Closed-loop synchronization versus conventional synchronization in spontaneously breathing pediatric patients (CHESTSIPP) - a randomized controlled cross-over study.

To determine if, compared to pressure support (PS), neurally adjusted ventilatory assist (NAVA) reduces patient-ventilator asynchrony in intensive care patients undergoing noninvasive ventilation with an oronasal face mask. In this prospective interventional study we compared patient-ventilator synchrony between PS (with ventilator settings determined by the clinician) and NAVA (with the level set so as to obtain the same maximal airway pressure as in PS). Two 20-min recordings of airway pressure, flow and electrical activity of the diaphragm during PS and NAVA were acquired in a randomized order. Trigger delay (T(d)), the patient's neural inspiratory time (T(in)), ventilator pressurization duration (T(iv)), inspiratory time in excess (T(iex)), number of asynchrony events per minute and asynchrony index (AI) were determined. The study included 13 patients, six with COPD, and two with mixed pulmonary disease. T(d) was reduced with NAVA: median 35 ms (IQR 31-53 ms) versus 181 ms (122-208 ms); p = 0.0002. NAVA reduced both premature and delayed cyclings in the majority of patients, but not the median T(iex) value. The total number of asynchrony events tended to be reduced with NAVA: 1.0 events/min (0.5-3.1 events/min) versus 4.4 events/min (0.9-12.1 events/min); p = 0.08. AI was lower with NAVA: 4.9 % (2.5-10.5 %) versus 15.8 % (5.5-49.6 %); p = 0.03. During NAVA, there were no ineffective efforts, or late or premature cyclings. PaO(2) and PaCO(2) were not different between ventilatory modes. Compared to PS, NAVA improved patient ventilator synchrony during noninvasive ventilation by reducing T(d) and AI. Moreover, with NAVA, ineffective efforts, and late and premature cyclings were absent.

Background: Administration of nebulized medications is a very common practice in the ICU. Although several aerosol generating devices can be selected, most ICUs use the small volume jet nebulizers. Although some recommendations on where to place aerosol generators when administering aerosol treatments to patients undergoing invasive and noninvasive mechanical ventilation or high-flow nasal cannula (HFNC) have been published, there are still many inconsistencies in the clinical setting. Placement of these aerosol generators can be adversely affected by humidification devices and lead to significant changes in pulmonary mechanics. The goal of this study was to determine where respiratory therapists (RTs) place nebulizer when administering a treatment in the ICU. Methods: For this prospective, observational study, pediatric and adult subjects who were placed on invasive mechanical ventilation (IMV), and noninvasive mechanical ventilation (NIV) or high flow nasal cannula (HFNC) with an order to receive a nebulized treatment were included. The study was conducted at a large university-affiliated hospital in Texas and was approved by the IRB. The research team communicated with RTs when it was time to administer an aerosol treatment to subjects in the ICU. Once the subject was identified, the electronic medical record was accessed to collect demographic information and placement of the nebulizer was documented in the data collection form as the treatment was administered. Results: A total of 32 subjects were selected for analysis; 18 from the pediatric ICU and 14 from the adult ICU. The majority of the sample was on IMV (50%), followed by HFNC (28.1%), and NIV (21.9%). The nebulizer was placed on the dry side of the heated humidifier (HH) in every patient on IMV. For all patients on NIV, nebulizers were placed on the inspiratory limb of the circuit between the interface and the exhalation valve. When placed on HFNC, the nebulizer was connected to the dry side of the HH in 3 subjects while 6 subjects had their nebulizers placed on the inspiratory limb of the breathing circuit. Conclusions: The results of this study suggest that while there is variation in regard to where RTs place the aerosol generator when using HFNC, they are consistent in their practice of placing the nebulizer when using IMV or NIV as recommended in published guidelines. Further evaluation of practices while delivering aerosol treatments to patients on HFNC may be required.

