To summarize the current literature describing high-flow nasal cannula use in children, the components and mechanisms of action of a high-flow nasal cannula system, the appropriate clinical ...applications, and its role in the pediatric emergency department.
A computer-based search of PubMed/MEDLINE and Google Scholar for literature on high-flow nasal cannula use in children was performed.
High-flow nasal cannula, a non-invasive respiratory support modality, provides heated and fully humidified gas mixtures to patients via a nasal cannula interface. High-flow nasal cannula likely supports respiration though reduced inspiratory resistance, washout of the nasopharyngeal dead space, reduced metabolic work related to gas conditioning, improved airway conductance and mucociliary clearance, and provision of low levels of positive airway pressure. Most data describing high-flow nasal cannula use in children focuses on those with bronchiolitis, although high-flow nasal cannula has been used in children with other respiratory diseases. Introduction of high-flow nasal cannula into clinical practice, including in the emergency department, has been associated with decreased rates of endotracheal intubation. Limited prospective interventional data suggest that high-flow nasal cannula may be similarly efficacious as continuous positive airway pressure and more efficacious than standard oxygen therapy for some patients. Patient characteristics, such as improved tachycardia and tachypnea, have been associated with a lack of progression to endotracheal intubation. Reported adverse effects are rare.
High-flow nasal cannula should be considered for pediatric emergency department patients with respiratory distress not requiring immediate endotracheal intubation; prospective, pediatric emergency department-specific trials are needed to better determine responsive patient populations, ideal high-flow nasal cannula settings, and comparative efficacy vs. other respiratory support modalities.
Resumir a literatura atual que descreve o uso da cânula nasal de alto fluxo em crianças, os componentes e mecanismos de ação do sistema de cânula nasal de alto fluxo, as aplicações clínicas adequadas e o papel desse sistema no departamento de emergência pediátrico.
Realizamos uma pesquisa informatizada na PubMed/MEDLINE e utilizamos o Google Acadêmico para encontrar literatura sobre o uso da cânula nasal de alto fluxo em crianças.
A cânula nasal de alto fluxo, modalidade de suporte respiratório não invasiva, fornece misturas de gases aquecidas e totalmente umidificadas para pacientes por meio de uma cânula nasal. A cânula nasal de alto fluxo provavelmente auxilia a respiração por meio da redução da resistência inspiratória, eliminação do espaço morto anatômico nasofaríngeo, redução do trabalho metabólico relacionado ao condicionamento de gás, melhora da condutância das vias aéreas e transporte mucociliar e fornecimento de baixos níveis de pressão positiva nas vias aéreas. A maior parte dos dados que descrevem o uso da cânula nasal de alto fluxo em crianças é focada em crianças com bronquiolite, embora a cânula nasal de alto fluxo tenha sido usada em crianças com outras causas de doenças respiratórias. A introdução da cânula nasal de alto fluxo na prática clínica, incluindo o departamento de emergência, foi associada à redução dos índices de intubação endotraqueal. Dados intervencionistas prospectivos limitados sugerem que a cânula nasal de alto fluxo pode ser tão eficaz quanto a pressão positiva contínua nas vias aéreas e mais eficaz do que a oxigenoterapia padrão em alguns pacientes. As características dos pacientes, como melhora da taquicardia e taquipneia, foram associadas a uma ausência de progressão para intubação endotraqueal. Foram raros os efeitos adversos relatados.
A cânula nasal de alto fluxo deve ser considerada para pacientes do departamento de emergência pediátrico com insuficiência respiratória que não precisam de intubação endotraqueal imediata, contudo, são necessários ensaios clínicos prospectivos específicos para o departamento de emergência pediátrico para determinar melhor as populações de pacientes que respondem ao tratamento, as configurações ideais da cânula nasal de alto fluxo e a eficácia comparada a outras modalidades de suporte respiratório.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Initial respiratory support with noninvasive positive pressure ventilation or high-flow nasal cannula may prevent the need for invasive mechanical ventilation in PICU patients with bronchiolitis. ...However, it is not clear whether the initial choice of respiratory support modality influences the need for subsequent invasive mechanical ventilation. The purpose of this study is to compare the rate of subsequent invasive mechanical ventilation after initial support with noninvasive positive pressure ventilation or high-flow nasal cannula in children with bronchiolitis.
Analysis of the Virtual Pediatric Systems database.
Ninety-two participating PICUs.
Children less than 2 years old admitted to a participating PICU between 2009 and 2015 with a diagnosis of bronchiolitis who were prescribed high-flow nasal cannula or noninvasive positive pressure ventilation as the initial respiratory treatment modality.
None. Subsequent receipt of invasive mechanical ventilation was the primary outcome.
