Lung ultrasound score assessing the pulmonary edema in pediatric acute respiratory distress syndrome received continuous hemofiltration therapy: a prospective observational study

Tailoring ventilation and respiratory management in pediatric critical care: optimizing care with precision medicine

PURPOSE OF REVIEW

Critically ill children admitted to the intensive care unit frequently need respiratory care to support the lung function. Mechanical ventilation is a complex field with multiples parameters to set. The development of precision medicine will allow clinicians to personalize respiratory care and improve patients' outcomes.

RECENT FINDINGS

Lung and diaphragmatic ultrasound, electrical impedance tomography, neurally adjusted ventilatory assist ventilation, as well as the use of monitoring data in machine learning models are increasingly used to tailor care. Each modality offers insights into different aspects of the patient's respiratory system function and enables the adjustment of treatment to better support the patient's physiology. Precision medicine in respiratory care has been associated with decreased ventilation time, increased extubation and ventilation wean success and increased ability to identify phenotypes to guide treatment and predict outcomes. This review will focus on the use of precision medicine in the setting of pediatric acute respiratory distress syndrome, asthma, bronchiolitis, extubation readiness trials and ventilation weaning, ventilation acquired pneumonia and other respiratory tract infections.

SUMMARY

Precision medicine is revolutionizing respiratory care and will decrease complications associated with ventilation. More research is needed to standardize its use and better evaluate its impact on patient outcomes.

ESICM-ESPNIC international expert consensus on quantitative lung ultrasound in intensive care

PURPOSE

To provide an international expert consensus on technical aspects and clinical applications of quantitative lung ultrasound in adult, paediatric and neonatal intensive care.

METHODS

The European Society of Intensive Care (ESICM) and the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) endorsed the project. We selected an international panel of 20 adult, paediatric and neonatal intensive care experts with clinical and research expertise in quantitative lung ultrasound, plus two non-voting methodologists. Fourteen clinical questions were proposed by the chairs to the panel, who voted for their priority (1-9 Likert-type scale) and proposed modifications/supplementing (two-round vote). All the questions achieved the predefined threshold (mean score > 5) and 14 groups of 3 mixed adult/paediatric experts were identified to develop the statements for each clinical question; predefined groups of experts in the fields of adult and paediatric/neonatal intensive care voted statements specific for these subgroups. An iterative approach was used to obtain the final consensus statements (two-round vote, 1-9 Likert-type scale); statements were classified as with agreement (range 7-9), uncertainty (4-6), disagreement (1-3) when the median score and ≥ 75% of votes laid within a specific range.

RESULTS

A total of 46 statements were produced (4 adults-only, 4 paediatric/neonatal-only, 38 interdisciplinary); all obtained agreement. This result was also achieved by acknowledging in the statements the current limitations of quantitative lung ultrasound.

CONCLUSION

This consensus guides the use of quantitative lung ultrasound in adult, paediatric and neonatal intensive care and helps identify the fields where further research will be needed in the future.

Lung ultrasound in neonates under cardiac surgery: feasible and predictive

PURPOSE

To determine whether pre- and postoperative follow-up based on lung ultrasound is associated with the respiratory and clinical evolution of patients undergoing cardiac surgery in the neonatal period.

METHODS

Prospective observational unicentric study from December 2020 to October 2023 in a neonatal intensive care unit, a referral center for congenital heart diseases (CHD). Neonates with CHD exposed to heart surgery or percutaneous catheterization in their first 28 days of life were included. LU follow-up was performed before surgery (LUSpre) and on days 1 (LUS_1), 3 (LUS_3), and 7 (LUS_7) afterwards by mean of a dedicated score (LUS) ranging from 0 to 3 points in 8 areas (total score 0-24).

RESULTS

Fifty-five neonates were included. Median gestational age was 39.1 weeks (37.8-40.1), birth weight 3088 g (IQR 2910-3400). Forty-nine received surgery and 6 only percutaneous catheterization. Median LUSpre score was associated with total respiratory support in the first 30 postoperative days (p = 0.034). Median postoperative LUS was significantly higher than LUSpre in the surgery cohort at all time points (p < 0.05). LUS_1 was associated with respiratory and several clinical outcomes: for each point increase in the ultrasound score, the days on invasive mechanical ventilation, the need for any respiratory support within the first 30 postoperative days, and the length of NICU stay increased significantly (p < 0.05). The presence of consolidations in any area in the postoperative lung ultrasounds was associated with worse respiratory outcomes: higher invasive mechanical ventilation duration (6.84 days), longer total respiratory support (6.07 days), and NICU admission (21.61 days). The presence of consolidations in LUS_7 was significantly associated with the occurrence of ipsilateral diaphragmatic paralysis (odds ratio of 10.25 (95% CI 2.05-51.26, p = 0.006).

CONCLUSION

Performance of lung ultrasound follow-up in CHD in the NICU is feasible and predictive of the respiratory evolution of the patient. LUS_1 presented the highest predictive values. The presence of consolidations is associated with a worse respiratory evolution and if they persist for a week after the procedure, it may raise suspicion of ipsilateral diaphragmatic paralysis.

