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Bose SN, Defante A, Greenstein JL, Haddad GG, Ryu J, Winslow RL. A data-driven model for early prediction of need for invasive mechanical ventilation in pediatric intensive care unit patients. PLoS One 2023; 18:e0289763. [PMID: 37540703 PMCID: PMC10403092 DOI: 10.1371/journal.pone.0289763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 07/25/2023] [Indexed: 08/06/2023] Open
Abstract
RATIONALE Acute respiratory failure is a life-threatening clinical outcome in critically ill pediatric patients. In severe cases, patients can require mechanical ventilation (MV) for survival. Early recognition of these patients can potentially help clinicians alter the clinical course and lead to improved outcomes. OBJECTIVES To build a data-driven model for early prediction of the need for mechanical ventilation in pediatric intensive care unit (PICU) patients. METHODS The study consists of a single-center retrospective observational study on a cohort of 13,651 PICU patients admitted between 1/01/2010 and 5/15/2018 with a prevalence of 8.06% for MV due to respiratory failure. XGBoost (extreme gradient boosting) and a convolutional neural network (CNN) using medication history were used to develop a prediction model that could yield a time-varying "risk-score"-a continuous probability of whether a patient will receive MV-and an ideal global threshold was calculated from the receiver operating characteristics (ROC) curve. The early prediction point (EPP) was the first time the risk-score surpassed the optimal threshold, and the interval between the EPP and the start of the MV was the early warning period (EWT). Spectral clustering identified patient groups based on risk-score trajectories after EPP. RESULTS A clinical and medication history-based model achieved a 0.89 area under the ROC curve (AUROC), 0.6 sensitivity, 0.95 specificity, 0.55 positive predictive value (PPV), and 0.95 negative predictive value (NPV). Early warning time (EWT) median [inter-quartile range] of this model was 9.9[4.2-69.2] hours. Clustering risk-score trajectories within a six-hour window after the early prediction point (EPP) established three patient groups, with the highest risk group's PPV being 0.92. CONCLUSIONS This study uses a unique method to extract and apply medication history information, such as time-varying variables, to identify patients who may need mechanical ventilation for respiratory failure and provide an early warning period to avert it.
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Affiliation(s)
- Sanjukta N Bose
- Enterprise Data and Analytics, University of Maryland Medical System, Linthicum Heights, MD, United States of America
| | - Andrew Defante
- Rady Children's Hospital, San Diego, CA, United States of America
| | - Joseph L Greenstein
- Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, United States of America
| | - Gabriel G Haddad
- Rady Children's Hospital, San Diego, CA, United States of America
- Division of Respiratory Medicine, Department of Pediatrics, University of California San Diego, La Jolla, CA, United States of America
- Department of Neurosciences, University of California San Diego, La Jolla, CA, United States of America
| | - Julie Ryu
- Division of Respiratory Medicine, Department of Pediatrics, University of California San Diego, La Jolla, CA, United States of America
| | - Raimond L Winslow
- Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, United States of America
- Roux Institute at Northeastern University, Portland, ME, United States of America
- Department of Bioengineering, Northeastern University, Boston, MA, United States of America
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Schranc Á, Diaper J, Südy R, Peták F, Habre W, Albu G. Lung recruitment by continuous negative extra-thoracic pressure support following one-lung ventilation: an experimental study. Front Physiol 2023; 14:1160731. [PMID: 37256073 PMCID: PMC10225513 DOI: 10.3389/fphys.2023.1160731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/03/2023] [Indexed: 06/01/2023] Open
Abstract
Lung recruitment maneuvers following one-lung ventilation (OLV) increase the risk for the development of acute lung injury. The application of continuous negative extrathoracic pressure (CNEP) is gaining interest both in intubated and non-intubated patients. However, there is still a lack of knowledge on the ability of CNEP support to recruit whole lung atelectasis following OLV. We investigated the effects of CNEP following OLV on lung expansion, gas exchange, and hemodynamics. Ten pigs were anesthetized and mechanically ventilated with pressure-regulated volume control mode (PRVC; FiO2: 0.5, Fr: 30-35/min, VT: 7 mL/kg, PEEP: 5 cmH2O) for 1 hour, then baseline (BL) data for gas exchange (arterial partial pressure of oxygen, PaO2; and carbon dioxide, PaCO2), ventilation and hemodynamical parameters and lung aeration by electrical impedance tomography were recorded. Subsequently, an endobronchial blocker was inserted, and OLV was applied with a reduced VT of 5 mL/kg. Following a new set of measurements after 1 h of OLV, two-lung ventilation was re-established, combining PRVC (VT: 7 mL/kg) and CNEP (-15 cmH2O) without any hyperinflation maneuver and data collection was then repeated at 5 min and 1 h. Compared to OLV, significant increases in PaO2 (154.1 ± 13.3 vs. 173.8 ± 22.1) and decreases in PaCO2 (52.6 ± 11.7 vs. 40.3 ± 4.5 mmHg, p < 0.05 for both) were observed 5 minutes following initiation of CNEP, and these benefits in gas exchange remained after an hour of CNEP. Gradual improvements in lung aeration in the non-collapsed lung were also detected by electrical impedance tomography (p < 0.05) after 5 and 60 min of CNEP. Hemodynamics and ventilation parameters remained stable under CNEP. Application of CNEP in the presence of whole lung atelectasis proved to be efficient in improving gas exchange via recruiting the lung without excessive airway pressures. These benefits of combined CNEP and positive pressure ventilation may have particular value in relieving atelectasis in the postoperative period of surgical procedures requiring OLV.