BackgroundResearch on pediatric intensive care unit (PICU) readmission is lacking in China. This study was conducted to describe the risk factors associated with PICU readmission within 1 year after PICU discharge.MethodsThis retrospective case-control study included patients aged from 1 month to 16 years who were discharged between January 2018 and May 2020. The case group included readmitted patients with two or more PICU admissions within 1 year during the study period. The control group included survivors with only one PICU admission during the same study period, and the controls were matched on age and sex. Demographic and clinical variables were collected from the electronic administrative database. Risk factors were analyzed by univariate and multivariate analyses.ResultsFrom January 2018 to May 2020, 2,529 patients were discharged from the PICU, and 103 (4.07%) were readmitted within 1 year. In the univariate analysis, PICU readmission within 1 year was associated with lower weight, the presence of chronic conditions, a higher StrongKids score on admission, length of PICU stay of more than 2 weeks, the presence of dysfunction at discharge, sedation medications use, vasopressor use, and invasive mechanical ventilation in the first PICU stay. Patients had a higher StrongKids score as a surrogate for increased risk of malnutrition. In the multivariate analysis, the factors most significantly associated with PICU readmission within 1 year were the presence of chronic conditions, a higher StrongKids score on admission, and length of PICU stay of more than 2 weeks in the first PICU stay. In the subgroup analysis, compared with the control group, the factors most significantly associated with readmission within 48 h of discharge were the presence of chronic conditions, a higher StrongKids score on admission, and vasopressor use during the first PICU stay. The mortality rate was 8.74% (9/103) in patients with PICU readmission. The overall PICU mortality rate was 7.39% (201/2,721) during the study period.ConclusionsPatients with chronic conditions, a higher StrongKids score on admission, and length of PICU stay of more than 2 weeks were at much higher risk for PICU readmission within 1 year. Patients with vasopressor use during the first PICU hospitalization were more likely to be readmitted within 48 h of discharge.

To address the current practice of liberating patients from invasive mechanical ventilation in pediatric intensive care units, with a focus on the use of standardized protocols, criteria, parameters, and indications for noninvasive respiratory support postextubation. Electronic research was carried out from November 2021 to May 2022 in Ibero-American pediatric intensive care units. Physicians and respiratory therapists participated, with a single representative for each pediatric intensive care unit included. There were no interventions. The response rate was 48.9% (138/282), representing 10 Ibero-American countries. Written invasive mechanical ventilation liberation protocols were available in only 34.1% (47/138) of the pediatric intensive care units, and their use was associated with the presence of respiratory therapists (OR 3.85; 95%CI 1.79 - 8.33; p = 0.0008). The most common method of liberation involved a gradual reduction in ventilatory support plus a spontaneous breathing trial (47.1%). The mean spontaneous breathing trial duration was 60 - 120 minutes in 64.8% of the responses. The presence of a respiratory therapist in the pediatric intensive care unit was the only variable associated with the use of a spontaneous breathing trial as the primary method of liberation from invasive mechanical ventilation (OR 5.1; 95%CI 2.1 - 12.5). Noninvasive respiratory support protocols were not frequently used postextubation (40.4%). Nearly half of the respondents (43.5%) reported a preference for using bilevel positive airway pressure as the mode of noninvasive ventilation postextubation. A high proportion of Ibero-American pediatric intensive care units lack liberation protocols. Our study highlights substantial variability in extubation readiness practices, underscoring the need for standardization in this process. However, the presence of a respiratory therapist was associated with increased adherence to guidelines.

BackgroundConventional pressure support ventilation (PSP) is triggered and cycled off by pneumatic signals such as flow. Patient-ventilator asynchrony is common during pressure support ventilation, thereby contributing to an increased inspiratory effort. Using diaphragm electrical activity, neurally controlled pressure support (PSN) could hypothetically eliminate the asynchrony and reduce inspiratory effort. The purpose of this study was to compare the differences between PSN and PSP in terms of patient-ventilator synchrony, inspiratory effort, and breathing pattern.MethodsEight post-operative patients without respiratory system comorbidity, eight patients with acute respiratory distress syndrome (ARDS) and obvious restrictive acute respiratory failure (ARF), and eight patients with chronic obstructive pulmonary disease (COPD) and mixed restrictive and obstructive ARF were enrolled. Patient-ventilator interactions were analyzed with macro asynchronies (ineffective, double, and auto triggering), micro asynchronies (inspiratory trigger delay, premature, and late cycling), and the total asynchrony index (AI). Inspiratory efforts for triggering and total inspiration were analyzed.ResultsTotal AI of PSN was consistently lower than that of PSP in COPD (3% vs. 93%, P = 0.012 for 100% support level; 8% vs. 104%, P = 0.012 for 150% support level), ARDS (8% vs. 29%, P = 0.012 for 100% support level; 16% vs. 41%, P = 0.017 for 150% support level), and post-operative patients (21% vs. 35%, P = 0.012 for 100% support level; 15% vs. 50%, P = 0.017 for 150% support level). Improved support levels from 100% to 150% statistically increased total AI during PSP but not during PSN in patients with COPD or ARDS. Patients’ inspiratory efforts for triggering and total inspiration were significantly lower during PSN than during PSP in patients with COPD or ARDS under both support levels (P < 0.05). There was no difference in breathing patterns between PSN and PSP.ConclusionsPSN improves patient-ventilator synchrony and generates a respiratory pattern similar to PSP independently of any level of support in patients with different respiratory system mechanical properties. PSN, which reduces the trigger and total patient's inspiratory effort in patients with COPD or ARDS, might be an alternative mode for PSP.Trial RegistrationClinicalTrials.gov, NCT01979627; https://clinicaltrials.gov/ct2/show/record/NCT01979627.

