Use of Flow-Volume Loops on a Mechanically Ventilated Pediatric Patient as a Diagnostic Tool for Fixed Airway Obstruction.

The flow-volume loop (FV-loop) provides a graphical representation of the inspiratory and expiratory flow of both mechanically provided breaths and patient-triggered breaths during invasive mechanical ventilation. The FV-loop on the ventilator-delivered breath displays the active inspiratory flow reflective of lung compliance and the passive expiratory flow reflective of airway resistance. Our case report highlights the importance of the FV-loop in determining a fixed airway obstruction. A five-month-old male presented to the emergency department with worsening respiratory distress in the setting of rhino-enterovirus. He was admitted to the pediatric intensive care unit (PICU) and intubated for acute hypoxic respiratory failure. The findings on his ventilator FV-loop graphics denoted a fixed airway obstruction, as seen by the truncation of inspiratory and expiratory flow. The patient was subsequently found to have a left pulmonary artery (LPA) sling with a vascular ring and several complete tracheal rings. He was transferred to a referral institution for operative management, returned to our PICU, and discharged home after 47 days of hospital management. During mechanical ventilation, FV-loops can be effectively utilized to assist in the diagnosis of fixed intra- or extra-thoracic airway obstructions.

RDS-NExT workshop: consensus statements for the use of surfactant in preterm neonates with RDS.

OBJECTIVE: To provide the best clinical practice guidance for surfactant use in preterm neonates with respiratory distress syndrome (RDS). The RDS-Neonatal Expert Taskforce (RDS-NExT) initiative was intended to add to existing evidence and clinical guidelines, where evidence is lacking, with input from an expert panel. STUDY DESIGN: An expert panel of healthcare providers specializing in neonatal intensive care was convened and administered a survey questionnaire, followed by 3 virtual workshops. A modified Delphi method was used to obtain consensus around topics in surfactant use in neonatal RDS. RESULT: Statements focused on establishing RDS diagnosis and indicators for surfactant administration, surfactant administration methods and techniques, and other considerations. After discussion and voting, consensus was achieved on 20 statements. CONCLUSION: These consensus statements provide practical guidance for surfactant administration in preterm neonates with RDS, with a goal to contribute to improving the care of neonates and providing a stimulus for further investigation to bridge existing knowledge gaps.

Randomized Trial of Surfactant Therapy via Laryngeal Mask Airway Versus Brief Tracheal Intubation in Neonates Born Preterm.

OBJECTIVE: To evaluate the possible noninferiority of surfactant administration via laryngeal mask airway (LMA) vs endotracheal tube (ETT) in avoiding the requirement for mechanical ventilation in preterm neonates with respiratory distress syndrome (RDS). STUDY DESIGN: This was a randomized controlled trial including infants born at 27 to 36 weeks of gestation, >800 g, diagnosed with RDS and receiving fraction of inspired oxygen 0.30-0.60 via noninvasive respiratory support. Infants were randomized to surfactant via LMA (with atropine premedication) or ETT (InSuRE approach with atropine and remifentanil premedication). Primary outcome was failure of surfactant treatment to prevent the need for mechanical ventilation. RESULTS: Patients were randomized, 51 to LMA and 42 to the ETT group. Both groups had similar baseline characteristics, with birth weights ranging from 810 to 3560 g. Failure rate was 29% in the ETT group and 20% in the LMA group (P = .311). This difference was due to early failures (within 1 hour), with 12.5% in the ETT group and 2% in the LMA group (P = .044). Surfactant therapy via LMA was non-inferior to administration via ETT; failure risk difference -9.0% (CI -∞ to 5.7%). Efficacy in decreasing fraction of inspired oxygen, number of surfactant doses administered, time to wean off all respiratory support, rates of adverse events, and outcomes including pneumothorax and BPD diagnosis did not differ between groups. CONCLUSIONS: Surfactant therapy via LMA was noninferior to administration via ETT and it decreased early failures, possibly by avoiding adverse effects of premedication, laryngoscopy, and intubation. These characteristics make LMA a desirable conduit for surfactant administration. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02164734.

Impact of COVID-19 on Respiratory Admissions in a Tertiary Pediatric Intensive Care Unit.

Background Pediatric inpatient admissions for viral respiratory infections decreased worldwide during the early part of the coronavirus disease 2019 (COVID-19) pandemic. This was likely due to social distancing measures and mask mandates leading to a decreased spread of viruses. We question if there was an increase in respiratory admissions during the winter of 2020-2021 due to the overlap of seasonal respiratory viruses and COVID-19 and the severity of those admissions. Methods We performed a single-center retrospective chart review of all respiratory admissions to our pediatric intensive care unit (PICU) from October to April during the years 2018-2019, 2019-2020, and 2020-2021. We compared the total number of respiratory admissions from different viruses and respiratory admissions by diagnoses among those time periods. Second, we compared the PICU length of stay and duration of mechanical ventilation (both invasive and non-invasive) for these respiratory admissions during those years. Results We saw a drastic decrease in the total respiratory admissions to the PICU in 2020-2021 compared to the same period of time in the last two years. The greatest contributor to this decrease was admissions secondary to bronchiolitis. We noticed a statistically significant decrease in both asthma (p<0.001) and chronic respiratory failure admissions (p=0.0029) during the pandemic winter compared to previous winters. Although, the total number of all respiratory viral admissions is not significant, admissions specific to the respiratory syncytial virus (RSV) (p<0.0001), rhino-enterovirus (p<0.0001), and multi-virus (p=0.0016), achieved statistical significance. There was no statistical difference between the PICU length of stay and duration of mechanical ventilation during the three years. Conclusion Despite a decrease in pediatric respiratory admissions during the COVID-19 pandemic, the severity of illness based on length of stay in the PICU and length of time on respiratory support remains unchanged compared to the previous two years.

