The impact of changing toward higher welfare broiler production systems on greenhouse gas emissions: a Dutch case study using life cycle assessment.

In the Netherlands, the Dutch Retail Broiler (DRB) and Better Life one Star (BLS) production systems have been introduced with the aim to improve broiler welfare. Simultaneously, retailers set targets for reduction of greenhouse gas (GHG) emissions in the whole broiler production chain. The GHG emissions of DRB and BLS may differ from conventional systems because of differences in slaughter age, feed intake, and diet composition. The aim of this study was to estimate GHG emissions of the conventional, DRB, and BLS production systems. A deterministic, spreadsheet based model was developed that included the breeder, hatchery, and broiler farm stages. First, the model calculates feed intake of different diets and energy use, based on performance objectives and literature. Selection of feed ingredients for the different types of diets was based on least cost formulation with nutritional constraints for each diet. Second, GHG emissions were estimated from cradle to broiler farm gate for processes along the broiler production chain by using life cycle assessment, and expressed as kg CO2-equivalents per kg live weight (kg CO2-eq/kg LW). Results showed that BLS (3.55 kg CO2-eq/kg LW) had lower GHG emissions compared to conventional (3.65 kg CO2-eq/kg LW) and DRB (3.98 kg CO2-eq/kg LW) at the broiler farm gate. Emissions from land use change (LUC) from feed production, mainly from soybean products, had highest impact on total GHG emissions (>50%) for the systems and these soybean products had the lowest inclusion in the diets of the BLS production system. Sensitivity analyses showed that variation in slaughter weight and feed intake could result in overlap of GHG emissions between systems. When soybean products were sourced from a country with low LUC emissions, conventional (1.37 kg CO2-eq/ kg LW) had the lowest GHG emissions and BLS (1.79 kg CO2-eq/kg LW) the highest. This study showed that origin of and including or excluding LUC emissions from soybean production results in different conclusions for achieving the GHG emissions reduction targets set by retailers.

Association between C-reactive protein levels and outcome in acute lung injury in children.

UNLABELLED: High plasma C-reactive protein (CRP) levels are associated with favorable outcome in adults with acute lung injury (ALI). The association between CRP levels and outcome has not been studied in ALI in children. We performed a historical cohort study in 93 mechanically ventilated children (0-18 years) with ALI. The CRP level within 48 h of disease onset was tested for association with 28-day mortality and ventilator-free days (VFD). Clinical parameters and ventilator settings were evaluated for possible confounding. Fourteen patients died within 28 days. The median (interquartile range) CRP level in nonsurvivors was 126 mg/L (64; 187) compared with 56 mg/L (20; 105) in survivors (p = 0.01). For every 10-mg/L rise in CRP level, the unadjusted odds (95% confidence interval (95% CI)) for mortality increased 8.7% (2.1-15.8%). Cardiovascular organ failure at onset of ALI was the strongest predictor for mortality (odds ratio, 30.5 (6.2-152.5)). After adjustment for cardiovascular organ failure, for every 10-mg/L rise in CRP level, the OR (95% CI) for mortality increased 4.7% (-2.7-12.6%; p = 0.22). Increased CRP levels were associated with a decrease in VFD (ρ = -0.26, p = 0.01). CONCLUSION: increased plasma CRP levels are not associated with favorable outcome in ALI in children. This is in contrast with findings in adults with ALI.

Food safety in free-range and organic livestock systems: risk management and responsibility.

Animal production systems that offer outdoor access to the animals have become increasingly popular in the Western world due to the growing general discontent of consumers with conventional bioindustrial farming practices. These open production systems offer improved animal welfare but may create new problems for animal health, resulting in increased food safety risks from bacterial, viral, or parasitic infections or environmental contaminants. Examples of these new problems include increased Toxoplasma gondii infections in pigs and high dioxin levels in eggs from free-range hens. In this review, the relation between positive and negative points of free-range and organic livestock production systems is discussed with reference to production in The Netherlands. We investigated how proponents of more animal welfare friendly systems deal with potential negative issues in public and whether any risk communication is used. Generally, we found that the existence of a dilemma is disputed or avoided in communication with the consumer. This avoidance could be detrimental for public trust in alternative animal production systems, should problems occur. To prevent future problems, it will be necessary to communicate about the relevant types and sources of the food safety risks to the consumers. The responsibility for protecting food safety should be properly divided among the various parties involved: producers, processors, governments, nongovernmental organizations, and consumers.

