 8 years old, treated with heliox through facial mask, nasal prongs or non-invasive ventilation were studied. Diagnoses were bronchiolitis (25), upper postextubation respiratory insufficiency (19), respiratory insufficiency after airway surgery (14), and croup-laryngotracheomalacia (7). Response to heliox treatment was measured by the change in clinical scores, respiratory rate, heart rate, pulse oximetry, blood gas analysis, and the need for non-invasive and invasive mechanical ventilation. RESULTS Fifty-four patients (83.1 %) improved after heliox therapy, with statistically significant differences in clinical score (from 8.7 to 5.5), respiratory rate (from 51.4 to 38.8 rpm), and heart rate (from 161.6 to 145.6 bpm). No changes were observed in saturation or blood gas analysis. After heliox therapy, 29.8 % of patients required non-invasive ventilation and 26.5 % required intubation. Patients with bronchiolitis and those aged less than 1 year had a lesser response to heliox therapy and more frequently required non-invasive ventilation. No significant differences were found in intubation requirements. No adverse effects were observed. CONCLUSIONS Heliox therapy improved clinical scores in infants and children with upper and lower airway respiratory insufficiency, but a significant percentage of patients needed non-invasive or invasive mechanical ventilation.
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Affiliation(s)
- C Iglesias Fernández
- Sección de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, España
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Kneyber MCJ, van Heerde M, Markhorst DG, Plötz FB. Mechanical ventilation with heliox decreases respiratory system resistance and facilitates CO2 removal in obstructive airway disease. Intensive Care Med 2006; 32:1676-7. [PMID: 16927073 DOI: 10.1007/s00134-006-0348-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2006] [Indexed: 11/26/2022]
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Martinón-Torres F, Rodríguez-Núñez A, Martinón-Sánchez JM. Nasal continuous positive airway pressure with heliox in infants with acute bronchiolitis. Respir Med 2006; 100:1458-62. [PMID: 16406757 DOI: 10.1016/j.rmed.2005.11.026] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2005] [Revised: 11/17/2005] [Accepted: 11/29/2005] [Indexed: 11/19/2022]
Abstract
This is the first study aiming to assess the effects of heliox in combination with nasal continuous positive airway pressure (Hx-nCPAP) as a rescue treatment in infants with refractory acute bronchiolitis. Fifteen out of 78 infants with acute bronchiolitis consecutively admitted to PICU fulfilled the inclusion criteria: clinical score>or=5 or arterial oxygen saturation (SatO2)<or=92% or PCO2>50 mmHg, despite supportive therapy, nebulized L-epinephrine, and heliox therapy through non-rebreathing reservoir facemask. Hx-nCPAP was added as a rescue treatment. Baseline mean (standard deviation) values were: clinical score of 7.4 (1.2) points; PCO2 of 63.8 (12) mmHg; respiratory rate (RR) of 66.4 (9.9); and SatO2 of 88.6 (4.7)%. Clinical score, PCO2, RR and SatO2 improved during the study time (P<0.05). After 1 h the mean clinical score decreased by 1.5 points, with a total average decrease of 3.5 points at the end of the study period. The mean PCO2 diminished by 9 and 25 mmHg, after 1 and 48 h, respectively. The mean RR decreased 13 rpm after 1 h and 30 rpm after 48 h. The Hx-nCPAP total duration ranged from 2 to 14 days. Only one patient required endotracheal intubation. No adverse effects were detected. All patients recovered fully. In conclusion, Hx-nCPAP improved the clinical score, decreased the tachypnea and enhanced the CO2 elimination of infants with refractory acute bronchiolitis within 1h of administration, in a safe and non-invasive manner. Hx-nCPAP might reduce the need for endotracheal intubation. Further studies are needed.
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Affiliation(s)
- Federico Martinón-Torres
- Pediatric Emergency and Critical Care Division, Department of Pediatrics, Complejo Hospitalario Universitario de Santiago de Compostela, A Choupana s.n. 15705 Santiago de Compostela, Spain.