Lung ultrasound score evaluation of the effect of pressure-controlled ventilation volume-guaranteed on patients undergoing laparoscopic-assisted radical gastrectomy

BACKGROUND

Laparoscopic-assisted radical gastrectomy (LARG) is the standard treatment for early-stage gastric carcinoma (GC). However, the negative impact of this procedure on respiratory function requires the optimized intraoperative management of patients in terms of ventilation.

AIM

To investigate the influence of pressure-controlled ventilation volume-guaranteed (PCV-VG) and volume-controlled ventilation (VCV) on blood gas analysis and pulmonary ventilation in patients undergoing LARG for GC based on the lung ultrasound score (LUS).

METHODS

The study included 103 patients with GC undergoing LARG from May 2020 to May 2023, with 52 cases undergoing PCV-VG (research group) and 51 cases undergoing VCV (control group). LUS were recorded at the time of entering the operating room (T0), 20 minutes after anesthesia with endotracheal intubation (T1), 30 minutes after artificial pneumoperitoneum (PP) establishment (T2), and 15 minutes after endotracheal tube removal (T5). For blood gas analysis, arterial partial pressure of oxygen (PaO2) and partial pressure of carbon dioxide (PaCO2) were observed. Peak airway pressure (Ppeak), plateau pressure (Pplat), mean airway pressure (Pmean), and dynamic pulmonary compliance (Cdyn) were recorded at T1 and T2, 1 hour after PP establishment (T3), and at the end of the operation (T4). Postoperative pulmonary complications (PPCs) were recorded. Pre- and postoperative serum interleukin (IL)-1β, IL-6, and tumor necrosis factor-α (TNF-α) were measured by enzyme-linked immunosorbent assay.

RESULTS

Compared with those at T0, the whole, anterior, lateral, posterior, upper, lower, left, and right lung LUS of the research group were significantly reduced at T1, T2, and T5; in the control group, the LUS of the whole and partial lung regions (posterior, lower, and right lung) decreased significantly at T2, while at T5, the LUS of the whole and some regions (lateral, lower, and left lung) increased significantly. In comparison with the control group, the whole and regional LUS of the research group were reduced at T1, T2, and T5, with an increase in PaO2, decrease in PaCO2, reduction in Ppeak at T1 to T4, increase in Pmean and Cdyn, and decrease in Pplat at T4, all significant. The research group showed a significantly lower incidence of PPCs than the control group within 3 days postoperatively. Postoperative IL-1β, IL-6, and TNF-α significantly increased in both groups, with even higher levels in the control group.

CONCLUSION

LUS can indicate intraoperative non-uniformity and postural changes in pulmonary ventilation under PCV-VG and VCV. Under the lung protective ventilation strategy, the PCV-VG mode more significantly improved intraoperative lung ventilation in patients undergoing LARG for GC and reduced lung injury-related cytokine production, thereby alleviating lung injury.

Knowledge, attitude, practice, needs, and implementation status of intensive care unit staff toward continuous renal replacement therapy: a survey of 66 hospitals in central and South China

BACKGROUND

Continuous renal replacement therapy (CRRT) is a commonly utilized form of renal replacement therapy (RRT) in the intensive care unit (ICU). A specialized CRRT team (SCT, composed of physicians and nurses) engage playing pivotal roles in administering CRRT, but there is paucity of evidence-based research on joint training and management strategies. This study armed to evaluate the knowledge, attitude, and practice (KAP) of ICU staff toward CRRT, and to identify education pathways, needs, and the current status of CRRT implementation.

METHODS

This study was performed from February 6 to March 20, 2023. A self-made structured questionnaire was used for data collection. Descriptive statistics, T-tests, Analysis of variance (ANOVA), multiple linear regression, and Pearson correlation coefficient tests (α = 0.05) were employed.

RESULTS

A total of 405 ICU staff from 66 hospitals in Central and South China participated in this study, yielding 395 valid questionnaires. The mean knowledge score was 51.46 ± 5.96 (61.8% scored highly). The mean attitude score was 58.71 ± 2.19 (73.9% scored highly). The mean practice score was 18.15 ± 0.98 (85.1% scored highly). Multiple linear regression analysis indicated that gender, age, years of CRRT practice, ICU category, and CRRT specialist panel membership independently affected the knowledge score; Educational level, years of CRRT practice, and CRRT specialist panel membership independently affected the attitude score; Education level and teaching hospital employment independently affected the practice score. The most effective method for ICU staff to undergo training and daily work experience is within the department.

CONCLUSION

ICU staff exhibit good knowledge, a positive attitude and appropriately practiced CRRT. Extended CRRT practice time in CRRT, further training in a general ICU or teaching hospital, joining a CRRT specialist panel, and upgraded education can improve CRRT professional level. Considering the convenience of training programs will enhance ICU staff participation. Training should focus on basic CRRT principles, liquid management, and alarm handling.

