Pediatric (PARDS) and neonatal (NARDS) acute respiratory distress syndrome have different age-specific characteristics and definitions. Trials on surfactant for ARDS in children and neonates have ...been performed well before the PARDS and NARDS definitions and yielded conflicting results. This is mainly due to heterogeneity in study design reflecting historic lack of pathobiology knowledge. We reviewed the available clinical and preclinical data to create an expert consensus aiming to inform future research steps and advance the knowledge in this area. Eight trials investigated the use of surfactant for ARDS in children and ten in neonates, respectively. There were improvements in oxygenation (7/8 trials in children, 7/10 in neonates) and mortality (3/8 trials in children, 1/10 in neonates) improved. Trials were heterogeneous for patients' characteristics, surfactant type and administration strategy. Key pathobiological concepts were missed in study design. Consensus with strong agreement was reached on four statements: 1. There are sufficient preclinical and clinical data to support targeted research on surfactant therapies for PARDS and NARDS. Studies should be performed according to the currently available definitions and considering recent pathobiology knowledge. 2. PARDS and NARDS should be considered as syndromes and should be pre-clinically studied according to key characteristics, such as direct or indirect (primary or secondary) nature, clinical severity, infectious or non-infectious origin or patients' age. 3. Explanatory should be preferred over pragmatic design for future trials on PARDS and NARDS. 4. Different clinical outcomes need to be chosen for PARDS and NARDS, according to the trial phase and design, trigger type, severity class and/or surfactant treatment policy. We advocate for further well-designed preclinical and clinical studies to investigate the use of surfactant for PARDS and NARDS following these principles.
Purpose
Much of the common practice in paediatric mechanical ventilation is based on personal experiences and what paediatric critical care practitioners have adopted from adult and neonatal ...experience. This presents a barrier to planning and interpretation of clinical trials on the use of specific and targeted interventions. We aim to establish a European consensus guideline on mechanical ventilation of critically children.
Methods
The European Society for Paediatric and Neonatal Intensive Care initiated a consensus conference of international European experts in paediatric mechanical ventilation to provide recommendations using the Research and Development/University of California, Los Angeles, appropriateness method. An electronic literature search in PubMed and EMBASE was performed using a combination of medical subject heading terms and text words related to mechanical ventilation and disease-specific terms.
Results
The Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) consisted of a panel of 15 experts who developed and voted on 152 recommendations related to the following topics: (1) general recommendations, (2) monitoring, (3) targets of oxygenation and ventilation, (4) supportive measures, (5) weaning and extubation readiness, (6) normal lungs, (7) obstructive diseases, (8) restrictive diseases, (9) mixed diseases, (10) chronically ventilated patients, (11) cardiac patients and (12) lung hypoplasia syndromes. There were 142 (93.4%) recommendations with “strong agreement”. The final iteration of the recommendations had none with equipoise or disagreement.
Conclusions
These recommendations should help to harmonise the approach to paediatric mechanical ventilation and can be proposed as a standard-of-care applicable in daily clinical practice and clinical research.
Severe bronchiolitis patients are often supported with non-invasive ventilation (NIV). In case of NIV failure, we recently started to use non-invasive neurally adjusted ventilatory assist ventilation ...(NIV-NAVA) with a total face mask interface (TFM) and report now our experience with this modality of respiratory support. Retrospective study was made from October 2022 to May 2023 at the Geneva University Hospital Paediatric Intensive Care Unit. Inclusion criteria were children, aged from 0 to 6 months, with severe bronchiolitis with initial NIV failure and switch to NIV-NAVA-TFM. From 49 children with respiratory syncytial virus (RSV)-induced bronchiolitis requiring any form of respiratory support, 10 (median age 61 days (IQR 44–73) failing CPAP or NIV underwent rescue treatment with NIV-NAVA using a TFM. Patients were switched to TFM-NIV-NAVA 8 h (IQR 3–22) after admission for 24.5 h (IQR 13–60). After initiation of TFM-NIV-NAVA, oxygenation improved significantly as early as 1 h after initiation, whereas transcutaneous CO
2
values remained stable. None of the patients needed to be intubated and there was no episode of TFM discontinuation due to interface discomfort or other unwanted side effects. Sedation was used in all patients with high proportion of intravenous dexmedetomidine. Median ventilatory assistance duration was 2.5 days (IQR 2–4) and median PICU stay was 4.5 (IQR 3–6).
Conclusion
: In infants with severe RSV-induced bronchiolitis, respiratory support with TFM-NIV-NAVA seems to be feasible as a rescue therapy and might be considered in selected patients.
What is Known:
• Bronchiolitic patients with NIV support failure may require invasive mechanical ventilation.
• Interface related complications, especially facial sores, can be a cause of NIV failure.