We identified 6,496 subjects with a median age 3.9 months (1.7-9.5 mo). Most (59.7%) were male, and 23.4% had an identified comorbidity. After initial support with noninvasive positive pressure ventilation or high-flow nasal cannula, 12.3% of patients subsequently received invasive mechanical ventilation. Invasive mechanical ventilation was more common in patients initially supported with noninvasive positive pressure ventilation compared with high-flow nasal cannula (20.1% vs 11.0%: p < 0.001). In a multivariate logistic regression model that adjusted for age, weight, race, viral etiology, presence of a comorbid diagnosis, and Pediatric Index of Mortality score, initial support with noninvasive positive pressure ventilation was associated with a higher odds of subsequent invasive mechanical ventilation compared with high-flow nasal cannula (odds ratio, 1.53; 95% CI, 1.24-1.88).
In this large, multicenter database study of infants with acute bronchiolitis that received initial respiratory support with high-flow nasal cannula or noninvasive positive pressure ventilation, noninvasive positive pressure ventilation use was associated with higher rates of invasive mechanical ventilation, even after adjusting for demographics, comorbid condition, and severity of illness. A large, prospective, multicenter trial is needed to confirm these findings.
More than 4 billion passengers travel on commercial airline flights yearly. Although in-flight medical events involving adult passengers have been well characterized, data describing those affecting ...children are lacking. This study seeks to characterize pediatric in-flight medical events and their immediate outcomes, using a worldwide sample.
We reviewed the records of all in-flight medical events from January 1, 2015, to October 31, 2016, involving children younger than 19 years treated in consultation with a ground-based medical support center providing medical support to 77 commercial airlines worldwide. We characterized these in-flight medical events and determined factors associated with the need for additional care at destination or aircraft diversion.
From a total of 75,587 in-flight medical events, we identified 11,719 (15.5%) involving children. Most in-flight medical events occurred on long-haul flights (76.1%), and 14% involved lap infants. In-flight care was generally provided by crew members only (88.6%), and physician (8.7%) or nurse (2.1%) passenger volunteers. Most in-flight medical events were resolved in flight (82.9%), whereas 16.5% required additional care on landing, and 0.5% led to aircraft diversion. The most common diagnostic categories were nausea or vomiting (33.9%), fever or chills (22.2%), and acute allergic reaction (5.5%). Events involving lap infants, syncope, seizures, burns, dyspnea, blunt trauma, lacerations, or congenital heart disease; those requiring the assistance of a volunteer medical provider; or those requiring the use of oxygen were positively correlated with the need for additional care after disembarkment.
Most pediatric in-flight medical events are resolved in flight, and very few lead to aircraft diversion, yet 1 in 6 cases requires additional care.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
To describe rates and associated risk factors for functional decline 6 months after critical bronchiolitis in a large, multicenter dataset.
Nonprespecified secondary analysis of existing 6-month ...follow-up data of patients in the Randomized Evaluation of Sedation Titration for Respiratory Failure trial ( RESTORE , NCT00814099).
Patients recruited to RESTORE in any of 31 PICUs in the United States, 2009-2013.
Mechanically ventilated PICU patients under 2 years at admission with a primary diagnosis of bronchiolitis.
There were no interventions in this secondary analysis; in the RESTORE trial, PICUs were randomized to protocolized sedation versus usual care.
"Functional decline," defined as worsened Pediatric Overall Performance Category and/or Pediatric Cerebral Performance Category (PCPC) scores at 6 months post-PICU discharge as compared with preillness baseline. Quality of life was assessed using Infant Toddler Quality of Life Questionnaire (ITQOL; children < 2 yr old at follow-up) or Pediatric Quality of Life Inventory (PedsQL) at 6 months post-PICU discharge. In a cohort of 232 bronchiolitis patients, 28 (12%) had functional decline 6 months postdischarge, which was associated with unfavorable quality of life in several ITQOL and PedsQL domains. Among 209 patients with normal baseline functional status, 19 (9%) had functional decline. In a multivariable model including all subjects, decline was associated with greater odds of worse baseline PCPC score and longer PICU length of stay (LOS). In patients with normal baseline status, decline was also associated with greater odds of longer PICU LOS.
In a random sampling of RESTORE subjects, 12% of bronchiolitis patients had functional decline at 6 months. Given the high volume of mechanically ventilated patients with bronchiolitis, this observation suggests many young children may be at risk of new morbidities after PICU admission, including functional and/or cognitive morbidity and reduced quality of life.
Describe the frequency with which transfusion and medications that modulate lung injury are administered to children meeting at-risk for pediatric acute respiratory distress syndrome (ARF-PARDS) ...criteria and evaluate for associations of transfusion, fluid balance, nutrition, and medications with unfavorable clinical outcomes.
