Relationship of Viral Detection with Duration of Ventilation in Critically Ill Infants with Lower Respiratory Tract Infection.

Rationale: Although respiratory virus testing is frequently done for critically ill infants with bronchiolitis, the prognostic value of this testing is unknown for those requiring positive-pressure ventilation (PPV). Objectives: To determine the differences in PPV use according to viral detection and to explore the association between viral detection and duration of PPV in critically ill children with presumed respiratory infection. Methods: This is a retrospective cohort study in a quaternary pediatric intensive care unit from February 2014 until February 2017. We evaluated 984 children less than 1 year of age who received PPV for presumed respiratory infection without significant congenital heart disease, care limitations, baseline PPV usage, or tracheostomy. Respiratory viruses were identified using a PCR panel. Analyses of duration of PPV according to viral etiology were performed using univariate and multivariable logistic regression and truncated negative binomial regression with calculated mean marginal effects (MME). Results: Overall, 85 (9%) infants had no viruses identified, 629 (64%) had a single virus detected, most commonly respiratory syncytial virus (417, 42%) followed by rhinovirus/enterovirus (145, 15%), 230 (23%) had two viruses detected, and 40 (4%) had three viruses detected. Compared with those with one or no virus detected, infants with ⩾2 viruses received longer total PPV duration in adjusted analysis (relative risk [RR], 1.4; 95% confidence interval [CI], 1.2-1.6; P < 0.001; MME = 29 h). Detection of rhinovirus/enterovirus alone, compared with respiratory syncytial virus alone, was associated with significantly shorter duration of total PPV (RR, 0.7; 95% CI, 0.62-0.87; P = <0.001; MME = -23 h), noninvasive PPV (RR, 0.7; 95% CI, 0.60-0.85; P < 0.001; MME = -15 h), and invasive PPV (RR, 0.7; 95% CI, 0.54-0.83; P < 0.001; MME = -54 h) when adjusted for weight, prematurity, and administration of early antibiotic therapy. Conclusions: Identification of viral type and number in severe bronchiolitis is an important predictor of duration of PPV.

Validity and Reliability of a New Tool to Evaluate Impaired Airway Clearance in Hospitalized Pediatric Subjects With Respiratory Distress.

BACKGROUND: Chest physiotherapy has been reported to be beneficial in specific clinical contexts, yet it carries a risk of potential serious adverse events with little benefit in other patients. Therefore, identifying and limiting airway clearance therapies to patients with the greatest potential benefit and least risk is clinically relevant and important. This study aims to validate the Airway Clearance and Expansion Index (ACE-I) for the serial assessment of hospitalized pediatric patients with impaired airway clearance and to establish reliability in score acquisition across a range of pediatric respiratory disease states. METHODS: Content validity of the category importance and category choices was assessed via a survey of well-established pediatric pulmonary and critical care physicians, as well as respiratory therapists (RTs). Inter-rater reliability testing was performed on hospitalized children from October 2016 through April 2017 and analyzed using a one-way random effects intraclass correlation. RESULTS: 51 providers (24 of 37 physicians and 27 of 92 RTs) responded to the survey. Agreement was defined as any score of 6 or greater out of 10 on a scale of 1-10. The total ACE-I scale content validity index (S-CVI) scores for category importance and category choices for physicians were 1 and 0.75, respectively, and for RTs the scores were 0.75 and 0.75, respectively. 172 subjects were scored by multiple raters, resulting in an excellent overall intraclass correlation coefficient of 0.77 (95% CI 0.71-0.83) and the following component scores: cough, 0.72 (95% CI 0.64-0.79); breath sounds, 0.54 (95% CI 0.43-0.64); chest radiograph findings, 0.84 (95% CI 0.79-0.88); and secretions 0.85, (95% CI 0.81-0.89). CONCLUSIONS: The ACE-I score addresses and quantifies 4 components of the respiratory assessment that RTs and pediatric physicians deem important in identifying patients who have impaired airway clearance and might benefit from airway clearance and expansion therapies. In addition, the ACE-I score had excellent inter-rater reliability and clinical feasibility within our single institution.

Dexmedetomidine as Single Continuous Sedative During Noninvasive Ventilation: Typical Usage, Hemodynamic Effects, and Withdrawal.

OBJECTIVES: Dexmedetomidine use in pediatric critical care is increasing. Its prolonged effects as a single continuous agent for sedation are not well described. The aim of the current study was to describe prolonged dexmedetomidine therapy without other continuous sedation, specifically the hemodynamic effects, discontinuation strategies, and risk factors for withdrawal. DESIGN: Retrospective chart review. SETTING: Large, single-center, quaternary care pediatric academic institution. PATIENTS: Data from 382 children, less than 18 years old admitted to the PICU who received dexmedetomidine for more than 24 hours without other infusions for sedation during noninvasive positive pressure ventilation. INTERVENTIONS: Usual care practices for dexmedetomidine use were described. Discontinuation strategies were categorized as abrupt discontinuation, wean from dexmedetomidine infusion, and transition to enteral clonidine. MEASUREMENTS AND MAIN RESULTS: Median peak and cumulative doses with interquartile range were 1 µg/kg/hr (0.6-1.2 µg/kg/hr) and 30 µg/kg (20-50 µg/kg), respectively, and median duration was 45 hours (34-66 hr). Four hours after reaching peak dose, we observed a decrease in heart rate (p < 0.01) with 28% prevalence of bradycardia and an increase in systolic blood pressure (p < 0.01) with 33% prevalence of hypertension and 2% hypotension. During the escalation phase, the prevalence of bradycardia and hypotension were 75% and a 30%, respectively. Three-hundred thirty-six patients (88%) had abrupt discontinuation, 37 (10%) were weaned, and nine (2%) were transitioned to clonidine. Nineteen patients (5%) experienced withdrawal. Univariate risk of withdrawal was most associated with duration: odds ratio equal to 1.5 (1.3-1.7) for each 12-hour period (p < 0.01). By multivariate analysis including age, discontinuation group, dexmedetomidine cumulative dose, and peak dose, only cumulative dose remained significant with an odds ratio equal to 1.3 (1.1-1.5) for each 10 µg/kg (p < 0.01). CONCLUSIONS: Dexmedetomidine use for noninvasive positive pressure ventilation sedation in pediatric critical care has predictable hemodynamic effects including bradycardia and hypertension. Although withdrawal was associated with higher cumulative dose, these symptoms were effectively managed with short-term enteral clonidine.

An Unusual Complication With the Administration of a Volatile Anesthetic Agent for Status Asthmaticus in the Pediatric Intensive Care Unit: Case Report and Review of the Literature.

In severe cases of status asthmaticus, when conventional therapies fail, volatile anesthetic agents remain a therapeutic option. When delivered outside of the operating room setting, specialized delivery techniques are needed to ensure the safe and effective use of volatile anesthetic agents. We present a 16-year-old adolescent with status asthmaticus who required the therapeutic administration of the volatile anesthetic agent, sevoflurane, in the pediatric intensive care unit (PICU). Although initially effective in reducing bronchospasm, progressive hypercarbia developed due to defective functioning of the carbon dioxide absorber of the anesthesia machine. This failure occurred as the soda lime compartment filled with water accumulated from circuit humidification and continuous albuterol therapy. The role of volatile anesthetic agents in the treatment of status asthmaticus in the PICU is discussed, options for delivery outside of the operating room presented, and potential problems with delivery reviewed.