Introduction: Bronchiolitis is one of the most common reasons for pediatric intensive care unit (PICU) admission in the U.S., yet it has significant disparities in treatment based on social determinants of health. The purpose of this study was to assess for associations between the Child Opportunity Index (COI) and PICU outcomes in children with bronchiolitis. Methods: Secondary analysis of a multicenter retrospective cohort study including data from 15 PICUs from 1/1/2019-12/31/2020. The dataset was queried for patients 0-2 years of age with bronchiolitis as the primary diagnosis for PICU admission. Patient addresses were mapped to COI 2.0 and assigned to a quintile (very low, low, moderate, high, very high). Demographics and clinical features were compared by COI quintile. Primary outcomes were severity of illness on presentation via PRISM III score and use of invasive mechanical ventilation (IMV) and noninvasive ventilation (NIV). Secondary outcomes were PICU length of stay (LOS) and mortality. Results: Of 3,671 total admissions, the very low COI group had the highest proportion of admissions (28.1%) and history of prematurity (33%). There was no difference in PRISM III scores across all groups. Paired comparisons of COI groups revealed significantly higher use of NIV in the very high COI group compared to the lowest 3 COI groups (p ≤ 0.008). Both the very high and very low groups had lower rates of intubation compared to low and moderate groups (p ≤ 0.04). Neither PICU LOS nor mortality differed significantly across all groups. Multivariate analysis showed PRISM III score (aOR 2.77, 95% CI 2.34-3.27) and prematurity (aOR 1.32, 95% CI 1.05-1.66) as independent risk factors for any positive pressure ventilation (PPV [both IMV and NIV]), but no difference for COI group. Conclusions: In this study, children admitted to the PICU with bronchiolitis are more often from very low COI neighborhoods. Patients from very high COI neighborhoods are more likely to receive NIV support and less likely to require intubation. Interestingly, patients from the very low COI group are also less likely to need intubation compared to the low and moderate COI groups. Higher PRISM III scores and prematurity were risk factors for PPV use, but COI group was not.

Objective To discuss the clinical features and risk factors of death in children with severe pneumonia treated with invasive mechanical ventilation. Methods Through a retrospective analysis of children with severe pneumonia treated with invasive mechanical ventilation, who were hospitalized in PICU of Tianjin Children′s Hospital from Jan 2011 to Dec 2014, we analyzed the distribution of age, etiologic characteristics, mechanical ventilation, complications and background diseases.The single factor analysis and multiple factors Logistic regression analysis were performed to evaluate the risk factors of death. Results A total of 214 pediatric patients were included, 134 were male, and 80 were female.The case fatality rate was 6.17%, the relevance ratio of pathogenic microorganism was 16.36%.The median age of death group was older than that of the survival group(4 mouths vs 2 mouths, P=0.039). The pediatric patients who were more than 1 year old in death group were more than the survival group(21.43% vs 15.8%, P<0.001). The common complications included dencephalopathy(11.68%) and electrolyte imbalance(8.41%). Anemia, cardiopathy and alloplasia of respiratory system were the top background diseases.The results of Logistic multivariate regression analysis showed that there were significant differences in the age above 1 year old(OR: 1.019, 95%CI: 1.003-1.030, P=0.019), secondary acute respiratory distress syndrome(OR: 7.254, 95%CI: 1.581-33.277, P=0.011) and accompanying cardiopathy(OR: 0.47, 95%CI: 0.273-0.81, P=0.007). Conclusion The risk factors of death in children with severe pneumonia treated with invasive mechanical ventilation are the following: the age above 1 year old, secondary acute respiratory distress syndrome or accompanying cardiopathy. Key words: Severe pneumonia; Invasive mechanical ventilation; Clinical feature; Risk factors of death,