Modelling the effect of sub(lethal) heat treatment of Bacillus subtilis spores on germination rate and outgrowth to exponentially growing vegetative cells.

Spores of Bacillus subtilis were subjected to relatively mild heat treatments in distilled water and properties of these spores were studied. These spores had lost all or part of their dipicolinic acid (DPA) depending on the severity of the heat treatment. Even after relatively mild heat treatments these spore lost already a small but significant amount of DPA. When these spores were inoculated in nutrient medium-tryptone soy broth (TSA)-the non-lethally heated spores started to germinate. Results of classical optical density measurements showed that both phase darkening and subsequent outgrowth could be affected by sub-lethal heat. A study of single cells in TSB showed that lag times originating from exponentially growing cells followed a normal distribution, whereas lag times originating from spores followed a Weibull distribution. Besides classical optical density measurements were made to study the effect of previous heating on the kinetics of the first stages of germination. The germination kinetics could be described by the model as was proposed by Geeraerd et al. [Geeraerd, A.H., Herremans, C.H. and Van Impe, J.F., 2000. Structural model requirements to describe microbial inactivation during a mild heat treatment. International Journal of Food Microbiology 59, 185-209]. Two of the 4 parameters of the sigmoid model of Geeraerd were dependent on heating time and heating temperature, whereas the two other parameters were considered as independent of the heating conditions. Based on these observations, a secondary model could be developed that describes the combined effect of heating temperature and heating time on the kinetics of germination. To have more detailed information of the kinetics of germination samples incubated in TSB were tested at regular time intervals by flow cytometry. To that end the cells were stained with syto 9 to distinguish between the various germination stages. There was a qualitative agreement between the results of flow cytometry and those of optical density measurements, but there was a difference in quantitative terms. The results have shown that germination rate of spores is dependent on previous heating conditions both in the first stage when phase darkening occurs and also during the later stages of outgrowth when the phase dark spore develops to the vegetative cell.

ACE mediates ventilator-induced lung injury in rats via angiotensin II but not bradykinin.

Ventilator-induced lung injury is characterised by inflammation and apoptosis, but the underlying mechanisms are poorly understood. The present study proposed a role for angiotensin-converting enzyme (ACE) via angiotensin II (Ang II) and/or bradykinin in acute lung injury. The authors assessed whether ACE and, if so, Ang II and/or bradykinin are implicated in inflammation and apoptosis by mechanical ventilation. Rats were ventilated for 4 h with low- or high-pressure amplitudes in the absence or presence of the ACE inhibitor captopril. Nonventilated animals served as controls. ACE activity, Ang II and bradykinin levels, as well as inflammatory parameters (total protein, macrophage inflammatory protein-2 and interleukin-6) were determined. Apoptosis was assessed by the number of activated caspase-3 and TUNEL (terminal deoxynucleotidyltransferase-mediated deoxyuridine triphosphate nick-end labelling)-positive cells. Bronchoalveolar lavage fluid ACE activity, levels of total protein, inflammatory parameters and the number of apoptotic cells were increased in the high-pressure amplitude group as compared with the control group. Blocking ACE activity by captopril attenuated inflammation and apoptosis in the latter group. Similar results were obtained by blocking Ang II receptors, but blocking bradykinin receptors did not attenuate the anti-inflammatory and anti-apoptotic effects of captopril. The current authors conclude that inflammation and apoptosis in ventilator-induced lung injury is, at least in part, due to angiotensin-converting enzyme-mediated angiotensin II production.

Pediatric acute lung injury.

Among ventilated children, the incidence of acute lung injury (ALI) was 9%; of that latter group 80% developed the acute respiratory distress syndrome (ARDS). The population-based prevalence of pediatric ARDS was 5.5 cases/100.000 inhabitants. Underlying diseases in children were septic shock (34%), respiratory syncytial virus infections (16%), bacterial pneumonia (15%), near-drowning 9%, and others. Mortality ranged from 18% to 27% for ALI (including ALI-non ARDS and ARDS) and from 29% to 50% for ARDS. Mortality was only 3%-11% in children with ALI-non ARDS. As risk factors, oxygenation indices and multi-organ failure have been identified. New insights into the pathophysiology (for example the interplay between intraalveolar coagulation/fibrinolysis and inflammation and the genetic polymorphism for the angiotensin-converting enzyme) offer new therapeutic options. Lung protective mechanical ventilation with optimal lung recruitment is the mainstay of supportive therapy. New therapeutic modalities refer to corticosteroid and surfactant treatment. Well-designed follow up studies are needed.