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

Objective

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

Methods

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

Results

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

Conclusions

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

Nutritional management of children with acute kidney injury-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

The nutritional management of children with acute kidney injury (AKI) is complex. The dynamic nature of AKI necessitates frequent nutritional assessments and adjustments in management. Dietitians providing medical nutrition therapies to this patient population must consider the interaction of medical treatments and AKI status to effectively support both the nutrition status of patients with AKI as well as limit adverse metabolic derangements associated with inappropriately prescribed nutrition support. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, has developed clinical practice recommendations (CPR) for the nutritional management of children with AKI. We address the need for intensive collaboration between dietitians and physicians so that nutritional management is optimized in line with AKI medical treatments. We focus on key challenges faced by dietitians regarding nutrition assessment. Furthermore, we address how nutrition support should be provided to children with AKI while taking into account the effect of various medical treatment modalities of AKI on nutritional needs. Given the poor quality of evidence available, a Delphi survey was conducted to seek consensus from international experts. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs, based on the clinical judgment of the treating physician and dietitian. Research recommendations are provided. CPRs will be regularly audited and updated by the PRNT.

Monitoring in Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

OBJECTIVES

Monitoring is essential to assess changes in the lung condition, to identify heart-lung interactions, and to personalize and improve respiratory support and adjuvant therapies in pediatric acute respiratory distress syndrome (PARDS). The objective of this article is to report the rationale of the revised recommendations/statements on monitoring from the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2).

DATA SOURCES

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

STUDY SELECTION

We included studies focused on respiratory or cardiovascular monitoring of children less than 18 years old with a diagnosis of PARDS. We excluded studies focused on neonates.

DATA EXTRACTION

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

DATA SYNTHESIS

The Grading of Recommendations Assessment, Development and Evaluation approach was used to identify and summarize evidence and develop recommendations. We identified 342 studies for full-text review. Seventeen good practice statements were generated related to respiratory and cardiovascular monitoring. Four research statements were generated related to respiratory mechanics and imaging monitoring, hemodynamics monitoring, and extubation readiness monitoring.

CONCLUSIONS

PALICC-2 monitoring good practice and research statements were developed to improve the care of patients with PARDS and were based on new knowledge generated in recent years in patients with PARDS, specifically in topics of general monitoring, respiratory system mechanics, gas exchange, weaning considerations, lung imaging, and hemodynamic monitoring.

2021 Year in Review: Pediatric Mechanical Ventilation

Mechanical ventilation is commonly used in the pediatric intensive care unit. This paper reviews studies of pediatric mechanical ventilation published in 2021. Topics include physiology, ventilator modes, alarms, disease states, airway suctioning, ventilator liberation, prolonged ventilation, and others.

Lung Ultrasound in Pediatric Acute Respiratory Distress Syndrome Received Extracorporeal Membrane Oxygenation: A Prospective Cohort Study

OBJECTIVE

The aim of this study was to assess the prognostic value of the lung ultrasound (LUS) score in patients with pediatric acute respiratory distress syndrome (pARDS) who received extracorporeal membrane oxygenation (ECMO).

METHODS

A prospective cohort study was conducted in a pediatric intensive care unit (PICU) of a tertiary hospital from January 2016 to June 2021. The severe pARDS patients who received ECMO were enrolled in this study. LUS score was measured at initiation of ECMO (LUS-0 h), then at 24 h (LUS-24 h), 48 h (LUS-48 h), and 72 h (LUS-72 h) during ECMO, and when weaned from ECMO (LUS-wean). The value of LUS scores at the first 3 days of ECMO as a prognostic predictor was analyzed.

RESULTS

Twenty-nine children with severe pARDS who received ECMO were enrolled with a median age of 26 (IQR 9, 79) months. The median duration of ECMO support was 162 (IQR 86, 273) h and the PICU mortality was 31.0% (9/29). The values of LUS-72 h and LUS-wean were significantly lower in survivors than that in non-survivors (both P < 0.001). Daily fluid balance volume during the first 3 days of ECMO support were strongly correlated with LUS score [1st day: r = 0.460, P = 0.014; 2nd day: r = 0.540, P = 0.003; 3rd day: r = 0.589, P = 0.001]. The AUC of LUS-72 h for predicting PICU mortality in these patients was 1.000, and the cutoff value of LUS-72 h was 24 with a sensitivity of 100.0% and a specificity of 100.0%. Furthermore, patients were stratified in two groups of LUS-72 h ≥ 24 and LUS-72 h < 24. Consistently, PICU mortality, length of PICU stay, ratio of shock, vasoactive index score value, and the need for continuous renal replacement therapy were significantly higher in the group of LUS-72 h ≥ 24 than in the group of LUS-72 h < 24 (all P < 0.05).

CONCLUSION

Lung ultrasound score is a promising tool for predicting the prognosis in patients with ARDS under ECMO support. Moreover, LUS-72 h ≥ 24 is associated with high risk of PICU mortality in patients with pARDS who received ECMO.