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Affiliation(s)
- Álmos Schranc
- Unit for Anesthesiological Investigations, Department of Anesthesiology Pharmacology, Intensive Care and Emergency Medicine, University of Geneva, Geneva, Switzerland
| | - John Diaper
- Unit for Anesthesiological Investigations, Department of Anesthesiology Pharmacology, Intensive Care and Emergency Medicine, University of Geneva, Geneva, Switzerland
| | - Roberta Südy
- Unit for Anesthesiological Investigations, Department of Anesthesiology Pharmacology, Intensive Care and Emergency Medicine, University of Geneva, Geneva, Switzerland
| | - Ferenc Peták
- Department of Medical Physics and Informatics, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Walid Habre
- Unit for Anesthesiological Investigations, Department of Anesthesiology Pharmacology, Intensive Care and Emergency Medicine, University of Geneva, Geneva, Switzerland
| | - Gergely Albu
- Unit for Anesthesiological Investigations, Department of Anesthesiology Pharmacology, Intensive Care and Emergency Medicine, University of Geneva, Geneva, Switzerland
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Jose D, Parameswaran N. Advances in Management of Respiratory Failure in Children. Indian J Pediatr 2023; 90:470-480. [PMID: 37010692 DOI: 10.1007/s12098-023-04559-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 03/07/2023] [Indexed: 04/04/2023]
Abstract
Providing the right respiratory support is an essential skill, vital for anyone treating sick children. Recent advances in respiratory support include developments in both non-invasive and invasive ventilatory strategies. In non-invasive ventilation, newer modalities are being developed, in an attempt to decrease the need for invasive ventilation. This include newer techniques like Heated humidified high-flow nasal cannula (HHHFNC) and improvements in existing modes. The success of Continuous positive airway pressure (CPAP) and other non-invasive modes depend to a large extent on choosing and maintaining a suitable interface. When it comes to invasive ventilation, recent advances are focussing on increasing automation, improving patient comfort and minimising lung injury. Concepts like mechanical power are attempts at understanding the mechanisms of unintended injuries resulting from respiratory support and newer monitoring methods like transpulmonary pressure, thoracic impedance tomography are attempts at measuring potential markers of lung injury. Using the vast arrays of available ventilatory options judiciously, considering their advantages and drawbacks in every individual case will be the prime responsibility of clinicians in the future. Simultaneously, efforts have been made to identify potential drugs that can favourably modify the pathophysiology of acute respiratory distress syndrome (ARDS). Unfortunately, though eagerly awaited, most pharmaceutical agents tried in pediatric ARDS have not shown definite benefit. Pulmonary local drug and gene therapy using liquid ventilation strategies may revolutionize our future understanding and management of lung diseases.
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Affiliation(s)
- Divakar Jose
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Narayanan Parameswaran
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India.
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Annunziata A, Calabrese C, Simioli F, Coppola A, Flora M, Marotta A, Di Spirito V, Didonna F, Cicalese M, Fiorentino G. Negative-Pressure Ventilation in Neuromuscular Diseases in the Acute Setting. J Clin Med 2022; 11:2589. [PMID: 35566729 PMCID: PMC9101364 DOI: 10.3390/jcm11092589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 04/23/2022] [Accepted: 04/29/2022] [Indexed: 11/16/2022] Open
Abstract
Mechanical ventilation started with negative-pressure ventilation (NPV) during the 1950s to assist patients with respiratory failure, secondary to poliomyelitis. Over the years, technological evolution has allowed for the development of more comfortable devices, leading to an increased interest in NPV. The patients affected by neuromuscular diseases (NMD) with chronic and acute respiratory failure (ARF) may benefit from NPV. The knowledge of the available respiratory-support techniques, indications, contraindications, and adverse effects is necessary to offer the patient a personalized treatment that considers the pathology's complexity.
