Plasma Ascorbic Acid Levels in Critically Ill Pediatric Patients.

Ascorbic acid, or vitamin C, is a physiological antioxidant that has been found to be deficient in critically ill adults with sepsis and acute respiratory distress system. In adults, ascorbic acid supplementation has been shown to reduce the need for vasopressors and mechanical ventilation. This study aimed to describe the prevalence of ascorbic acid deficiency in critically ill pediatric patients. This prospective, single-centered study analyzed 34 patients aged 1 month to 18 years old with septic shock and/or acute respiratory failure requiring mechanical ventilation in a quaternary, urban, pediatric intensive care unit. Plasma ascorbic acid levels were measured by high-performance liquid chromatography within 24 hours of meeting eligibility criteria. The median level was 23.34 µM (IQR [11.45, 39.14]). Twenty-three patients had repeat samples that were collected 3 to 5 days later. The median for repeat samples was higher at 42.41 µM (IQR [13.08, 62.43]). Patients who were enterally fed had significantly higher levels than those who were not (62.4 ± 7.7 µM vs. 32.4 ± 7.1 µM; p = 0.03). Ascorbic acid levels vary widely among critically ill children with septic shock and/or respiratory failure requiring mechanical ventilation, but one-half of our patients had deficient levels that are typically seen in scurvy. Further studies are warranted to investigate the significance of low levels as well as the impact of normalizing levels through nutritional support.

Safety and Acceptance of Acupuncture and Acupressure in Children, Adolescents, and Young Adults Undergoing Hematopoietic Stem Cell Transplant.

BACKGROUND: Hematopoietic stem cell transplant (HSCT) is associated with significant morbidity and high symptom burden including mucositis pain, nausea, and vomiting. There is little documentation in the literature regarding acupuncture or acupressure for children undergoing HSCT. OBJECTIVE: The purpose of this study was to determine the safety and acceptance of acupuncture and acupressure in children undergoing HSCT in a large tertiary care children's hospital. METHODS: This is a descriptive retrospective study that evaluated 80 admissions to the HSCT unit over a 24-month period. Every child admitted for HSCT was offered acupuncture or acupressure as part of their care. RESULTS: Of 80 patients, 46 were male patients (ages range, 0-32 years; mean, 8 years). Diagnoses include leukemia/lymphoma, sickle cell disease, aplastic anemia, neuroblastoma, and other metabolic, other solid tumor, or other hematologic disorders. Both allogenic and autologous were represented. Sixty-six patients (82.5%) agreed to treatment with acupuncture, acupressure, or both. There were no adverse effects or safety concerns noted. Symptoms addressed by acupuncture or acupressure included pain from mucositis, nausea, constipation, diarrhea, anxiety, insomnia, and general wellness or healing. CONCLUSION: This study demonstrates that acupuncture and acupressure are well accepted by children and their families admitted for HSCT and are safe even when performed in the first 4 weeks following transplant when the patient is likely to have thrombocytopenia. IMPLICATIONS FOR PRACTICE: These findings suggest that there may be more therapies for patients undergoing HSCT to help with symptom control.

National survey of health services provided by pediatric post-acute care facilities in the US.

PURPOSE: The need for pediatric post-acute facility care (PAC) is growing due to technological advances that extend the lives of many children, especially those with complex medical needs. The objectives were to describe [1] the types and settings of PAC; [2] the clinical characteristics of the pediatric patients requiring PAC; and [3] perceptions of PAC care delivery by clinical staff. METHODS: An online survey was administered between 6/2018 to 12/2018 to administrative leaders in PAC facilities that have licensed beds for children and who were active members of the Pediatric Complex Care Association. Survey topics included types of health services provided; pediatric patient characteristics; clinical personnel characteristics; and perceptions of pediatric PAC health care delivery. RESULTS: Leaders from 26 (54%) PAC facilities in 16 U.S. states completed the survey. Fifty-four percent identified as skilled nursing facility/long-term care, 19% intermediate care facilities, 15% respite and medical group homes, and 12% post-acute rehabilitation facilities. Sixty-nine percent of facilities had a significant increase in the medical complexity of patients over the past 10 years. Most reported capability to care for children with tracheostomy/invasive ventilation (100%), gastrostomy tubes (96%), intrathecal baclofen pump (89%), non-invasive positive pressure ventilation (85%), and other medical technology. Most facilities (72%) turned away patients for admission due to bed unavailability occasionally or always. Most facilities (62%) reported that insurance reimbursement to cover the cost of providing PAC to children was not acceptable, and most reported that it was difficult to hire clinical staff (77%) and retain staff (58%). CONCLUSION: PAC in the U.S. is provided to an increasingly medically-complex population of children. There is a critical need to investigate financially-viable solutions for PAC facilities to meet the patient demands for their services and to sufficiently reimburse and retain staff for the challenging and important care that they provide.

Cost of Pediatric Concurrent Hospice Care: An Economic Analysis of Relevant Cost Components, Review of the Literature, and Case Illustration.

Background: Concurrent care enables seriously ill pediatric Medicaid and Children's Health Insurance Program (CHIP) beneficiaries to continue curative treatments along with the supportive services usually associated with hospice care. Although a few studies have examined pediatric concurrent care, none has explored the economics of this care delivery approach for medically complex children. Objective: The purpose of this study was to identify the cost components relevant for an economic analysis of pediatric concurrent hospice care and demonstrate the use of the cost components in an economic case illustration. Methods: A scoping review of the hospice cost literature was conducted to identify article focused on hospice costs that were published in the journal literature from 2000 to 2019. A preliminary economic analysis was also conducted using a cost-minimization approach with data from a large mid-Atlantic pediatric hospice provider. We compared costs between concurrent versus standard hospice care for children. Results: Fifteen hospice cost articles were identified and no article on concurrent care costs. Most articles in the scoping review focused on hospice personnel costs, followed by supplies/equipment, and other. Personnel and costs were higher for standard hospice children compared with concurrent care, whereas concurrent care children had higher supplies/equipment costs. Conclusions: Identifying cost components are critical to economic analysis of pediatric concurrent care. These findings provide preliminary evidence about the difference in costs between concurrent and standard hospice care for children.