Background: To compare the demographic characteristics, clinical symptoms, laboratory findings, and comorbidities of hospitalized children with the Coronavirus disease (COVID-19) who required invasive mechanical ventilation (IMV) and analyse them to find out potential predictors for requirement of mechanical ventilation. Methods: Study design was of single centre, retrospective record review. Settings were tertiary care hospital in New Delhi, India, between April, 2020 to October, 2020 Results: 100-laboratory confirmed COVID-19 cases were admitted during the study period. Thirty-five patients required IMV. Median age of ventilated patients was 65 (10.5, 126) months and median weight was 15 (8.5, 23.3) kg. Forty-three percent (43%) of patients were underweight (p=0.46) while 40% had chronic co-morbidity (p=0.015). Gastrointestinal symptoms (p&lt;0.05), altered sensorium at presentation (p&lt;0.001) and hypoxia at admission (p&lt;0.00) were significantly greater in those who required ventilation. A statistically significant difference was also noted in inflammatory markers between ventilated and non-ventilated patients. Acute kidney injury (p=0.003) and transaminitis (p=0.05) at admission were 26 and 32% respectively in ventilated patients. The most common indicators for ventilation need were primary respiratory disease (35%) followed by shock (31%) and low Glasgow coma scale (23%). Nearly 70% of these were intubated within 48 hours of hospital admission. Multivariate analysis highlighted that presence of low SpO2 at admission (adjusted OR, 6.9; 95% CI, 1.3-36.6) was significantly associated with need of IMV. Conclusions: Study highlights important characteristics of paediatric population from developing country with COVID-19 who required IMV. Presence of low oxygen saturation at admission significantly associated with need of IMV.

Important Outcomes for Parents of Critically Ill Children.

Background Neurally adjusted ventilatory assistance (NAVA) is a new mode of ventilation that uses the electrical activity of the diaphragm (Edi) as a trigger to the patient’s breath, and this causes better patient–ventilator synchrony. The study aims to compare asynchrony during NAVA ventilation and conventional ventilation. Methods This prospective crossover study included 15 patients needing mechanical ventilation who were admitted to Pediatric Intensive Care Unit in Cairo University Children’s Hospital during the period from 2021 to 2024. Each patient was ventilated alternately with NAVA and conventional ventilation, switching modes every 6 h until weaning and extubation. The final 15 min of each 6-h interval were recorded and analyzed for asynchronous events. Results The asynchrony index (AI) was much lower during NAVA ventilation with a mean value of 3.48% (0%–15%), while during conventional ventilation mean AI was 11.73% (1.23%–31%), with a P value of 0.009 (mean difference: − 8.24%, 95% CI: − 13.89 to − 2.59). The main asynchronous event during NAVA was double triggering while auto-triggering was the main asynchronous event during conventional ventilation. Conclusion Neurally adjusted ventilatory assist was found to improve patient–ventilator interaction and is associated with a lower asynchrony index compared to conventional ventilation; however, the small sample size requires cautious interpretation and further validation in larger cohorts.

Objective: To describe the characteristics of children with H1N1 influenza who required PICU (paediatric intensive care unit) treatment. Patients and Methods: We reviewed the charts of all children with laboratory-confirmed H1N1 influenza requiring PICU admission between September 2009 and March 2010 in the Erasmus MC-Sophia Children's Hospital, the Netherlands. Results: 12 children were admitted to our PICU, whereas 1 died before transport to our hospital due to cardiorespiratory failure. Of these 12 children (50% boys, mean age 10.8 years), 7 (58%) had clinical significant previous medical conditions. All 12 presented with fever and flu-like symptoms. Mean interval between onset of symptoms and PICU admission was 2 days (0-5 days). PICU treatment consisted of oseltamivir (n=12, 100%), high flow oxygen through a non-rebreathing mask (n=5, 42%, mean duration 1 day), invasive mechanical ventilation (n=1, 8%, duration 2 days) and extracorporeal membrane oxygenation (ECMO) because of severe cardiorespiratory failure (n=6, 50%). The latter 6 children were referred by other Dutch PICU tertiary centres for ECMO therapy. Of these 6 children, 4 (66%) had clinical significant previous medical conditions. Four of the 6 were discharged alive from the PICU after a mean ECMOduration of 7.5 days, whereas 2 died after a mean ECMO-duration of 31 days because of refractory respiratory failure with a staphylococcus-infection. Conclusions: The majority of children with H1N1 admitted to our PICU were teenagers and had clinical significant previous medical conditions. 50% were referred by other PICU for ECMO treatment. Overall mortality was high (23%).