Secondary analysis of the Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology study, a prospective point prevalence study. All enrolled ARF-PARDS patients were included unless they developed subsequent pediatric acute respiratory distress syndrome (PARDS) within 24 hours of PICU admission or PICU length of stay was less than 24 hours. Univariate and multivariable analyses were used to identify associations between therapies given during the first 2 calendar days after ARF-PARDS diagnosis and subsequent PARDS diagnosis (primary outcome), 28-day PICU-free days (PFDs), and 28-day ventilator-free days (VFDs).
Thirty-seven international PICUs.
Two hundred sixty-seven children meeting Pediatric Acute Lung Injury Consensus Conference ARF-PARDS criteria.
None.
During the first 2 days after meeting ARF-PARDS criteria, 55% of subjects received beta-agonists, 42% received corticosteroids, 28% received diuretics, and 9% were transfused. Subsequent PARDS (15%) was associated with platelet transfusion (n = 11; adjusted odds ratio: 4.75 95% CI 1.03-21.92) and diuretics (n = 74; 2.55 1.19-5.46) in multivariable analyses that adjusted for comorbidities, PARDS risk factor, initial oxygen saturation by pulse oximetry:Fio2 ratio, and initial type of ventilation. Beta-agonists were associated with lower adjusted odds of subsequent PARDS (0.43 0.19-0.98). Platelets and diuretics were also associated with fewer PFDs and fewer VFDs in the multivariable models, and TPN was associated with fewer PFDs. Corticosteroids, net fluid balance, and volume of enteral feeding were not associated with the primary or secondary outcomes.
There is an independent association between platelet transfusion, diuretic administration, and unfavorable outcomes in children at risk for PARDS, although this may be related to treatment bias and unmeasured confounders. Nevertheless, prospective evaluation of the role of these management strategies on outcomes in children with ARF-PARDS is needed.
Over 20,000 children are hospitalized in the United States for asthma every year. Although initial treatment guidelines are well established, there is a lack of high-quality evidence regarding the ...optimal respiratory support devices for these patients.
The objective of this study was to evaluate institutional and temporal variability in the use of respiratory support modalities for pediatric critical asthma.
We conducted a retrospective cohort study using data from the Virtual Pediatrics Systems database. Our study population included children older than 2 years old admitted to a VPS contributing pediatric intensive care unit from January 2012 to December 2021 with a primary diagnosis of asthma or status asthmaticus. We evaluated the percentage of encounters using a high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), noninvasive bilevel positive pressure ventilation (NIV), and invasive mechanical ventilation (IMV) for all institutions, then divided institutions into quintiles based on the volume of patients. We created logistic regression models to determine the influence of institutional volume and year of admission on respiratory support modality use. We also conducted time-series analyses using Kendall's tau.
Our population included 77,115 patient encounters from 163 separate institutions. Institutional use of respiratory modalities had significant variation in HFNC (28.3%, interquartile range IQR, 11.0-49.0%;
< 0.01), CPAP (1.4%; IQR, 0.3-4.3%;
< 0.01), NIV (8.6%; IQR, 3.5-16.1%;
< 0.01), and IMV (5.1%; IQR, 3.1-8.2%;
< 0.01). Increased institutional patient volume was associated with significantly increased use of NIV (odds ratio OR, 1.33; 1.29-1.36;
< 0.01) and CPAP (OR, 1.20; 1.15-1.25;
< 0.01), and significantly decreased use of HFNC (OR, 0.80; 0.79-0.81;
< 0.01) and IMV (OR, 0.82; 0.79-0.86;
< 0.01). Time was also associated with a significant increase in the use of HFNC (11.0-52.3%;
< 0.01), CPAP (1.6-5.4%;
< 0.01), and NIV (3.7-21.2%;
< 0.01), whereas there was no significant change in IMV use (6.1-4.0%;
= 0.11).
Higher-volume centers are using noninvasive positive pressure ventilation more frequently for pediatric critical asthma and lower frequencies of HFNC and IMV. Treatment with HFNC, CPAP, and NIV for this population is increasing in the last decade.
Background
Periostin is a protein that serves as a downstream marker of the T‐helper type 2 (Th2) cell response. It may serve to identify drug‐responsive inflammatory phenotypes, particularly in ...children with asthma and possibly bronchiolitis. There are no published levels of periostin in healthy children <2 years of age, limiting interpretation of periostin levels in disease. We sought to explore the range of periostin levels of children <2 years without significant confounding illnesses.
Methods
Children undergoing clinically indicated phlebotomy or having a peripheral intravenous catheter inserted prior to general anesthesia or procedural sedation were enrolled. A 0.5 mL sample of blood was collected and frozen at −70°C. After thawing, periostin was measured with a Luminex assay (R&D Systems, Minneapolis, MN). Medical record review and/or parental interview elicited potential variables associated with periostin. Association was evaluated using Mann‐Whitney rank sum test, Kruskal‐Wallis ANOVA, and Spearman correlation as appropriate.
