The influence of body mass index on airway resistance in children with sickle cell disease: A longitudinal study based on impulse oscillometry.

BACKGROUND: Impulse oscillometry (IOS) is an effective tool for assessing airway mechanics and diagnosing obstructive airway disease (OAD) in children with sickle cell disease (C-SCD). Obesity is known to be associated with OAD, and untreated OAD often leads to hypoxia-related complications in C-SCD. Considering the increasing prevalence of obesity in C-SCD, it is important to explore the influence of body mass index (BMI) on OAD in this disease population. METHODS: A longitudinal retrospective chart review was conducted on 55 C-SCD (161 IOS observations) and 35 non-SCD asthmatic children (C-Asthma) (58 observations), primarily to investigate the association between BMI and airway resistance in C-SCD and C-Asthma. We conducted generalized linear mixed models (GLMM), adjusted for pharmacotherapies, to demonstrate the influence of BMI on total (R5), central (R20), and peripheral (R5-20) airway resistance and reactance (X5, resonant frequency (Fres)). We further compared age, BMI, and IOS indices between C-SCD and C-Asthma using the Mann-Whitney test. RESULTS: Age and BMI were not statistically different between the two groups. In C-SCD, BMI was associated with R5 (GLMM t-statistics:3.75, 95%CI:1.01,3.27, p-value<0.001*) and R20 (t-statistics:4.01, 95%CI:1.04,1.15, p-value<0.001*), but not with R5-20 or airway reactance. In asthmatics, BMI was not associated with IOS estimates except Fres (t-statistics: 3.93, 95%CI: -0.06, -0.02, p-value<0.001*). C-SCD demonstrated higher airway resistances (R5 and R20) and reactance (Fres) compared to C-Asthma (Mann-Whitney: p-values<0.05). CONCLUSION: BMI significantly influenced total and central airway resistance in C-SCD. While higher airway resistances reflected increased OAD in C-SCD than asthmatics, higher Fres perhaps indicated progressive pulmonary involvement in C-SCD.

Characteristics and Outcomes of Intrahospital Transfers from Neonatal Intensive Care to Pediatric Intensive Care Units.

OBJECTIVE: Critically ill children may be transferred from the neonatal intensive care unit (NICU) to the pediatric intensive care unit (PICU) for further critical care, but the frequency and outcomes of this patient population are unknown. The aims of this study are to describe the characteristics and outcomes in patients transferred from NICU to PICUs. We hypothesized that a higher-than-expected mortality would be present for patients with respiratory or cardiovascular diagnoses that underwent a NICU to PICU transition and that specific factors (timing of transfer, illness severity, and critical care interventions) are associated with a higher risk of mortality in the cardiovascular group. STUDY DESIGN: Retrospective analysis of Virtual Pediatric Systems, LLC (2011-2019) deidentified cardiovascular and respiratory NICU to PICU subject data. We evaluated demographics, PICU length of stay, procedures, disposition, and mortality scores. Pediatric Index of Mortality 2 (PIM2) score was utilized to determine the standardized mortality ratio (SMR). RESULTS: SMR of 4,547 included subjects (3,607 [79.3%] cardiovascular and 940 [20.7%] respiratory) was 1.795 (95% confidence interval: 1.62-1.97, p < 0.0001). Multivariable logistic regression analysis demonstrated transfer age (cardiovascular: odds ratio, 1.246 [1.10-1.41], p = 0.0005; respiratory: 1.254 [1.07-1.47], p = 0.0046) and PIM2 scores (cardiovascular: 1.404 [1.25-1.58], p < 0.0001; respiratory: 1.353 [1.08-1.70], p = 0.0095) were significantly associated with increased odds of mortality. CONCLUSION: In this present study, we found that NICU to PICU observed deaths were high and various factors, particularly transfer age, were associated with increased odds of mortality. While the type of patients evaluated in this study likely influenced mortality, further investigation is warranted to determine if transfer timing is also a factor. KEY POINTS: · NICU patients may be transitioned to the PICU.. · NICU to PICU observed deaths were high.. · Transfer timing may be a factor..

Practice Patterns of Central Venous Catheter Placement and Confirmation in Pediatric Critical Care.

Optimal practices for the placement of central venous catheters (CVCs) in critically ill children are unclear. This study describes the clinical practice of pediatric critical care medicine (PCCM) providers regarding CVC placement, including site selection, confirmation practices and assessment of complications. Two-hundred fourteen PCCM providers responded to an electronic survey, including 170 (79%) attending physicians, 30 (14%) fellow physicians, and 14 (7%) advanced practice providers. PCCM providers most commonly place internal jugular (IJ) and femoral CVCs, with subclavian CVCs and peripherally inserted central catheters (PICCs) placed less commonly (IJ 99%, femoral 95%, subclavian 40%, PICC 19%). The IJ is the most preferred site (128/214 (60%)); decreased infection risk is the most common reason for preferring this site. The subclavian is the least preferred site (150/214 [70%]) due to concern for increased risk of complications (51%) and personal discomfort with the procedure (49%). One-hundred twenty-six (59%) of respondents reported receiving formal ultrasound (US) or echocardiography training. Respondents reported using dynamic US guidance for placement in 90% of IJ, 86% of PICC, 78% of femoral, and 12% of subclavian CVCs. Plain radiography (X-ray) was the most preferred modality for confirming CVC tip position (85%) compared with US (9%) and no imaging (5%). Most providers reported using X-ray to evaluate for pneumothorax following upper extremity CVC placement, with only 5% reporting use of US and none relying on physical exam alone. This study demonstrates wide variability in PCCM providers' CVC placement practices. Potential training gaps exist for placement of subclavian catheters and use of US.