Aims & Objectives: To investigate the effect of tobacco smoke exposure among severely pediatric intensive care unit (PICU) patients. Methods: A prospective epidemiological observational study was conducted among children with bronchiolitis younger than 2 years of age admitted to a PICU in a tertiary hospital in Madrid, Spain, during the October 2017 to March 2018 outbreak. On admission, parents were asked whether they smoked. In children who required invasive mechanical ventilation, endotracheal aspirate was collected at the time of intubation. Main outcome measures included: need for invasive mechanical ventilation (IMV), pulmonary bacterial infection (PBI) and PICU length of stay. Results: A total of 102 patients with bronchiolitis were studied. Among these, 14 (47%) of 30 infants whose parents smoked required invasive mechanical ventilation vs. 14 (19%) of 72 whose parents were nonsmokers (p=0.007) (RR 2.4; 95% CI 1.3–4.4). Among patients on invasive mechanical ventilation, 10 (71%) of 14 infants with secondhand smoke exposure presented PBI vs. 3 (21%) of 14 in the unexposed (p=0.012) (RR 3.3; 95% CI 1.2–9.6). PICU stay was 3 (IQR 3-6) days in infants whose parents didn´t smoke, and 5 (IQR 3-11) days in infants whose parents smoked (p=0.01). Conclusions: Secondhand smoke exposure is an additional high risk for PBI, IMV, and PICU length of stay, in infants with severe acute bronchiolitis.

Lung ultrasound scoring in invasive mechanically ventilated children with severe bronchiolitis.

Patient-ventilator asynchrony (PVA) is frequent in intensive care. Its presence is associated with prolonged days of mechanical ventilation and may lead to increased mortality in the intensive care unit (ICU) and hospital. Little is known about the ability of Colombian intensive care professionals to identify asynchronies, and the factors associated with their correct identification are not apparent. To describe the ability of Colombian intensive care professionals to identify patient-ventilator asynchronies (PVA) using waveform analysis. In addition, to define the characteristics associated with correctly detecting PVA. We conducted a multicenter, cross-sectional, national survey-based study between January and August 2024. Colombian physiotherapists, respiratory therapists, nurses and intensive care physicians from 24 departments participated in the study. An online survey was used. They were asked to identify six different PVAs presented as videos. The videos were displayed using pressure/time and flow/time waveform of a Puritan Bennett 840 ventilator. We recruited 900 participants, 60% female, most of whom were physiotherapists (53%). Most professionals had specialty training in critical care (42%), and 32% reported having specific PVA training. Double triggering was the most frequently identified PVA (75%). However, only 3.67% of participants recognized all six PVAs. According to multiple logistic regression analysis, working in a mixed unit (OR 2.59; 95% CI 1.19 - 5.54), caring for neonates (OR 5.19; 95% CI 1.77 - 15.20), and having specific training (OR 2.38; 95% CI 1.16 - 4.76) increases the chance of correctly recognizing all PVAs. In Colombia, a low percentage of professionals recognize all PVAs. Having specific training in this topic, working in mixed ICUs and neonatal intensive care was significantly associated with identifying all PVAs.

Ineffective effort (IE) is a frequent patient-ventilator asynchrony in invasive mechanical ventilation. This study aimed to investigate the incidence of IE and to explore its relationship with respiratory drive in subjects with acute brain injury undergoing invasive mechanical ventilation. We retrospectively analyzed a clinical database that assessed patient-ventilator asynchrony in subjects with acute brain injury. IE was identified based on airway pressure, flow, and esophageal pressure waveforms collected at 15-min intervals 4 times daily. At the end of each data set recording, airway-occlusion pressure (P0.1) was determined by the airway occlusion test. IE index was calculated to indicate the severity of IE. The incidence of IE in different types of brain injuries as well as its relationship with P0.1 was determined. We analyzed 852 data sets of 71 subjects with P0.1 measured and undergoing mechanical ventilation for at least 3 d after enrollment. IE was detected in 688 (80.8%) data sets, with a median index of 2.2% (interquartile range 0.4-13.1). Severe IE (IE index ≥ 10%) was detected in 246 (28.9%) data sets. The post craniotomy for brain tumor and the stroke groups had higher median IE index and lower P0.1 compared with the traumatic brain injury group (2.6% [0.7-9.7] vs 2.7% [0.3-21] vs 1.2% [0.1-8.5], P = .002; 1.4 [1-2] cm H2O vs 1.5 [1-2.2] cm H2O vs 1.8 [1.1-2.8] cm H2O, P = .001). Low respiratory drive (P0.1 < 1.14 cm H2O) was independently associated with severe IE in the expiratory phase (IEE) even after adjusting for confounding factors by logistic regression analysis (odds ratio 5.18 [95% CI 2.69-10], P < .001). IE was very common in subjects with acute brain injury. Low respiratory drive was independently associated with severe IEE.