High incidence of acute lung injury in children with Down syndrome.

OBJECTIVE: Acute respiratory tract infection is a common reason for hospitalization in children with Down syndrome (CDS) and is characterized by a high morbidity. The severe course of disease in CDS may be related to a higher incidence of acute lung injury (ALI). This study evaluated the incidence of ALI and acute respiratory distress syndrome (ARDS) in mechanically ventilated CDS. DESIGN AND SETTING: Retrospective cohort study in a pediatric ICU. PATIENTS AND PARTICIPANTS: Cases were all mechanically ventilated CDS admitted to our unit between January 1998 and July 2005. All mechanically ventilated patients without Down syndrome from January 1998 to January 2001 served as controls. Postoperative patients (cases and controls) and those with a cardiac left to right shunt were excluded. MEASUREMENTS AND RESULTS: The main outcome measure was the incidence of ALI and ARDS. The criteria for ALI were met in 14 of 24 CDS (58.3%) in 41 of 317 of controls (12.9%; OR 9.4, 95% CI 3.9-22.6). The criteria for ARDS were met in 11 of 24 CDS (46%) and in 21 of 317 of controls (7%; OR 11.9, 95% CI 4.8-29.8). None of the CDS with ALI died; in the control group ten patients with ALI died. CONCLUSIONS: CDS had a significantly higher incidence of ALI and ARDS than children without Down syndrome. The explanation for this remains to be elucidated; further study is necessary before clinical implications become clear.

[The practice guideline 'Volume suppletion in critically-ill neonates and children up to the age of 18 years' of the Dutch Paediatric Association]. / Richtlijn 'Volumesuppletie bij kritisch zieke pasgeborenen en kinderen tot 18 jaar' van de Nederlandse Vereniging voor Kindergeneeskunde.

Hypovolaemia is the most common cause of circulatory failure in children. Treatment consists of volume suppletion with a crystalloid or colloid solution; which agent is the best in children is not clear. This evidence-based practice guideline formulates recommendations as to which fluid should be used for volume suppletion in critically-ill neonates and children up to the age of 18 years with hypovolaemia. Before the guideline development first-choice fluid for volume resuscitation was in 50% a colloid and in 50% a crystalloid solution for both neonatologists and paediatric intensivists. The neonatologists used human albumin as a priority, and the paeditric intensivists predominantly used a synthetic colloid. The guideline was developed on the basis of a comprehensive search and analysis of the literature according to the principles of evidence-based guideline development. The recommendations were formulated by a committee based on evidence from the literature and, when evidence from the literature was insufficient, on consensus after discussion in the committee. Since colloids are much more expensive than crystalloids and can give an anaphylactic reaction, their added value over crystalloids must be proven. In sick neonates and children, insufficient clinical trials have been done to reach the conclusion that colloids are more effective than crystalloids in hypovolaemia. A number of meta-analyses in adults revealed excess mortality in the group treated with albumin, but one recent, large, randomised study showed no difference in mortality. No added value could be demonstrated for the administration of synthetic colloids. On the basis of data from the literature and considerations regarding the applicability of evidence in adults to children and neonates, the side effects of resuscitation fluids, pathophysiology and costs, the first-choice fluid for neonates and children with hypovolaemia is isotonic saline. Albumin should not be used for the treatment of hypovolaemia. The volume to be administered and the infusion rate depend on the severity of the hypovolaemia and should be determined on an individual basis.

Absence of human metapneumovirus co-infection in cases of severe respiratory syncytial virus infection.

It has been suggested that co-infection of human metapneumovirus (hMPV) in severe respiratory syncytial (RSV) virus bronchiolitis is very common. To evaluate the epidemiology of hMPV co-infection in children with severe lower respiratory tract infection caused by RSV virus. This was an observational cohort study in which hMPV and RSV viral load was measured by RT-PCR in tracheal specimens from the target population. hMPV could not be detected in any of the 30 mechanically ventilated children with RSV lower respiratory tract infection. Our study suggests that hMPV co-infection is not very common in severe RSV lower respiratory tract infection.

Mechanical ventilation affects alveolar fibrinolysis in LPS-induced lung injury.

