A narrative review of advanced ventilator modes in the pediatric intensive care unit.

Respiratory failure is a common reason for pediatric intensive care unit admission. The vast majority of children requiring mechanical ventilation can be supported with conventional mechanical ventilation (CMV) but certain cases with refractory hypoxemia or hypercapnia may require more advanced modes of ventilation. This paper discusses what we have learned about the use of advanced ventilator modes [e.g., high-frequency oscillatory ventilation (HFOV), high-frequency percussive ventilation (HFPV), high-frequency jet ventilation (HFJV) airway pressure release ventilation (APRV), and neurally adjusted ventilatory assist (NAVA)] from clinical, animal, and bench studies. The evidence supporting advanced ventilator modes is weak and consists of largely of single center case series, although a few RCTs have been performed. Animal and bench models illustrate the complexities of different modes and the challenges of applying these clinically. Some modes are proprietary to certain ventilators, are expensive, or may only be available at well-resourced centers. Future efforts should include large, multicenter observational, interventional, or adaptive design trials of different rescue modes (e.g., PROSpect trial), evaluate their use during ECMO, and should incorporate assessments through volumetric capnography, electric impedance tomography, and transpulmonary pressure measurements, along with precise reporting of ventilator parameters and physiologic variables.

High-Frequency Jet Ventilation in Neonatal and Pediatric Subjects: A Narrative Review.

High-frequency ventilation is commonly utilized with neonates and with children with severe respiratory failure. Both high-frequency oscillatory ventilation (HFOV) and high-frequency jet ventilation (HFJV) are used extensively in neonates. HFJV can also be used in older, larger children. The purpose of this narrative review is to discuss the physiologic principles behind HFJV, examine the evidence supporting its use in neonatal and pediatric ICUs, give meaningful guidance for clinical application, and highlight potential areas for future research.

Evaluating Endotracheal Tube Depth in Infants Weighing Less Than 1 Kilogram.

BACKGROUND: Endotracheal tube (ETT) depth in premature infants is of critical importance because potentially life-threatening adverse events can occur if the tube is malpositioned. Analysis of current data indicates that the accuracy of current resuscitation guidelines for infants <1 kg is poor. We hypothesized that a weight-based formula that is used clinically in our institution would accurately predict appropriate ETT placement in infants weighing < 1 kg. METHODS: The medical records, from July 2013 to November 2016, of all infants < 1 kg who were intubated were retrospectively reviewed and included. The 2 formulas utilized were the Duke formulas 5.5 cm + 1 cm/kg for infants 500-999 g or 5.0 + 1 cm/kg for infants <500 g. The appropriate ETT position was defined as the tip of the ETT below the thoracic inlet and above the carina, at approximately thoracic vertebrae 2 or 3 on an initial chest radiograph. The formula was defined as being accurate if the documented ETT depth was within 0.2 cm of the predicted depth. Post hoc analysis of current resuscitation guidelines (6 cm plus the weight of the infant in kg) was performed after the Duke formula performed worse than expected. RESULTS: A total of 131 subjects (mean ± gestational age, 26 ± 1.8 wk; mean ± weight, 729 ± 140 g) were included. The documented depth was accurately predicted by the Duke formula for 47% of the subjects, with 69% of the ETTs appropriately positioned as seen on a chest radiograph. Sensitivity was 46.6%, specificity was 53.6%, positive predictive value was 68.8% and negative predictive value was 31.4% for the Duke formula. Post hoc analysis current resuscitation guidelines found that the documented depth was accurately predicted for 23% infants, with 70% of these appropriately positioned ETTs. CONCLUSIONS: Our weight-based, institutional formula had a low sensitivity for predicting proper ETT depth. Weight-based formulas may have clinical utility; however, analysis of current data did not support use in infants < 1 kg. Rapid radiologic assessment of ETT placement is required for this patient population.