What is New:
• Total face mask with non-invasive neurally adjusted ventilatory assist (TFM-NIV-NAVA) seems feasible as a rescue therapy in deteriorating patients with CPAP or NIV failure.
• TFM-NIV-NAVA can improve oxygenation rapidly in patients with aggravating hypoxemia and seems to be well tolerated.
Endotracheal suctioning is a widely used procedure to remove secretions from the airways of ventilated patients. Despite its prevalence, regional effects of this maneuver have seldom been studied. In ...this study, we explore its effects on regional lung aeration in neonates and young infants using electrical impedance tomography (EIT) as part of the large EU-funded multicenter observational study CRADL. 200 neonates and young infants in intensive care units were monitored with EIT for up to 72 h. EIT parameters were calculated to detect changes in ventilation distribution, ventilation inhomogeneity and ventilation quantity on a breath-by-breath level 5-10 min before and after suctioning. The intratidal change in aeration over time was investigated by means of regional expiratory time constants calculated from all respiratory cycles using an innovative procedure and visualized by 2D maps of the thoracic cross-section. 344 tracheal suctioning events from 51 patients could be analyzed. They showed no or very small changes of EIT parameters, with a dorsal shift of the center of ventilation by 0.5% of the chest diameter and a 7% decrease of tidal impedance variation after suctioning. Regional time constants did not change significantly. Routine suctioning led to EIT-detectable but merely small changes of the ventilation distribution in this study population. While still a measure requiring further study, the time constant maps may help clinicians interpret ventilation mechanics in specific cases.
Purpose
To determine whether, during mechanical ventilation, an optimal positive end-expiratory pressure (PEEP) can be identified by measurement of regional tidal volume and compliance
V
T(reg)
,
C
...RS(reg)
.
Methods
Sixteen anaesthetized intubated neonatal piglets underwent a stepwise vital capacity manoeuvre performed during pressure control ventilation, with 5 cmH
2
O PEEP increments to 25 cmH
2
O, and decrements to 0 cmH
2
O. Peak inflating pressure was 10 cmH
2
O above PEEP throughout. The manoeuvre was performed in the normal lung, after repeated saline lavage and after surfactant therapy. Global
V
T
and
C
RS
were measured at the airway opening;
V
T(reg)
and
C
RS(reg)
were measured in the ventral, medial and dorsal lung using electrical impedance tomography (EIT).
Results
Most uniform distribution of regional tidal ventilation was noted during PEEP decrements after lung recruitment, at varying PEEP levels. In the lavaged and surfactant-treated lung the PEEP optimal for ventilation distribution was also associated with highest mean
V
T(reg)
lavaged: 95 ± 9.3% of maximum, mean ± standard deviation (SD); surfactant-treated: 92 ± 17% and global
V
T
(96 ± 10%; 96 ± 15%). Regional
C
RS
plots clearly demonstrated co-existent ventral overdistension and dorsal recruitment, particularly during PEEP increments; whereas during PEEP decrements, peak
C
RS(reg)
values showed considerable interregional concordance e.g. peak
C
RS(reg)
in the lavaged left lung; ventral: 0.017 ± 0.0036; medial: 0.016 ± 0.0054; dorsal: 0.017 ± 0.0073 cmH
2
O
−1
;
P
= 0.98, analysis of variance (ANOVA).
Conclusions
After lung recruitment, a PEEP level can be identified by EIT at which tidal ventilation is uniformly distributed, with associated concordance in compliance between lung regions. Bedside monitoring of regional tidal ventilation and compliance using EIT may thus aid in PEEP selection.
The aim of this study was to evaluate the impact of pre-extracorporeal membrane oxygenation (ECMO) ventilatory parameters with in-hospital mortality in children with pediatric acute respiratory ...distress syndrome undergoing ECMO for respiratory indication. In this retrospective analysis of the Extracorporeal Life Support Organization (ELSO) Registry, all pediatric patients (≥29 days to ≤18 years) who required ECMO for respiratory indications were screened. The primary outcome was in-hospital mortality. From 2013 to 2017, 2,727 pediatric ECMO runs with a respiratory indication were reported to the ELSO registry. Overall mortality was 37%. Oxygenation Index (OI) and duration of mechanical ventilation (MV) before ECMO deployment were both independently associated with in-hospital mortality. No threshold effect for OI was observed. Pre-ECMO positive end-expiratory pressure and delta pressure levels were respectively lower and higher than recommended. Mortality rates for OI values between 4 and 60 and above oscillated between 32% and 45%. Children within a wider range of pre-ECMO OI (either below or above 40) might be considered as reasonable candidates for ECMO deployment. Larger, prospective multicenter studies to confirm the discriminatory ability of OI are warranted.
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