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Affiliation(s)
- Anna Annunziata
- Department of Intensive Care, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy; (F.S.); (A.C.); (M.F.); (A.M.); (V.D.S.); (F.D.); (G.F.)
| | - Cecilia Calabrese
- Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy;
| | - Francesca Simioli
- Department of Intensive Care, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy; (F.S.); (A.C.); (M.F.); (A.M.); (V.D.S.); (F.D.); (G.F.)
| | - Antonietta Coppola
- Department of Intensive Care, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy; (F.S.); (A.C.); (M.F.); (A.M.); (V.D.S.); (F.D.); (G.F.)
| | - Martina Flora
- Department of Intensive Care, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy; (F.S.); (A.C.); (M.F.); (A.M.); (V.D.S.); (F.D.); (G.F.)
| | - Antonella Marotta
- Department of Intensive Care, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy; (F.S.); (A.C.); (M.F.); (A.M.); (V.D.S.); (F.D.); (G.F.)
| | - Valentina Di Spirito
- Department of Intensive Care, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy; (F.S.); (A.C.); (M.F.); (A.M.); (V.D.S.); (F.D.); (G.F.)
| | - Francesco Didonna
- Department of Intensive Care, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy; (F.S.); (A.C.); (M.F.); (A.M.); (V.D.S.); (F.D.); (G.F.)
| | - Marcellino Cicalese
- Department of Surgery, Unit of Thoracic Surgery, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy;
| | - Giuseppe Fiorentino
- Department of Intensive Care, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy; (F.S.); (A.C.); (M.F.); (A.M.); (V.D.S.); (F.D.); (G.F.)
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Dos Santos Rocha A, Habre W, Albu G. Novel ventilation techniques in children. Paediatr Anaesth 2022; 32:286-294. [PMID: 34837438 PMCID: PMC9300098 DOI: 10.1111/pan.14344] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 02/06/2023]
Abstract
Extraordinary progress has been made during the past few decades in the development of anesthesia machines and ventilation techniques. With unprecedented precision and performance, modern machines for pediatric anesthesia can deliver appropriate mechanical ventilation for children and infants of all sizes and with ongoing respiratory diseases, ensuring very small volume delivery and compensating for circuit compliance. Along with highly accurate monitoring of the delivered ventilation, modern ventilators for pediatric anesthesia also have a broad choice of ventilation modalities, including synchronized and assisted ventilation modes, which were initially conceived for ventilation weaning in the intensive care setting. Despite these technical advances, there is still room for improvement in pediatric mechanical ventilation. There is a growing effort to minimize the harm of intraoperative mechanical ventilation of children by adopting the protective ventilation strategies that were previously employed only for prolonged mechanical ventilation. More than ever, the pediatric anesthesiologist should now recognize that positive-pressure ventilation is potentially a harmful procedure, even in healthy children, as it can contribute to both ventilator-induced lung injury and ventilator-induced diaphragmatic dysfunction. Therefore, careful choice of the ventilation modality and its parameters is of paramount importance to optimize gas exchange and to protect the lungs from injury during general anesthesia. The present report reviews the novel ventilation techniques used for children, discussing the advantages and pitfalls of the ventilation modalities available in modern anesthesia machines, as well as innovative ventilation modes currently under development or research. Several innovative strategies and devices are discussed. These novel modalities are likely to become part of the armamentarium of the pediatric anesthesiologist in the near future and are particularly relevant for challenging ventilation scenarios.