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Piastra M, Caresta E, Tempera A, Langer A, Zorzi G, Pulitanò S, Chiaretti A, Genovese O, Viola L, Tortorolo L, Polidori G. Sharing features of uncommon respiratory syncytial virus complications in infants. Pediatr Emerg Care 2006; 22:574-8. [PMID: 16912626 DOI: 10.1097/01.pec.0000230704.74022.3e] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We describe 4 nonconsecutive cases of infants admitted to Catholic University pediatric intensive care unit (PICU) because of complicated respiratory syncytial virus (RSV) infection during winter RSV outbreaks from the year 2000 to the year 2003. A hyponatremic epileptic status (as in the first case) has been reported by several authors as a rare RSV complication, potentially leading to death. The second infant developed a serious pulmonary edema after a subglottic obstruction (croup) associated with RSV infection. The remaining 2 infants developed a pneumothorax and subcutaneous emphysema while breathing spontaneously during an RSV bronchiolitis. In all infants, a full recovery and PICU discharge was achieved despite the need for mechanical ventilation in cases 1 and 2. Increased intrapleural negative pressure or its combination with hypoxia/hypercapnia has been suggested as the common factor possibly joining these different clinical pictures.
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Affiliation(s)
- Marco Piastra
- Pediatric Intensive Care Unit, Catholic University Medical School, Gemelli Hospital, Rome, Italy.
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Miller TL, Singhaus CJ, Sherman TI, Greenspan JS, Shaffer TH. Physiologic implications of helium as a carrier gas for inhaled nitric oxide in a neonatal model of Bethanecol-induced bronchoconstriction. Pediatr Crit Care Med 2006; 7:159-64. [PMID: 16531948 DOI: 10.1097/01.pcc.0000200942.23574.ca] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare heliox to nitrogen-oxygen (nitrox) as a carrier gas for inducible nitric oxide (iNO) in the presence of pharmacologically inhaled bronchoconstriction. We hypothesized that respiratory resistance and gas exchange would improve when iNO is delivered with heliox. DESIGN Interventional laboratory study. SETTING An academic medical research facility in the northeastern United States. SUBJECTS Sedated, ventilated newborn piglets. INTERVENTIONS Newborn piglets (n = 16; 2.3 +/- 0.1 kg) were placed on a flow-controlled ventilator and given intravenous Bethanecol (2 x 1 mg/kg followed by 1 mg/kg/hr) to induce bronchoconstriction. Piglets were randomized to heliox or nitrox (Fio2 = 0.3) and given 80 ppm iNO. MEASUREMENTS AND MAIN RESULTS Hemodynamics, blood chemistry, and pulmonary mechanics were recorded at 30-min intervals for 2 hrs. Bethanecol dosing increased inspiratory respiratory resistance (cm H2O/L/min; p < .01) and decreased respiratory compliance (mL/cm H2O/kg; p < .01). Following carrier gas assignment, hemodynamics and respiratory compliance were similar between groups and respiratory resistance decreased (p < .01) in the heliox group. Over 2 hrs with iNO therapy, Paco2 increased (p < .01) whereas blood pH decreased (p < .01) in the heliox group. Respiratory resistance trended downward, oxygenation index improved (p < .01), and blood methemoglobin levels trended higher for nitrox compared with heliox. CONCLUSIONS The INOvent was effective for controlling heliox delivery of iNO. Despite marked reduction in respiratory resistance with heliox gas ventilation in a neonatal model of pharmacologic bronchoconstriction, nitrox might perform better as a delivery vehicle for iNO.
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Affiliation(s)
- Thomas L Miller
- Nemours Research Lung Center, Nemours Children's Clinic-Wilmington of the Nemours Foundation, Alfred I. duPont Children's Hospital, Wilmington, DE, USA
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Abstract
OBJECTIVE To provide a comprehensive, evidence-based review of helium-oxygen gas mixtures (heliox) in the management of pediatric respiratory diseases. DATA SOURCE A thorough, computerized bibliographic search of the preclinical and clinical literature regarding the properties of helium and its application in pediatric respiratory disease states. DATA SYNTHESIS After an overview of the potential benefits and technical aspects of helium-oxygen gas mixtures, the role of heliox is addressed for asthma, aerosolized medication delivery, upper airway obstruction, postextubation stridor, croup, bronchiolitis, and high-frequency ventilation. The available data are objectively classified based on the value of the therapy or intervention as determined by the study design from which the data are obtained. CONCLUSIONS Heliox administration is most effective during conditions involving density-dependent increases in airway resistance, especially when used early in an acute disease process. Any beneficial effect of heliox should become evident in a relatively short period of time. The medical literature supports the use of heliox to relieve respiratory distress, decrease the work of breathing, and improve gas exchange. No adverse effects of heliox have been reported. However, heliox must be administered with vigilance and continuous monitoring to avoid technical complications.