The aim of the present study was to determine the effects of mechanical ventilation on alveolar fibrin turnover in lipopolysaccharide (LPS)-induced lung injury. In a randomised controlled trial, Sprague-Dawley rats (n = 61) were allocated to three ventilation groups after intratracheal LPS (Salmonella enteritidis) instillations. Group I animals were subjected to 16 cmH(2)O positive inspiratory pressure (PIP) and 5 cmH(2)O positive end-expiratory pressure (PEEP); group II animals to 26 cmH(2)O PIP and 5 cmH(2)O PEEP; and group III animals to 35 cmH(2)O PIP and 5 cmH(2)O PEEP. Control rats (not mechanically ventilated) received LPS. Healthy rats served as a reference group. Levels of thrombin-antithrombin complex (TATc), D-dimer, plasminogen activator inhibitor (PAI) activity and PAI-1 antigen in bronchoalveolar lavage fluid were measured. LPS-induced lung injury increased TATc, D-dimer and PAI activity and PAI-1 antigen levels versus healthy animals. High pressure-amplitude ventilation increased TATc concentrations. D-dimer concentrations were not significantly raised. Instead, PAI activity increased with the amplitude of the pressure, from 0.7 U.mL(-1) in group I to 3.4 U.mL(-1) in group II and 5.0 U.mL(-1) in group III. There was no change in PAI-1 antigen levels. In conclusion, mechanical ventilation creates an alveolar/pulmonary anti-fibrinolytic milieu in endotoxin-induced lung injury which, at least in part, might be due to an increase in plasminogen activator inhibitor activity.

[Late presentation of congenital diaphragmatic hernia]. / Late presentatie van aangeboren hernia diaphragmatica.

A boy aged 6 months and a girl aged 9 months were admitted due to vomiting, among others, and a boy aged 11 months due to pneumonia. It turned out that they had a congenital diaphragmatic hernia. Primary operative repair was performed successfully in all patients, followed by recovery. The older boy experienced a relapse nearly 1 year later, which was treated by surgical correction. Most congenital diaphragmatic hernias present directly after birth, with cyanosis and respiratory distress. However, 10-20% of the cases are discovered after this period. In these children diagnosis can be difficult because of the diverse symptoms such as vomiting, feeding difficulties, tachypnoea or recurrent respiratory tract infections. Physical signs include the absence of breath sounds or the presence of bowel sounds in the chest. Chest X-ray, contrast upper gastrointestinal series or ultrasound imaging confirms the diagnosis. Delay in treatment can lead to complications such as necrosis of the bowel. In young children with acute or chronic respiratory infections or gastrointestinal complaints, a congenital diaphragmatic defect should be considered.

[Unnatural and unexplained death in a paediatric intensive-care unit, 1993-2002]. / Niet-natuurlijke en onverklaarde dood op een intensive care voor kinderen, 1993-2002.

OBJECTIVE: To analyse the causes of unnatural death in a general paediatric intensive-care unit. DESIGN: Retrospective and descriptive. METHODS: The cause of death was reviewed for all deceased children who were admitted to the paediatric intensive-care unit of the Emma Children's Hospital/Academic Medical Centre in Amsterdam, the Netherlands from 1993 through 2002. Three investigators independently categorised the cause of death as 'natural' or 'unnatural'. Unnatural death was defined as death by external cause, such as drowning, suffocation or violence, whether intentional or not. For all patients who died an unnatural death the cause of death and (if available) results of autopsy were analysed. RESULTS: During the study period, 5523 patients were admitted to the ICU, of whom 360 (6.5%) died during the period of admission. In 45 (12.5%) of these this was an unnatural death. In 7 (16%) patients there was a suspicion of death by deliberately caused injury. In 4 of these patients forensic autopsy was performed. The results of autopsy confirmed the suspicion of child battery in 3 patients, whereas in 1 case the diagnosis was refuted. CONCLUSION: In 16% of the children who died of unnatural causes there was a suspicion of child battery. A forensic autopsy was useful in all cases to confirm or refute the suspicion of child battery, but was not carried out in all cases.

[The transport of severely ill children in the Amsterdam region; 1995-2001]. / Het transport van ernstig zieke kinderen in de regio Amsterdam; 1995-2001.

