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Russi BW, Roberts AR, Nievas IF, Rogerson CM, Morrison JM, Sochet AA. Noninvasive Respiratory Support for Pediatric Critical Asthma: A Multicenter Cohort Study. Respir Care 2024; 69:534-540. [PMID: 38290751 DOI: 10.4187/respcare.11502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND Noninvasive respiratory support (NRS) for pediatric critical asthma includes CPAP; bi-level positive airway pressure (BPAP); and heated, humidified, high-flow nasal cannula (HFNC). We used the Virtual Pediatric System database to estimate NRS by prescribing rates for pediatric critical asthma and characterize patient clinical features and in-patient outcomes by the initial NRS device applied. METHODS We performed a retrospective cohort study from 125 participating pediatric ICUs among children 2-17 years of age hospitalized for critical asthma and prescribed NRS from 2017 through 2021. The primary outcomes were NRS modality prescribing rates and trends. Secondary outcomes were descriptive and included demographics, comorbidities, severity of illness indices, and NRS failure rates (defined as escalation from the initial NRS modality to invasive ventilation, HFNC to BPAP or CPAP, or CPAP to BPAP). RESULTS Of the 10,083 encounters studied, the initial NRS modalities prescribed varied widely by hospital center (HFNC: 69.7 ± 29.6%; BPAP: 27.2 ± 7.1%; CPAP: 3.1 ± 5.9%). The mean rates of HFNC use increased from 59.7% in 2017 to 71.9% in 2021 (+2.5%/y). In contrast, BPAP (-1.6%/y) and CPAP (-0.8%/y) utilization declined throughout the study period. Older children who were obese and with a higher Pediatric Risk of Mortality III-Probability of Mortality score were more frequently prescribed BPAP and CPAP compared with HFNC. Those children on HFNC experienced higher noninvasive respiratory support failure rates versus BPAP (7.3% vs 2.4%; P < .001) but a lower subsequent invasive ventilation rate versus BPAP (0.8% vs 2.4%; P < .001). CONCLUSIONS In this multi-center cohort study, we observed that children with critical asthma are increasingly exposed to HFNC compared with BPAP and CPAP. Rates of HFNC failure were greater than those of BPAP failure, but a majority were transitioned to BPAP without subsequent invasive ventilation. The next steps include prospective trials, including practical end points such as patient comfort and optimal delivery of nebulized treatments to distinguish device superiority and suitable NRS utilization.
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Affiliation(s)
- Brett W Russi
- Division of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Alexa R Roberts
- Division of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Ignacio F Nievas
- Division of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Colin M Rogerson
- Division of Pediatric Critical Care Medicine, Indiana University School of Medicine and Riley Hospital for Children at IU Health, Indianapolis, Indiana
| | - John M Morrison
- Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Anthony A Sochet
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, St. Petersburg, Florida.
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Li R, Liu L, Wei K, Zheng X, Zeng J, Chen Q. Effect of noninvasive respiratory support after extubation on postoperative pulmonary complications in obese patients: A systematic review and network meta-analysis. J Clin Anesth 2023; 91:111280. [PMID: 37801822 DOI: 10.1016/j.jclinane.2023.111280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 09/16/2023] [Accepted: 09/27/2023] [Indexed: 10/08/2023]
Abstract
STUDY OBJECTIVE Obesity is associated with an increased risk of sleep-disordered breathing (SDB) and postoperative pulmonary complications (PPCs). Postoperative noninvasive respiratory support (NRS) has been recommended to obese patients despite the controversy about its benefit. The network meta-analysis (NMA) was used in this study to compare the effect of different methods of NRS on preventing PPCs in obese patients. DESIGN This study is a network meta-analysis. SETTING Post-anesthesia care unit and inpatient ward. PATIENTS 20 randomized controlled trials involving 1184 obese patients were included in the final analysis. INTERVENTIONS One of the four NRS techniques, which include continuous positive airway pressure (CPAP), bi-level positive airway pressure (BiPAP), high-flow nasal cannula (HFNC), or conventional oxygen therapy (COT), was performed after general anesthesia. MEASUREMENTS The primary outcome was the incidence of PPCs, e.g., atelectasis, pneumonia, hypoxemia, and respiratory failure. The secondary outcomes included the incidence of oxygen treatment failure and anastomotic leakage, oxygenation index, and length of hospital stay (LOS). RevMan 5.3 and STATA 16.0 were used to analyze the results and any potential bias. MAIN RESULTS Compared with COT, BiPAP and HFNC were both effective in reducing the occurrence of postoperative atelectasis. There were no significant differences in the occurrence of other PPCs including pneumonia, hypoxemia and respiratory failure between the four NRS techniques. CPAP and HFNC were superior to other techniques in improving oxygenation and shortening LOS respectively. No differences were found in oxygen treatment failure and anastomotic leakage between the patients with different NRS. HFNC ranked the first in five of the eight outcomes (hypoxemia, respiratory failure, treatment failure, anastomotic leakage, LOS) in this review by the surface under the cumulative ranking curve (SUCRA). CONCLUSION Among the four postoperative NRS techniques, HFNC seems to be the optimal choice for obese patients which shows certain advantages in reducing the risk of PPCs and shortening LOS.