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Affiliation(s)
- Vineet K Gupta
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA.
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30
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Berkenbosch JW, Grueber RE, Graff GR, Tobias JD. Patterns of helium-oxygen (heliox) usage in the critical care environment. J Intensive Care Med 2005; 19:335-44. [PMID: 15523119 DOI: 10.1177/0885066604269670] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this study was to describe the patterns of heliox use in critical care units of an academic medical center. The design was a prospective case series involving 7 critical care units of an academic medical center. All patients receiving heliox therapy over a 4-year period were studied, with prospective recording of patient demographics and the location, mode, indication for, and duration of heliox use. Use pattern comparisons based on anatomic location (upper vs lower airway) and age group (pediatric vs adult) were performed by alpha(2) analysis and unpaired Student t test. Eighty-nine patients, aged 17.4 +/- 20.9 years, received heliox for 30.5 +/- 44.6 hours on 92 occasions. Pediatric (</= 18 years) applications accounted for 72.8% of heliox use. Use was greater in frequency and scope during the final 2 study years, particularly in adults. Applications were split between upper airway (47%) and lower airway (53%) disorders. Airway manipulation was required in more adults (7/16) than in children (3/27) with upper airway obstruction (P < .05). The use patterns mirrored current literature emphases on postextubation stridor and asthma. This is the first description of heliox use patterns in the tertiary care critical care environment. Heliox use may be as dependent on practitioner experience as on published data. As a benign and relatively inexpensive therapy, heliox use should continue to be attractive, although ongoing study regarding efficacy in a number of settings is indicated.
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Broughton S, Greenough A. Effectiveness of drug therapies to treat or prevent respiratory syncytial virus infection-related morbidity. Expert Opin Pharmacother 2003; 4:1801-8. [PMID: 14521489 DOI: 10.1517/14656566.4.10.1801] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Respiratory syncytial virus (RSV) infection causes a huge burden to the health service, as it results in a large number of in-patient days each year and increases the risk of asthma in childhood. In the acute phase, therapy is supportive as bronchodilators and corticosteroids have resulted, at best, only in short-term benefits; promising treatments for ventilated patients, such as exogenous surfactant, require further testing. Passive immunoprophylaxis reduces hospital admission in high risk groups. In the prevention of chronic respiratory morbidity following RSV infection, however, studies are needed to determine whether immunoprophylaxis will have a useful role and to identify which drug treatment will be most cost-effective.
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Affiliation(s)
- Simon Broughton
- Department of Child Health, Guy's King's and St Thomas' Medical School, 4th Floor Golden Jubilee Wing, King's College Hospital, London SE5 9RS, UK
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Abstract
This paper provides an update and critical review of available data on the treatment of acute viral bronchiolitis in previously healthy infants, with special focus on new or promising therapies. The main potential benefits of medical assistance in these patients reside in the careful monitoring of their clinical status, the maintenance of adequate hydration and oxygenation, the preservation of the airway opened and cleared of secretions and the option to perform parental education. There is no convincing evidence that any other form of therapy will reliably provide beneficial effects in infants with bronchiolitis and currently, any treatment beyond supportive care should be prescribed on a case-by-case basis with watchful appraisal of its effects. Therapies such as ribavirin, IFN, vitamin A, antibiotics, mist therapy or anticholinergics, have not demonstrated any measurable clinical effect. Several studies and meta-analyses with beta(2)-agonists and corticosteroids have failed to show any benefit of significant extent, however, physicians keep favouring their use. Presently, adrenaline has received rather consistent support from clinical trials but it is not yet widely prescribed. There are other therapeutic strategies, for instance, heliox, hypertonic saline, noninvasive ventilation, physical therapy techniques, thickened feeds or palivizumab that have shown promising potential benefits, but evidence supporting its use is still limited and further studies should be warranted. In the meantime, infants with acute viral bronchiolitis should be treated following evidence-based clinical practice guidelines, keeping the patient central in the process and being sensitive to social, cultural and familiar influences on their treatment strategy.
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Affiliation(s)
- Federico Martinón-Torres
- Department of Paediatrics, Universidad de Santiago de Compostela, Hospital Clínico Universitario de Santiago de Compostela, c/A choupana sn, 15706 Santiago de Compostela, Spain.