OBJECTIVE: To inventory experiences of the transport of critically ill children in the Amsterdam region. DESIGN: Retrospective, observational. METHOD: Data were collected from the 1299 children who were transported to our paediatric intensive-care unit from 1 January 1995 until 31 December 2001. Severity of illness was scored and mortality risk calculated. Data on 535 children who were retrieved by our intensive-care team were compared to those from the 764 who were attended by the referring team. The impact on the outcome of distance and duration of transports from both inside and outside the Amsterdam region was analyzed. RESULTS: Two thirds of the transports took place during the evening and night. The median age of the children was 7.5 months. Main indication for admission was respiratory or circulatory insufficiency. During the stabilizing procedure before retrieval, one or more interventions were conducted by our team in 368 (69%) of the 535 retrieved children. 940 children were transported within our region. There were no significant differences between retrieval and non-retrieval groups with respect to length of stay, length of ventilation and mortality. In patients from outside our region the mortality in the retrieval group was higher than in the non-retrieval group. CONCLUSION: Retrieval by a specialized team did not always contribute to a favourable outcome. However, from both a logistical and a medical point of view, a retrieval system seems warranted in order to guarantee a higher level of care. There is a need for more clarity regarding the indications for retrieval by an intensive-care team.

Incidence and short-term outcome of acute lung injury in mechanically ventilated children.

The aim of this study was to determine the incidence and short-term outcome of mechanically ventilated children suffering from acute lung injury (ALI) on a paediatric intensive care unit (PICU). Between January 1 1998 and January 1 2000, all mechanically ventilated children were evaluated using the criteria of an American-European Consensus Conference. Of the 443 children eligible for analysis, 44 (9.9%) were diagnosed as suffering from ALI. Of these, 79.5% developed the acute respiratory distress syndrome (ARDS); 54.5% (24 of 44) fulfilled the ARDS criteria at inclusion and 25% (11 of 44) later. PICU mortality for ALI was 27.3% (12 of 44) and within the ARDS subgroup 31.4% (11 of 35). Of the 12 children who died, 11 had ARDS; the main cause of death was cerebral damage (seven of 12). Acute lung injury and acute respiratory distress syndrome are rare diseases on a paediatric intensive care unit with a high mortality. Most of the children with acute lung injury develop acute respiratory distress syndrome. In the acute respiratory distress syndrome subgroup, mortality is higher than in the acute lung injury nonacute respiratory distress syndrome subgroup. Further investigations should confirm prognostic factors (e.g. respiratory parameters) for prediction of outcome.

Immune complex associated complications in the subacute phase of meningococcal disease: incidence and literature review.

AIM: To determine the incidence of immune complex associated complications (IAC) after severe meningococcal disease (SMD) in a group of Dutch children admitted to a paediatric intensive care unit (PICU). METHODS: Retrospective chart analysis and follow up of 130 survivors of SMD admitted to PICU. Signs of IAC, inflammatory parameters, and temperature profile were reviewed. RESULTS: Of 130 children with SMD, 20 (15.3%) showed one or more of the three manifestations of IAC: 18 (13.8%) developed arthritis (effusion, with or without erythema/arthralgia), 11 (8.4%) vasculitis, and five (3.8%) pleuritis. Eighteen of 20 (90%) patients with IAC had a secondary rise in temperature; in patients with no IAC this was 48 of 110 (43.6%). IAC was associated with leucocytosis in 82.3% versus 47.7% in patients without IAC, and with increased CRP in 86.6% versus 47.2% in patients without IAC. Leucocytes on admission were significantly lower in patients who would later develop IAC (mean 8.6 versus 13.8x10(9)/l). CONCLUSION: IAC is a common complication of SMD, mainly occurring 4-10 days after systemic disease. IAC presents clinically as arthritis or vasculitis, mostly accompanied by secondary fever and raised inflammatory parameters.

[Clinical thinking and decision-making in practice. A new-born with dyspnea]. / Klinisch denken en beslissen in de praktijk. Een pasgeborene met dyspnoe.

A 2-day-old girl, born at term after an uneventful pregnancy and delivery, was admitted to the paediatric intensive care unit with dyspnoea and tachypnoea. Misleading interpretations of the radiological investigations suggested a congenital diaphragmatic hernia. The patient underwent laparotomy but a diaphragmatic hernia was not found. Meanwhile the patient developed unexplained pulmonary hypertension and a progressive forward failure of the heart. The differential diagnosis did not take the pulmonary hypertension into account. Finally further investigations led to the diagnosis of a very rare congenital pulmonary vascular anomaly: an absent left pulmonary artery and systemic to pulmonary collateral arteries. The condition was considered inoperable and the patient, whose condition meanwhile had deteriorated markedly, died. This case illustrates (a) that the differential diagnosis must be based on all of the abnormal clinical findings, which should preferably be grouped together under one final diagnosis, and (b) that one must not jump to conclusions--which in this case led to unnecessary diagnostic and therapeutic interventions--, but as long as a diagnosis cannot be established, the diagnostic investigations should not be considered completed.