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Affiliation(s)
- Ruike Li
- The First Affiliated Hospital of Chongqing Medical University, Department of Anesthesiology, Youyi Road, Chongqing 400016, China
| | - Ling Liu
- The First Affiliated Hospital of Chongqing Medical University, Department of Anesthesiology, Youyi Road, Chongqing 400016, China
| | - Ke Wei
- The First Affiliated Hospital of Chongqing Medical University, Department of Anesthesiology, Youyi Road, Chongqing 400016, China.
| | - Xiaozhuo Zheng
- The First Affiliated Hospital of Chongqing Medical University, Department of Respiratory and Critical Care Medicine, Youyi Road, Chongqing 400016, China
| | - Jie Zeng
- Stomatological Hospital of Chongqing Medical University, Department of Anesthesiology, Songshibei Road, Chongqing 400016, China
| | - Qi Chen
- Chongqing University Cancer Hospital, Department of Anesthesiology, Hanyu Road, Chongqing 400016, China
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Coppadoro A, Bellani G, Foti G. A technique to measure tidal volume during noninvasive respiratory support by continuous-flow helmet CPAP. J Clin Monit Comput 2023; 37:1473-1479. [PMID: 37329389 PMCID: PMC10651536 DOI: 10.1007/s10877-023-01034-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 05/12/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE The coronavirus disease 2019 (COVID-19) pandemic has promoted the use of helmet continuous positive airway pressure (CPAP) for noninvasive respiratory support in hypoxic respiratory failure patients, despite the lack of tidal volume monitoring. We evaluated a novel technique designed to measure tidal volume during noninvasive continuous-flow helmet CPAP. METHODS A bench model of spontaneously breathing patients undergoing helmet CPAP therapy (three positive end-expiratory pressure [PEEP] levels) at different levels of respiratory distress was used to compare measured and reference tidal volumes. Tidal volume measurement by the novel technique was based on helmet outflow-trace analysis. Helmet inflow was increased from 60 to 75 and 90 L/min to match the patient's peak inspiratory flow; an additional subset of tests was conducted under the condition of purposely insufficient inflow (i.e., high respiratory distress and 60 L/min inflow). RESULTS The tidal volumes examined herein ranged from 250 to 910 mL. The Bland‒Altman analysis showed a bias of -3.2 ± 29.3 mL for measured tidal volumes compared to the reference, corresponding to an average relative error of -1 ± 4.4%. Tidal volume underestimation correlated with respiratory rate (rho = .411, p = .004) but not with peak inspiratory flow, distress, or PEEP. When the helmet inflow was maintained purposely low, tidal volume underestimation occurred (bias - 93.3 ± 83.9 mL), corresponding to an error of -14.8 ± 6.3%. CONCLUSION Tidal volume measurement is feasible and accurate during bench continuous-flow helmet CPAP therapy by the analysis of the outflow signal, provided that helmet inflow is adequate to match the patient's inspiratory efforts. Insufficient inflow resulted in tidal volume underestimation. In vivo data are needed to confirm these findings.
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Affiliation(s)
- Andrea Coppadoro
- Department of Anesthesia and Intensive care, San Gerardo Hospital, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Giacomo Bellani
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento, Trento, Italy
| | - Giuseppe Foti
- Department of Anesthesia and Intensive care, San Gerardo Hospital, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
- Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB, Italy.
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Itdhiamornkulchai S, Preutthipan A, Vaewpanich J, Anantasit N. Modified high-flow nasal cannula for children with respiratory distress. Clin Exp Pediatr 2022; 65:136-141. [PMID: 34044481 PMCID: PMC8898618 DOI: 10.3345/cep.2020.01403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 05/13/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND High-flow nasal cannula (HFNC) is a noninvasive respiratory support that provides the optimum flow of an air-oxygen mixture. Several studies demonstrated its usefulness and good safety profile for treating pediatric respiratory distress patients. However, the cost of the commercial HFNC is high; therefore, the modified high-flow nasal cannula was developed. PURPOSE This study aimed to compare the effectiveness, safety, and nurses' satisfaction of the modified system versus the standard commercial HFNC. METHODS This prospective comparative study was performed in a tertiary care hospital. We recruited children aged 1 month to 5 years who developed acute respiratory distress and were admitted to the pediatric intensive care unit. Patients were assigned to 2 groups (modified vs. commercial). The effectiveness and safety assessments included vital signs, respiratory scores, intubation rate, adverse events, and nurses' satisfaction. RESULTS A total of 74 patients were treated with HFNC. Thirty- nine patients were assigned to the modified group, while the remaining 35 patients were in the commercial group. Intubation rate and adverse events did not differ significantly between the 2 groups. However, the commercial group had higher nurses' satisfaction scores than the modified group. CONCLUSION Our findings suggest that our low-cost modified HFNC could be a useful respiratory support option for younger children with acute respiratory distress, especially in hospital settings with financial constraints.