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Abd-Allah SA, Rogers MS, Terry M, Gross M, Perkin RM. Helium-oxygen therapy for pediatric acute severe asthma requiring mechanical ventilation. Pediatr Crit Care Med 2003; 4:353-7. [PMID: 12831419 DOI: 10.1097/01.pcc.0000074267.11280.78] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To illustrate the use of helium-oxygen gas mixtures as therapy for pediatric patients with acute severe asthma requiring conventional mechanical ventilation. DESIGN Retrospective review. SETTING Tertiary care children's teaching hospital. PATIENTS All mechanically ventilated patients with severe asthma admitted to the pediatric intensive care unit from August 1994 to October 2000. INTERVENTIONS Within 24 hrs of intubation or admission, patients were stabilized on volume ventilation, bronchodilator therapy, corticosteroids, and antibiotics when indicated. Hypercapnia was permitted while maintaining arterial blood gas pH > or =7.25. A helium-oxygen gas mixture then was begun with helium flow set at 5-7 L/min, and oxygen flow was titrated to maintain desired oxygen saturation. Only sedated, chemically paralyzed patients with adequate pre-helium-oxygen and post-helium-oxygen measurements were statistically analyzed. MEASUREMENTS AND MAIN RESULTS Twenty-eight mechanically ventilated patients with severe asthma placed on helium-oxygen gas mixtures were identified who met study entry criteria. Mean patient age was 8.8 yrs (range, 1.1-14.6). Before helium-oxygen therapy began, mean peak inspiratory pressure was 40.5 +/- 4.2 cm H(2)O, mean arterial blood gas pH was 7.26 +/- 0.05, and mean CO(2) partial pressure was 58.2 +/- 8.5 torr. After patients were placed on helium-oxygen therapy, there was a significant decrease in mean peak inspiratory pressure to 35.3 +/- 3.0 cm H(2)O. Mean pH increased significantly to 7.32 +/- 0.06, and mean partial pressure CO(2) decreased significantly to 50.5 +/- 7.4 torr. Initial mean inspired helium was 57 +/- 4% (range, 32-74). Mechanical ventilation days ranged from 1 to 23 days (mean, 5.0). Hospital stay ranged from 4 to 29 days (mean, 10.1), with an average pediatric intensive care unit stay of 6.9 days (range, 2-24). There were two incidences of pneumothorax. CONCLUSIONS In the pediatric patient with severe asthma requiring conventional mechanical ventilation, helium-oxygen administration appears to be a safe therapy and may assist in lowering peak inspiratory pressure and improving blood gas pH and partial pressure CO(2).
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Affiliation(s)
- Shamel A Abd-Allah
- Pediatric Critical Care Division and Respiratory Care Department, Loma Linda University School of Medicine, Loma Linda, CA, USA
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Jolliet P, Tassaux D. Usefulness of helium-oxygen mixtures in the treatment of mechanically ventilated patients. Curr Opin Crit Care 2003; 9:45-50. [PMID: 12548029 DOI: 10.1097/00075198-200302000-00009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The density of helium is markedly lower than that of air or any of its components, leading to a substantial decrease in airway resistance to flow when it is inhaled. In mechanically ventilated patients with obstructive airway disease, replacing the usual air-oxygen mixture with helium-oxygen has been shown to reduce dynamic hyperinflation and intrinsic positive end-expiratory pressure; to decrease lung inflation pressures, respiratory acidosis, and work of breathing; and to improve arterial blood gases. Aerosol delivery to distal airways is enhanced with helium-oxygen. Preliminary data also suggest that the use of helium-oxygen could be a valuable approach to decrease postextubation respiratory distress. However, interference with ventilator function and added costs are two major disadvantages of helium-oxygen. Hence, before its widespread use in mechanically ventilated patients can be recommended, studies are needed to determine whether these favorable short-term effects can influence patient outcome.
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Affiliation(s)
- Philippe Jolliet
- Divisions of Medical Intensive Care and Anesthesiology, University Hospital, Geneva, Switzerland.