Dexamethasone for treatment of patients mechanically ventilated for lower respiratory tract infection caused by respiratory syncytial virus.

BACKGROUND: A study was undertaken to evaluate the efficacy of dexamethasone in patients mechanically ventilated for lower respiratory infection caused by respiratory syncytial virus (RSV-LRTI). METHODS: In a multicentre randomised controlled trial patients were randomised to receive either intravenous dexamethasone (0.15 mg/kg 6 hourly for 48 hours) or placebo. End points were the duration of mechanical ventilation, length of stay (LOS) in the pediatric intensive care unit (PICU) and in hospital, and the duration of supplemental oxygen administration. RESULTS: Thirty seven patients received dexamethasone and 45 received placebo. There was no significant difference in any of the end points between the two groups. In a post hoc analysis patients were stratified into those with mild gas exchange anomalies (PaO(2)/FiO(2) >200 mm Hg and/or mean airway pressure 10 cm H(2)O, pneumonia group). In the 39 patients with bronchiolitis the duration of mechanical ventilation was 4.3 days shorter in the dexamethasone group than in the placebo group (4.9 v 9.2 days, 95% CI -7.8 to -0.8, p=0.02) and the duration of supplemental oxygen was 3.6 days shorter (7.7 v 11.3 days, 95% CI -8.0 to -0.1, p=0.048). No differences in end points were found in the pneumonia group. CONCLUSIONS: Dexamethasone had no beneficial effect in patients mechanically ventilated for RSV-LRTI but was found to have a beneficial effect in patients with bronchiolitis.

Membrane permeabilization in relation to inactivation kinetics of Lactobacillus species due to pulsed electric fields.

Membrane permeabilization due to pulsed electric field (PEF) treatment of gram-positive Lactobacillus cells was investigated by using propidium iodide uptake and single-cell analysis with flow cytometry. Electric field strength, energy input, treatment time, and growth phase affected membrane permeabilization of Lactobacillus plantarum during PEF treatment. A correlation between PEF inactivation and membrane permeabilization of L. plantarum cells was demonstrated, whereas no relationship was observed between membrane permeabilization and heat inactivation. The same results were obtained with a Lactobacillus fermentum strain, but the latter organism was more PEF resistant and exhibited less membrane permeabilization, indicating that various bacteria have different responses to PEF treatment. While membrane permeabilization was the main factor involved in the mechanism of inactivation, the growth phase and the acidity of the environment also influenced inactivation. By using flow cytometry it was possible to sort cells in the L. plantarum population based on different cell sizes and shapes, and the results were confirmed by image analysis. An apparent effect of morphology on membrane permeabilization was observed, and larger cells were more easily permeabilized than smaller cells. In conclusion, our results indicate that the ability of PEF treatment to cause membrane permeabilization is an important factor in determining inactivation. This finding should have an effect on the final choice of the processing parameters used so that all microorganisms can be inactivated and, consequently, on the use of PEF treatment as an alternative method for preserving food products.

Biphasic positive airway pressure ventilation (PeV+) in children.

BACKGROUND: Biphasic positive airway pressure (BIPAP) (also known as PeV+) is a mode of ventilation with cycling variations between two continuous positive airway pressure levels. In adults this mode of ventilation is effective and is being accepted with a decrease in need for sedatives because of the ability to breathe spontaneously during the entire breathing cycle. We studied the use of BIPAP in infants and children. METHODS: We randomized 18 patients with respiratory failure for ventilation with either BIPAP (n = 11) or assisted spontaneous breathing (ASB) (n = 7) on Evita 4. Lorazepam and, if necessary, morphine were used as sedatives and adjusted in accordance with the Comfort scale. We compared number of randomized mode failure, duration and complications of ventilation and number and dosages of sedatives administered. RESULTS: No differences in patient characteristics, ventilatory parameters, complications of ventilation or use of sedatives were noted. Ten out of eleven patients that we intended to ventilate with BIPAP were successfully ventilated with BIPAP. Four out of seven patients that we intended to ventilate with ASB could not be ventilated adequately with ASB but were successfully crossed over to BIPAP without the need for further sedatives. CONCLUSIONS: BIPAP is an effective, safe and easy to use mode of ventilation in infants and children.