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Affiliation(s)
- André Dos Santos Rocha
- Division of Anesthesiology and Unit for Anesthesiological InvestigationsDepartment of Acute MedicineUniversity Hospitals of Geneva and University of GenevaGenevaSwitzerland
| | - Walid Habre
- Division of Anesthesiology and Unit for Anesthesiological InvestigationsDepartment of Acute MedicineUniversity Hospitals of Geneva and University of GenevaGenevaSwitzerland,Pediatric Anesthesia UnitDepartment of Acute MedicineUniversity Hospitals of GenevaGenevaSwitzerland
| | - Gergely Albu
- Division of Anesthesiology and Unit for Anesthesiological InvestigationsDepartment of Acute MedicineUniversity Hospitals of Geneva and University of GenevaGenevaSwitzerland
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Ishimori S, Okizuka Y, Onishi S, Shinomoto T, Minami H. Predictive factors of continuous negative extrathoracic pressure management failure in children with moderate to severe respiratory syncytial virus infection. Sci Rep 2021; 11:8063. [PMID: 33850205 PMCID: PMC8044183 DOI: 10.1038/s41598-021-87582-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 03/26/2021] [Indexed: 11/17/2022] Open
Abstract
Continuous negative extrathoracic pressure (CNEP) might be beneficial for children with severe respiratory tract infections. However, there are no available data on the predictors of its failure among individuals with respiratory syncytial virus (RSV) infections. Here, we conducted a retrospective cohort study between October 1, 2015 and October 31, 2018 in hospitalized children with moderate to severe symptoms of respiratory syncytial virus (RSV) infections. We divided 45 children requiring CNEP ventilation with a non-fluctuating negative pressure of − 12 cm H2O into two groups. They were classified based on improvement or deterioration of their respiratory disorder under CNEP ventilation (responder group: n = 27, failure group: n = 18). Based on the univariate analysis, the responder and failure groups significantly differed in terms of median age, days elapsed from RSV onset to the initiation of CNEP, white blood cell count (WBC), titer of venous pCO2, body temperature at admission, and modified Wood-Downes Score (mWDS) 6 h after initiating CNEP. Based on a logistic regression analysis adjusted for age < 1 year upon admission, less than 5 days elapsed from RSV onset to the initiation of CNEP, not high value of WBC and body temperature at admission, and high values of mWDS 6 h after initiating CNEP were found to be significant independent risk factors for CNEP ventilation failure. The former two variables were associated with less failure (odds ratio was approximately 5), and the latter two variables are associated with more failure (odds ratio was approximately 8–9). Thus, CNEP could be a valid option for children with moderate to severe RSV infections, especially in those who were aged > 1 year, and specific clinical and laboratory findings.
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Affiliation(s)
- Shingo Ishimori
- Department of Pediatrics, Takatsuki General Hospital, 1-3-13 Kosobe-cho, Takatsuki City, Osaka, 5691192, Japan.
| | - Yo Okizuka
- Department of Pediatrics, Intensive Care of Medicine, Takatsuki General Hospital, Osaka, Japan
| | - Satoshi Onishi
- Department of Pediatrics, Intensive Care of Medicine, Takatsuki General Hospital, Osaka, Japan
| | - Tadashi Shinomoto
- Department of Pediatrics, Intensive Care of Medicine, Takatsuki General Hospital, Osaka, Japan
| | - Hirotaka Minami
- Department of Pediatrics, Takatsuki General Hospital, 1-3-13 Kosobe-cho, Takatsuki City, Osaka, 5691192, Japan
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Praud JP. Long-Term Non-invasive Ventilation in Children: Current Use, Indications, and Contraindications. Front Pediatr 2020; 8:584334. [PMID: 33224908 PMCID: PMC7674588 DOI: 10.3389/fped.2020.584334] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 09/22/2020] [Indexed: 01/15/2023] Open
Abstract
This review focuses on the delivery of non-invasive ventilation-i.e., intermittent positive-pressure ventilation-in children lasting more than 3 months. Several recent reviews have brought to light a dramatic escalation in the use of long-term non-invasive ventilation in children over the last 30 years. This is due both to the growing number of children receiving care for complex and severe diseases necessitating respiratory support and to the availability of LT-NIV equipment that can be used at home. While significant gaps in availability persist for smaller children and especially infants, home LT-NIV for children with chronic respiratory insufficiency has improved their quality of life and decreased the overall cost of care. While long-term NIV is usually delivered during sleep, it can also be delivered 24 h a day in selected patients. Close collaboration between the hospital complex-care team, the home LT-NIV program, and family caregivers is of the utmost importance for successful home LT-NIV. Long-term NIV is indicated for respiratory disorders responsible for chronic alveolar hypoventilation, with the aim to increase life expectancy and maximize quality of life. LT-NIV is considered for conditions that affect respiratory-muscle performance (alterations in central respiratory drive or neuromuscular function) and/or impose an excessive respiratory load (airway obstruction, lung disease, or chest-wall anomalies). Relative contraindications for LT-NIV include the inability of the local medical infrastructure to support home LT-NIV and poor motivation or inability of the patient/caregivers to cooperate or understand recommendations. Anatomic abnormalities that interfere with interface fitting, inability to protect the lower airways due to excessive airway secretions and/or severely impaired swallowing, or failure of LT-NIV to support respiration can lead to considering invasive ventilation via tracheostomy. Of note, providing home LT-NIV during the COVID 19 pandemic has become more challenging. This is due both to the disruption of medical systems and the fear of contaminating care providers and family with aerosols generated by a patient positive for SARS-CoV-2 during NIV. Delay in initiating LT-NIV, decreased frequency of home visits by the home ventilation program, and decreased availability of polysomnography and oximetry/transcutaneous PCO2 monitoring are observed. Teleconsultations and telemonitoring are being developed to mitigate these challenges.
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Affiliation(s)
- Jean-Paul Praud
- Division of Pediatric Pulmonology, University of Sherbrooke, Sherbrooke, QC, Canada
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