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35
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Siddappa R, Dowhy MS, Rotta AT, Hernan LJ, Heard CMB, Fuhrman BP. Heliox enhances carbon dioxide clearance from lungs of normal rabbits during low bias flow oscillation. Pediatr Crit Care Med 2003; 4:89-93. [PMID: 12656551 DOI: 10.1097/00130478-200301000-00018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate carbon dioxide clearance in normal rabbits during high-frequency oscillatory ventilation with helium-oxygen mixtures by using a low bias flow oscillation (LBFO) system designed to conserve expensive gas. DESIGN A prospective, paired-controlled, interventional, in vivo animal laboratory study. SETTING Animal laboratory of a health science university. SUBJECTS Twelve New Zealand White rabbits. INTERVENTIONS Juvenile rabbits were anesthetized, paralyzed, and ventilated through a tracheostomy. LBFO was performed with a modified high-frequency oscillatory ventilation circuit that uses low bias flow (100 mL/kg) and a soda lime cartridge to clear carbon dioxide. LBFO-heliox trials were performed with 20%, 40%, 50%, 60%, and 70% helium (balanced with oxygen) for 30 mins. Each heliox trial was preceded by a paired control trial with 40% oxygen and 60% nitrogen for 30 mins. Ventilator settings in control and heliox trials were identical. During the second part of the study, four rabbits were made hypercapnic by decreasing the power (amplitude), and LBFO was performed with 70% helium against paired-control trials of 40% oxygen and 60% nitrogen. Arterial blood gases were measured at 15-min intervals and airway pressure amplitude was recorded. PaCO2 of control and heliox trials, alveolar PO2-PaO2 gradient of control, and 60% helium trials were compared by paired Student's t-test. MEASUREMENTS AND MAIN RESULTS At constant power, amplitude was unaffected by helium. Helium concentrations of 40%, 50%, 60%, and 70% decreased PaCO2 by 12%, 33%, 36%, and 46%, respectively. Alveolar PO2-PaO2 gradient was decreased by 40% during ventilation with 60% helium. Under hypercapnic conditions, 70% helium decreased PaCO2 by 20%. CONCLUSION Helium concentrations > or = 40% facilitate carbon dioxide clearance from lungs of normal rabbits during LBFO. This could be accomplished inexpensively with LBFO due to preservation of heliox when using this device.
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Affiliation(s)
- Rajashekhar Siddappa
- Division of Pediatric Critical Care, The Children's Hospital of Buffalo, State University of New York at Buffalo, USA.
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Leclerc F, Scalfaro P, Noizet O, Thumerelle C, Dorkenoo A, Fourier C. Mechanical ventilatory support in infants with respiratory syncytial virus infection. Pediatr Crit Care Med 2001; 2:197-204. [PMID: 12793941 DOI: 10.1097/00130478-200107000-00002] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE: To present a review of current knowledge of the use of mechanical ventilatory support in the management of infants with respiratory failure secondary to infection with respiratory syncytial virus (RSV). DATA SOURCES: MEDLINE and manual search for case reports and clinical trials that address management strategies for respiratory support of infants with RSV infection. Data Extraction and Synthesis: Critical appraisal of reported epidemiologic and clinical data regarding risk factors, pathophysiology, and efficacy of respiratory therapy. There is an increasing number of hospital admissions for RSV infection with a variable proportion of infants who need mechanical ventilatory support. The mortality rate is estimated to be <1% in infants without preexisting respiratory or cardiac disorders vs. <5% in those with preexisting respiratory or cardiac disorders. Optimal ventilator settings need to be refined according to the dominant obstructive or restrictive pattern with the aim to avoid barovolutrauma. The role of noninvasive ventilation and additional therapies (heliox, beta(2) agonists, surfactant) is not conclusively established. The indications for high-frequency oscillatory ventilation with the possible adjunction of inhaled nitric oxide deserve further study. Extracorporeal membrane oxygenation plays a minor role in severe cases that are refractory to conventional treatment. CONCLUSIONS: Conventional ventilation strategies are usually adequate for treating infants with severe RSV infection. Particular attention must be paid to the dominant pathophysiologic mechanism in a given condition. Prospective trials are needed to validate alternative therapeutic options and to improve the outcome of the rare but most severe cases that are difficult to control.
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Affiliation(s)
- F. Leclerc
- Service de Réanimation Pédiatrique, Hôpital Jeanne de Flandre, Lille-Cedex, France (Drs. Leclerc, Noizet, Thumerelle, Fourier, and Dorkenoo) and Soins intensifs médico-chirurgicaux de Pédiatrie, Département de Pédiatrie, Lausanne, Switzerland (Dr. Scalfaro)
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