Laryngeal Ultrasound Detects Vocal Fold Immobility in Adults: A Systematic Review.

Laryngeal ultrasound (US) is becoming widely accepted for assessing true vocal fold immobility (TVFI), a potential complication of laryngeal and thyroid surgery. The objective of this project is to perform a systematic review and meta-analysis of pooled evidence surrounding laryngeal US as a modality for diagnosing TVFI in adults at risk for the condition in comparison to laryngoscopy as a gold standard. Medical subject heading terms were used to search MEDLINE, Embase, Google Scholar, Web of Science, and the Cochrane Library for relevant citations from January 1, 2000, to June 30, 2020. Studies were included if they involved patients 16 years and older, where laryngeal US was compared to laryngoscopy for TVFI. Studies were excluded if there were insufficient data to compute a sensitivity/specificity table after attempting to contact the authors. Case reports, and case series were also excluded. The initial search returned 1357 citations. Of these, 109 were selected for review utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Thirty citations describing 6033 patients were included in the final meta-analysis. A bivariate random effects meta-analysis was performed, revealing a pooled sensitivity for laryngeal US of 0.95 (95% confidence interval [CI] 0.88-0.98), a specificity of 0.99 (95% CI 0.97-0.99), and a diagnostic odds ratio of 1328.2 (95% CI 294.0-5996.5). The area under the curve of the hierarchical summary receiver operating characteristic curve was 0.99 (95% CI 0.98-1.00). Laryngeal US demonstrates high sensitivity and specificity for detecting VFI in the hands of clinicians directly providing care to patients.

Assessment of Vocal Cord Motion Using Laryngeal Ultrasound in Children: A Systematic Review and Meta-Analysis.

OBJECTIVES: Laryngeal ultrasound is a nonirradiating, noninvasive method for assessing the upper airway in children. This systematic review and meta-analysis examine available evidence for accuracy of laryngeal ultrasound in diagnosing vocal cord immobility in infants and children after surgery and trauma affecting the vocal cords. DESIGN: Medical subject heading terms were used to search MEDLINE, Embase, Google Scholar, Web of Science, and the Cochrane Library for relevant citations. Publications from January 1, 2000, to June 30, 2020 were included in the search strategy. Study inclusion criteria consisted of randomized control trials and nonrandomized retrospective or prospective observational studies where vocal cord motion was evaluated by laryngeal ultrasound and compared with a reference test. Studies were excluded if there was insufficient data to compute a sensitivity/specificity table. Case reports, case series less than 10, and manuscripts not published in English were also excluded. PATIENTS: Studies which included subjects younger than or equal to 18 years were considered for full article review. SETTINGS: No restrictions on study settings were imposed in this systematic review. MEASUREMENTS AND MAIN RESULTS: The initial search returned 1,357 citations. After de-duplication, abstract, and full review, eight citations were included in the final meta-analysis. A bivariate random-effects meta-analysis was performed, which revealed a pooled sensitivity for laryngeal ultrasound in detecting vocal cord immobility of 91% (95% CI, 83-95%), specificity of 97% (95% CI, 82-100%), diagnostic odds ratio 333.56 (95% CI, 34.00-3,248.71), positive likelihood ratio 31.58 (95% CI, 4.50-222.05), and negative likelihood ratio 0.09 (95% CI, 0.05-0.19). CONCLUSIONS: Laryngeal ultrasound demonstrates high sensitivity and specificity for detecting vocal cord motion in children in a wide range of clinical settings. Laryngeal ultrasound offers a low-risk imaging option for assessing vocal cord function in children compared with the current gold standard of laryngoscopy.

A comparison between high-flow nasal cannula and noninvasive ventilation in the management of infants and young children with acute bronchiolitis in the PICU.

BACKGROUND: Different modalities of noninvasive respiratory support have been recommended for the management of acute bronchiolitis in the pediatric intensive care unit (PICU). High-flow nasal cannula (HFNC) is among the new modalities that have been widely used in the last decade. METHODS: This is a retrospective study involving infants and young children between the ages of 1 month and 2 years during the respiratory season of 2016-2017 (October-May). We compared the failure rate of HFNC with the failure rates of bi-level positive airway pressure (BiPAP) vs continuous positive airway pressure (CPAP) in the management of acute bronchiolitis in the PICU. Failure was defined as a change to another respiratory support modality or endotracheal intubation and mechanical ventilation. RESULTS: One hundred thirty-seven patients met the inclusion criteria, of which 77 patients needed HFNC, 10 needed CPAP, and 50 were on BiPAP. Among baseline characteristics, there were significant variations in age among the three groups. HFNC had a higher failure rate compared with the other two noninvasive ventilation modalities (50.6% for HFNC [n = 39 out of 77] vs 0% for CPAP [n = 0 out of 10] vs 8% for BiPAP [n = 4 out of 50], P < .01). Among the 39 patients who failed HFNC, 90% were successfully shifted to BiPAP and weaned off later, whereas the other 4 were intubated and required mechanical ventilation. However, all four patients who failed BiPAP were intubated and mechanically ventilated. No respiratory complications or mortalities were reported in the three groups. No differences were observed among the three groups in terms of the lengths of PICU or hospital stays. CONCLUSIONS: We observed a higher failure rate of HFNC compared with BiPAP or CPAP in the management of infants and children with acute bronchiolitis in the PICU. Further prospective randomized trials are recommended to confirm this finding.