Volatile gas scavenging in the paediatric intensive care unit: Occupational health and safety assessment.

Introduction: The use of volatile anesthetic agents in the paediatric intensive care unit (PICU) is experiencing increased interest since the availability of the miniature vapourizing device. However, the effectiveness of scavenging systems in the presence of humidifiers in the ventilator circuit is unknown. Approach Methods: We performed a bench study to evaluate the effectiveness of the Deltasorb® scavenging system in the presence of isoflurane and active humidity by simulating both infant and child ventilator test settings. A total of four ventilators were set to ventilate test lungs, all with active humidity and a Deltasorb scavenging canister collecting exhaled ventilation gas. Two ventilators also had isoflurane delivered using the Anesthesia Conserving Device- small (ACD®-S) on the inspiratory limb (also called alternative ventilator configuration). We performed instantaneous measurements of isoflurane and continuous sampling with passive badges to measure average environmental exposure over a test period of 6.5 hours. Scavenging canisters were returned to the company, where desorption analysis showed the volume of water and isoflurane captured in each canister. Findings: Both instantaneous point sampling and diffusive sampling results were below the occupational exposure limit confirming safety. The canisters collected both isoflurane and a portion of the water vapour delivered; the percentage of captured water and isoflurane collected in infants was higher than the child ventilator test settings. Practice implications Conclusion: The tested scavenging configuration was effective in maintaining a safe working environment with active humidity and inspiratory limb (alternative) ventilator configuration of the the miniature vapourizing device.

Airway opening pressure maneuver to detect airway closure in mechanically ventilated pediatric patients.

Background: Airway closure, which refers to the complete collapse of the airway, has been described under mechanical ventilation during anesthesia and more recently in adult patients with acute respiratory distress syndrome (ARDS). A ventilator maneuver can be used to identify airway closure and measure the pressure required for the airway to reopen, known as the airway opening pressure (AOP). Without that maneuver, AOP is unknown to clinicians. Objective: This study aims to demonstrate the technical adaptation of the adult maneuver for children and illustrate its application in two cases of pediatric ARDS (p-ARDS). Methods: A bench study was performed to adapt the maneuver for 3-50 kg patients. Four maneuvers were performed for each simulated patient, with 1, 2, 3, and 4 s of insufflation time to deliver a tidal volume (Vt) of 6 ml/kg by a continuous flow. Results: Airway closure was simulated, and AOP was visible at 15 cmH2O with a clear inflection point, except for the 3 kg simulated patient. Regarding insufflation time, a 4 s maneuver exhibited a better performance in 30 and 50 kg simulated patients since shorter insufflation times had excessive flowrates (>10 L/min). Below 20 kg, the difference in resistive pressure between a 3 s and a 4 sec maneuver was negligible; therefore, prolonging the maneuver beyond 3 s was not useful. Airway closure was identified in two p-ARDS patients, with the pediatric maneuver being employed in the 28 kg patient. Conclusions: We propose a pediatric AOP maneuver delivering 6 ml/kg of Vt at a continuous low-flow inflation for 3 s for patients weighing up to 20 kg and for 4 s for patients weighing beyond 20 kg.

A Delphi Survey of Canadian Respiratory Therapists' Practice Statements on Pediatric Mechanical Ventilation.

BACKGROUND: Pediatric mechanical ventilation practice guidelines are not well established; therefore, the European Society for Paediatric and Neonatal Intensive Care (ESPNIC) developed consensus recommendations on pediatric mechanical ventilation management in 2017. However, the guideline's applicability in different health care settings is unknown. This study aimed to determine the consensus on pediatric mechanical ventilation practices from Canadian respiratory therapists' (RTs) perspectives and consensually validate aspects of the ESPNIC guideline. METHODS: A 3-round modified electronic Delphi survey was conducted; contents were guided by ESPNIC. Participants were RTs with at least 5 years of experience working in standalone pediatric ICUs or units with dedicated pediatric intensive care beds across Canada. Round 1 collected open-text feedback, and subsequent rounds gathered feedback using a 6-point Likert scale. Consensus was defined as ≥ 75% agreement; if consensus was unmet, statements were revised for re-ranking in the subsequent round. RESULTS: Fifty-two RTs from 14 different pediatric facilities participated in at least one of the 3 rounds. Rounds 1, 2, and 3 had a response rate of 80%, 93%, and 96%, respectively. A total of 59 practice statements achieved consensus by the end of round 3, categorized into 10 sections: (1) noninvasive ventilation and high-flow oxygen therapy, (2) tidal volume and inspiratory pressures, (3) breathing frequency and inspiratory times, (4) PEEP and FIO2 , (5) advanced modes of ventilation, (6) weaning, (7) physiological targets, (8) monitoring, (9) general, and (10) equipment adjuncts. Cumulative text feedback guided the formation of the clinical remarks to supplement these practice statements. CONCLUSIONS: This was the first study to survey RTs for their perspectives on the general practice of pediatric mechanical ventilation management in Canada, generally aligning with the ESPNIC guideline. These practice statements considered information from health organizations and institutes, supplemented with clinical remarks. Future studies are necessary to verify and understand these practices' effectiveness.

Simulation use in paediatric student respiratory therapy training.

At SickKids it is a perennial challenge for clinical leads and preceptors to ensure that student respiratory therapists (SRTs) acquire the entire scope of the paediatric skill set as set out by the 2016 National Competency Profile. As such, simulation has historically been used to supplement the clinical experience for SRTs at Sick Kids; however, the extent to which simulation-based education can replace clinical experience is not clearly established in the literature. At SickKids, we have created an alternative paediatric rotation where the percentage of time spent in the simulation environment is greater than in the traditional, clinical-based rotation. We hypothesize that there should be comparable levels of performance in a simulated setting between students in clinical and simulation-based rotations, as well as comparable measures of self-reported values for cognitive load, self-appraisal, and self-efficacy. Thus far, we have enrolled 59 students, with 54 completing postclinical rotation testing. Follow-up retention testing has been complicated by geographical factors. Following data analysis, we will publish our findings.