Results
Among 43 children (23 male, 20 female, age range 9‐15.7 months), periostin levels were inversely correlated to age (r = −0.438, P = 0.003). Periostin levels also differed significantly between children <12mo (734.0 576.6‐906.5 ng/mL), 12‐18mo (645.1 363.8‐538.2 ng/mL) and >18mo (416.4 363.8‐538.15 ng/mL) (P < 0.001).
Conclusion
In our sample of relatively healthy patients <2 years old, periostin levels were inversely correlated with age and not dependent on other studied variables. However, further work is needed to establish normal periostin values in young children.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Children with status asthmaticus refractory to first-line therapies of systemic corticosteroids and inhaled beta-agonists often receive additional treatments. Because there are no national guidelines ...on the use of asthma therapies in the PICU, we sought to evaluate institutional variability in the use of adjunctive asthma treatments and associations with length of stay (LOS) and PICU use.
Multicenter retrospective cohort study.
Administrative data from the Pediatric Health Information Systems (PHIS) database.
All inpatients 2-18 years old were admitted to a PHIS hospital between 2013 and 2021 with a diagnostic code for asthma.
None.
This study included 213,506 inpatient encounters for asthma, of which 29,026 patient encounters included care in a PICU from 39 institutions. Among these PICU encounters, large variability was seen across institutions in both the number of adjunctive asthma therapies used per encounter (min: 0.6, median: 1.7, max: 2.5, p < 0.01) and types of adjunctive asthma therapies (aminophylline, ipratropium, magnesium, epinephrine, and terbutaline) used. The center-level median hospital LOS ranged from 1 (interquartile range IQR: 1, 3) to 4 (3, 6) days. Among all the 213,506 inpatient encounters for asthma, the range of asthma admissions that resulted in PICU admission varied between centers from 5.2% to 47.3%. The average number of adjunctive therapies used per institution was not significantly associated with hospital LOS ( p = 0.81) nor the percentage of encounters with PICU admission ( p = 0.47).
Use of adjunctive therapies for status asthmaticus varies widely among large children's hospitals and was not associated with hospital LOS or the percentage of encounters with PICU admission. Wide variance presents an opportunity for standardizing care with evidence-based guidelines to optimize outcomes and decrease adverse treatment effects and hospital costs.
To describe mechanical ventilation management and factors associated with nonadherence to lung-protective ventilation principles in pediatric acute respiratory distress syndrome.
A planned ancillary ...study to a prospective international observational study. Mechanical ventilation management (every 6 hr measurements) during pediatric acute respiratory distress syndrome days 0-3 was described and compared with Pediatric Acute Lung Injury Consensus Conference tidal volume recommendations (< 7 mL/kg in children with impaired respiratory system compliance, < 9 mL/kg in all other children) and the Acute Respiratory Distress Syndrome Network lower positive end-expiratory pressure/higher Fio2 grid recommendations.
Seventy-one international PICUs.
Children with pediatric acute respiratory distress syndrome.
None.
Analyses included 422 children. On pediatric acute respiratory distress syndrome day 0, median tidal volume was 7.6 mL/kg (interquartile range, 6.3-8.9 mL/kg) and did not differ by pediatric acute respiratory distress syndrome severity. Plateau pressure was not recorded in 97% of measurements. Using delta pressure (peak inspiratory pressure - positive end-expiratory pressure), median tidal volume increased over quartiles of median delta pressure (p = 0.007). Median delta pressure was greater than or equal to 18 cm H2O for all pediatric acute respiratory distress syndrome severity levels. In severe pediatric acute respiratory distress syndrome, tidal volume was greater than or equal to 7 mL/kg 62% of the time, and positive end-expiratory pressure was lower than recommended by the positive end-expiratory pressure/Fio2 grid 70% of the time. In multivariable analysis, tidal volume nonadherence was more common with severe pediatric acute respiratory distress syndrome, fewer PICU admissions/yr, non-European PICUs, higher delta pressure, corticosteroid use, and pressure control mode. Adherence was associated with underweight stature and cuffed endotracheal tubes. In multivariable analysis, positive end-expiratory pressure/Fio2 grid nonadherence was more common with higher pediatric acute respiratory distress syndrome severity, ventilator decisions made primarily by the attending physician, pre-ICU cardiopulmonary resuscitation, underweight stature, and age less than 2 years. Adherence was associated with respiratory therapist involvement in ventilator management and longer time from pediatric acute respiratory distress syndrome diagnosis. Higher nonadherence to tidal volume and positive end-expiratory pressure recommendations were independently associated with higher mortality and longer duration of ventilation after adjustment for confounding variables. In stratified analyses, these associations were primarily influenced by children with severe pediatric acute respiratory distress syndrome.
Nonadherence to lung-protective ventilation principles is common in pediatric acute respiratory distress syndrome and may impact outcome. Modifiable factors exist that may improve adherence.
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