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Affiliation(s)
- Sarocha Itdhiamornkulchai
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Aroonwan Preutthipan
- Division of Pediatric Pulmonology, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jarin Vaewpanich
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nattachai Anantasit
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Abstract
Extremely preterm infants who must suddenly support their own gas exchange with lungs that are incompletely developed and lacking adequate amount of surfactant and antioxidant defenses are susceptible to lung injury. The decades-long quest to prevent bronchopulmonary dysplasia has had limited success, in part because of increasing survival of more immature infants. The process must begin in the delivery room with gentle assistance in establishing and maintaining adequate lung aeration, followed by noninvasive support and less invasive surfactant administration. Various modalities of invasive and noninvasive support have been used with varying degree of effect and are reviewed in this article.
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Dani C. Nasal Continuous Positive Airway Pressure and High-Flow Nasal Cannula Today. Clin Perinatol 2021; 48:711-724. [PMID: 34774205 DOI: 10.1016/j.clp.2021.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study reviews the mechanisms of action and physiologic effects of nasal continuous positive airway pressure (nCPAP) and high-flow nasal cannula (HFNC) in preterm infants with respiratory distress syndrome, discusses the main characteristics of available devices and patients' interfaces, reports on risk of failure and possible adverse effects, and summarizes clinical evidence regarding effectiveness for preventing mechanical ventilation as primary respiratory support or after extubation in the neonatal intensive care unit. nCPAP is preferred to HFNC as primary mode of noninvasive respiratory support in preterm infants with respiratory distress syndrome, whereas HFNC is an effective alternative to nCPAP after extubation.
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Affiliation(s)
- Carlo Dani
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy; Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy.
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Abstract
Respiratory distress is a common problem seen in neonates, both preterm and full term. Appropriate use of respiratory support can be life-saving in these neonates. While invasive ventilation is unavoidable in some situations, noninvasive ventilation may be sufficient in several neonates. In this review article, the authors have summarized the current evidence and the best practices to deliver effective noninvasive respiratory support.
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Affiliation(s)
- Rajendra Prasad Anne
- Department of Neonatology, Newborn Unit, Fernandez Hospitals, Unit 2, Hyderguda, Hyderabad, Telangana, India
| | - Srinivas Murki
- Department of Neonatology, Newborn Unit, Paramita Children's Hospital, Kothapet, L B Nagar, Hyderabad, Telangana, 500074, India.
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Rezoagli E, Villa S, Gatti S, Russotto V, Borgo A, Lucchini A, Foti G, Bellani G. Helmet and face mask for non-invasive respiratory support in patients with acute hypoxemic respiratory failure: A retrospective study. J Crit Care 2021; 65:56-61. [PMID: 34091270 DOI: 10.1016/j.jcrc.2021.05.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/20/2021] [Accepted: 05/22/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Non-invasive respiratory support could reduce the incidence of intubation in patients with Acute Hypoxemic Respiratory Failure (AHRF). The optimal interface or modality of non-invasive respiratory support is debated. We sought to evaluate the differences between patients who succeeded or failed non-invasive respiratory support, with a specific focus on the type of non-invasive respiratory support (i.e. helmet CPAP versus face mask NIV). MATERIALS AND METHODS In a single-center observational retrospective study, we investigated baseline, clinical characteristics and AHRF management by non-invasive respiratory support between January 2015 to December 2016. Data on gas exchange and respiratory mechanics, non-invasive respiratory support duration, ICU length of stay and mortality were collected. RESULTS 110 patients with AHRF were included of which 41 patients (37%) were intubated. The use of helmet CPAP (p = 0.016) and a lower fluid balance (p = 0.038) were independently associated with a decreased rate of intubation after adjustment for confounders. Face mask NIV patients trended to a higher respiratory frequency at 1 h after treatment [28 (22-36) versus 24 (18-29) hours, p = 0.067], and showed a longer ICU stay (p = 0.009) compared to patients treated with helmet CPAP. CONCLUSIONS Helmet CPAP and a lower fluid balance were independent predictors of a lower intubation rate in AHRF patients in ICU. Prospective studies aimed at identifying the optimal interface and modality of non-invasive respiratory support in AHRF patients are needed.