Wide Variation in Unplanned Extubation Rates Related to Differences in Operational Definitions.

OBJECTIVES: Unplanned extubation (UE) rate is a patient safety metric for which there are varied and inconsistently interpreted definitions. We aimed to test the sensitivity of UE rates to the application of different operational definitions. METHODS: We analyzed neonatal intensive care unit (NICU) quality improvement data on UE events defined inclusively as "any extubation that was not performed electively, or not previously intended for that time." Unplanned extubations were classified as involving an endotracheal tube (ETT) that was either objectively "dislodged" or "removed" without proof of prior dislodgement. We used descriptive statistics to explore how UE rates vary when applying alternate UE definitions. RESULTS: For 33 months, 241 UEs were documented, 70% involving dislodged tubes and 30% ETTs removed by staff. Among dislodged ETTs, only 9% were found completely externalized, whereas 77% were at an adequate depth but in the esophagus. Thirteen percent of events occurred outside the NICU and 13% were initially unreported. The overall UE rate was 4.9/100 ventilator days. If the least inclusive definition was used (i.e., counting only "self-extubations" by patients, requiring reintubation, and occurring within the NICU), 83% of UEs would have been excluded. CONCLUSIONS: Most UEs in our NICU population involved staff either removing ETTs from the trachea or partly removing them after internal dislodgement. In settings where ETTs removed by staff are not counted, UE rates may be substantially lower and associated risks underestimated. An inclusive, patient-centric operational definition along with a standardized classification would allow benchmarking, while enabling targeted approaches to minimize locally predominant causes of UEs.

Correlation of Respiratory Physiologic Parameters in Mechanically Ventilated Coronavirus Disease 2019 Patients.

Acute respiratory distress syndrome secondary to severe acute respiratory syndrome coronavirus-2 pneumonia or coronavirus disease 2019-related acute respiratory distress syndrome is the primary cause of mortality in coronavirus disease 2019. Some studies have described the concept of "high and low" elastance coronavirus disease 2019-related acute respiratory distress syndrome and proposed individualized management for the acute respiratory distress syndrome, deviating from low tidal volume ventilation. We report simultaneously measured respiratory parameters (static lung compliance, alveolar dead space ventilation, and shunt fraction) in 14 patients with advanced coronavirus disease 2019-related acute respiratory distress syndrome. The results were consistent with typical acute respiratory distress syndrome and did not support the concept of high-type coronavirus disease 2019-related acute respiratory distress syndrome and low-type coronavirus disease 2019-related acute respiratory distress syndrome.

Use of esophageal balloon manometry in the management of pediatric acute respiratory distress syndrome.

There is paucity of literature regarding the use of esophageal balloon manometry in the management of Pediatric Acute Respiratory Distress Syndrome. We describe our first ever experience of successful usage of esophageal balloon pressure manometry in a child with acute respiratory distress syndrome. This is a six-year-old girl who presented with shortness of breath and fever and was found to be in severe acute respiratory distress syndrome due to septic shock secondary to group A streptococcus. The patient was managed using an esophageal balloon manometry for positive end-expiratory pressure titration. She was liberated from invasive mechanical ventilation on day 7 of hospital course. Esophageal balloon manometry guided positive end-expiratory pressure for 103 out of 155 hours of ventilation with no obvious sequelae. Our case shows the feasibility of transpulmonary pressure measurements in pediatric patients. This practice may be useful to optimize management in pediatric acute respiratory distress syndrome to improve outcomes.

Efficacy, Safety, and Usability of Remifentanil as Premedication for INSURE in Preterm Neonates.

Background: We previously reported a 67% extubation failure with INSURE (Intubation, Surfactant, Extubation) using morphine as analgosedative premedication. Remifentanil, a rapid- and short-acting narcotic, might be ideal for INSURE, but efficacy and safety data for this indication are limited. Objectives: To assess whether remifentanil premedication increases extubation success rates compared with morphine, and to evaluate remifentanil's safety and usability in a teaching hospital context. Methods: Retrospective review of remifentanil orders for premedication, at a large teaching hospital neonatal intensive care unit (NICU). We compared INSURE failure rates (needing invasive ventilation after INSURE) with prior morphine-associated rates. Additionally, we surveyed NICU staff to identify usability and logistic issues with remifentanil. Results: 73 remifentanil doses were administered to 62 neonates (mean 31.6 ± 3.8 weeks' gestation). Extubation was successful in 88%, vs. 33% with morphine premedication (p < 0.001). Significant adverse events included chest wall rigidity (4%), one case of cardiopulmonary resuscitation (CPR) post-surfactant, naloxone reversal (5%), and notable transient desaturation (34%). Among 137 completed surveys, 57% indicated concerns, including delayed drug availability (median 1.1 h after order), rapid desaturations narrowing intubation timeframes and hindering trainee involvement, and difficulty with bag-mask ventilation after unsuccessful intubation attempts. Accordingly, 33% of ultimate intubators were attending neonatologists, versus 16% trainees. Conclusions: Remifentanil premedication was superior to morphine in allowing successful extubation, despite occasional chest wall rigidity and unfavorable conditions for trainees. We recommend direct supervision and INSURE protocols aimed at ensuring rapid intubation.

Use of jet ventilation in thoracoscopic tracheo-esophageal fistula repair-can both surgeons and anesthesiologists be happy?

Laparoscopic and open thoracic surgery in the neonate typically results in hypercapnea and low cardiac output with often poor surgical visualization as the anesthesiologist attempts to correct the respiratory derangements usually seen. We describe three cases in which jet ventilation provided not only superior ventilation with a return to normocapnea but also ideal operating conditions. In addition, jet ventilation utilizes lower mean airway pressures which typically results in improved cardiac output.