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Affiliation(s)
- Emanuele Rezoagli
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore, 48, Monza 20900, MB, Italy.; Department of Anesthesia and Intensive Care Medicine, San Gerardo Hospital, ASST Monza, Monza e Brianza, Via G. B. Pergolesi, 33, Monza 20900, MB, Italy
| | - Silvia Villa
- Department of Anesthesia and Intensive Care Medicine, San Gerardo Hospital, ASST Monza, Monza e Brianza, Via G. B. Pergolesi, 33, Monza 20900, MB, Italy
| | - Stefano Gatti
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore, 48, Monza 20900, MB, Italy
| | - Vincenzo Russotto
- Department of Anesthesia and Intensive Care Medicine, San Gerardo Hospital, ASST Monza, Monza e Brianza, Via G. B. Pergolesi, 33, Monza 20900, MB, Italy
| | - Asia Borgo
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore, 48, Monza 20900, MB, Italy
| | - Alberto Lucchini
- Department of Anesthesia and Intensive Care Medicine, San Gerardo Hospital, ASST Monza, Monza e Brianza, Via G. B. Pergolesi, 33, Monza 20900, MB, Italy
| | - Giuseppe Foti
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore, 48, Monza 20900, MB, Italy.; Department of Anesthesia and Intensive Care Medicine, San Gerardo Hospital, ASST Monza, Monza e Brianza, Via G. B. Pergolesi, 33, Monza 20900, MB, Italy
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore, 48, Monza 20900, MB, Italy.; Department of Anesthesia and Intensive Care Medicine, San Gerardo Hospital, ASST Monza, Monza e Brianza, Via G. B. Pergolesi, 33, Monza 20900, MB, Italy.
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Abstract
Within the last decades, therapeutic advances have significantly improved the survival of extremely preterm infants. In contrast, the incidence of major neonatal morbidities, including bronchopulmonary dysplasia, has not declined. Given the well-established relationship between exposure to invasive mechanical ventilation and neonatal lung injury, neonatologists have sought for effective strategies of noninvasive respiratory support in high-risk infants. Continuous positive airway pressure has replaced invasive mechanical ventilation for the initial stabilization and the treatment of respiratory distress syndrome. Today, noninvasive respiratory support has been adopted even in the tiniest babies with the highest risk of lung injury. Moreover, different modes of noninvasive respiratory support supplemented by a number of adjunctive measures and rescue strategies have entered clinical practice with the goal of preventing intubation or reintubation. However, does this unquestionably important paradigm shift to strategies focused on noninvasive support lull us into a false sense of security? Can we do better in (i) identifying those very immature preterm infants best equipped for noninvasive stabilization, can we improve (ii) determinants of failure of noninvasive respiratory support in the individual infant and underlying etiology, and can we enhance (iii) success of noninvasive respiratory support and (iv) better prevent ultimate harm to the developing lung? With increased survival of infants at the highest risk of developing lung injury and an unchanging burden of bronchopulmonary dysplasia, we should question indiscriminate use of noninvasive respiratory support and address the above issues.
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Affiliation(s)
- Kirsten Glaser
- Division of Neonatology, Department of Women's and Children's Health, University of Leipzig Medical Center, Leipzig, Germany
| | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
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Ekhaguere O, Patel S, Kirpalani H. Nasal Intermittent Mandatory Ventilation Versus Nasal Continuous Positive Airway Pressure Before and After Invasive Ventilatory Support. Clin Perinatol 2019; 46:517-536. [PMID: 31345544 DOI: 10.1016/j.clp.2019.05.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Continuous positive airway pressure (CPAP), noninvasive intermittent positive pressure ventilation (NIPPV), and heated humidified high-flow nasal cannula (HHFNC) are modes of noninvasive respiratory support used in neonatal practice. These modes of noninvasive respiratory support may obviate mechanical ventilation, prevent extubation failure, and reduce the risk of developing bronchopulmonary dysplasia. Although the physiologic bases of CPAP and HHFNC are well delineated, and their modes and practical application consistent, those of NIPPV are unproven and varied. Available evidence suggests that NIPPV is superior to CPAP as a primary and postextubation respiratory support in preterm infants.
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Affiliation(s)
- Osayame Ekhaguere
- Department of Pediatrics, Section of Neonatal-Perinatal Medicine, Indiana University, Riley Hospital for Children at Indiana University Health, 1030 West Michigan Street, C4600, Indianapolis, IN 46202, USA.
| | - Shama Patel
- Department of Pediatrics, Section of Neonatal-Perinatal Medicine, Indiana University, Riley Hospital for Children at Indiana University Health, 1030 West Michigan Street, C4600, Indianapolis, IN 46202, USA
| | - Haresh Kirpalani
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
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