Tracheal Agenesis: Vertical Division of the Native Esophagus - A Novel Surgical Approach and Review of the Literature.

INTRODUCTION: Tracheal agenesis (TA) is rare and usually fatal. Few survivors with concomitant tracheoesophageal fistulae (TEF) who underwent ligation of the distal esophagus with creation of a spit-fistula and neo-trachea from the proximal esophagus exist. We report a novel surgical technique whereby the esophagus is divided longitudinally to preserve a functional alimentation tract and a parallel neo-trachea. We review the literature of reported cases, including survivors beyond 12 months. METHODS: Case report and literature review. RESULTS: A female infant with prenatal polyhydramnios was born at 35 weeks gestation with immediate respiratory distress and absent cry. Oxygenation was maintained with a laryngeal mask airway. Despite a normal appearing larynx, she could not be intubated and emergent neck exploration disclosed no cervical trachea. The patient was placed on extra corporeal membranous oxygenation (ECMO), and later diagnosed with TA, Floyd Type I. Parental desire for reconstruction but refusal of a spit-fistula necessitated a novel procedure. The esophagus was divided longitudinally via a microstapler to preserve the original alimentary tract and create a parallel neo-trachea originating from the TEF and terminating as a cervical stoma. The healing process was complicated but the baby was ultimately discharged to home where she developed normally neurologically until succumbing one night to accidental decannulation at 16 months of age. CONCLUSION: We describe a novel surgical approach to manage TA. This includes avoiding creation of a spit fistula and preserving the native esophagus. We then survey the literature, reporting the survivorship duration and operative management of 174 reported cases of TA.

The Relationship Between Spirituality and the Developing Brain: A Framework for Pediatric Oncology.

Development, whether motor, language, social, or spiritual, is the functional expression of complex brain processes throughout one's life span, the foundations of which are laid in childhood. The effects of cancer, chemotherapy, radiation, and surgical procedures on early brain development have been measured using neuroimaging and developmental assessment tools. We propose that spiritual development may be substantially affected in children with oncological diseases that impact underlying brain processes. By drawing connections between science, spirituality, and medicine, we can better address the spiritual needs of children as they cope with oncological diseases, by mitigating emotional, cognitive, and physical symptoms and improving outcomes.

Mindful Mentors: Is a Longitudinal Mind-Body Skills Training Pilot Program Feasible for Pediatric Cardiology Staff?

BACKGROUND: Stress and burnout among medical professionals are common and costly, placing professionals, organizations, and patients at risk. OBJECTIVES: To determine feasibility and acceptability of a longitudinal mind-body skills training initiative to help staff decrease stress and burnout, improve well-being, and empower them to utilize basic mindfulness methods with coworkers, patients, and families. METHODS: Prospective cohort, mixed methods approach. Nurses, doctors, technicians, social workers, child life specialists were eligible to participate. The 12-month curriculum consisted of 16 hours of intensive education/practice over 2 days, with training in mindfulness skills, self-compassion, nonviolent communication, overcoming barriers to practice, and mindful listening/speaking, followed by monthly 1 hour booster/debriefing sessions. RESULTS: A total of 37 staff participated (RN = 18, MD = 5, Technician = 6, Social Worker = 3, Child life = 3, others = 2) in the initial training, and 24 (65%) completed the 3- and 12-month follow-up surveys. Compared with pretraining scores, there were significant improvements 3 to 12 months after the initial training in stress (P < .0001), distress (P ≤ .04), anxiety (P = .01), self-efficacy in providing non-drug therapies (P < .0001), mindfulness (P = .002), burnout (P < .0001), and confidence in providing compassionate care (P < .0001). In addition, 25 (67%) participants initiated projects incorporating what they learned into staff/patient wellness activities. CONCLUSION: This longitudinal pilot program was feasible and was associated with improvements in measures of psychological well-being over the 12-month intervention. The innovative approach of training participants to teach basic techniques to coworkers and other staff can increase the impact of this program beyond any individual participant. Future research will investigate the aspects of implementation and potential effects on patient care and experience.

Use of Post-Acute Facility Care in Children Hospitalized With Acute Respiratory Illness.

BACKGROUND: Recovery from respiratory illness (RI), a common reason for hospitalization, can be protracted for some children because of high illness severity or underlying medical complexity. OBJECTIVE: We assessed which children hospitalized with RI are the most likely to use post-acute facility care (PAC) for recovery. METHODS: Retrospective analysis of 609,800 hospitalizations for patients in 43 US children's hospitals between 2010- 2015 for RI, identified with the Agency for Healthcare Research and Quality Clinical Classification System. Discharge to PAC was identified using Centers for Medicare & Medicaid Services Discharge Status Codes. We compared patient characteristics by PAC use with generalized estimating equations. RESULTS: There were 2660 (0.4%) RI hospitalizations resulting in PAC transfer (n = 2660, 0.4%). Discharges to PAC had greater percentages of technology assistance (83.2% vs 15.1%), neuromuscular chronic condition (57.5% vs 8.9%), and mechanical ventilation (52.7% vs 9.1%), 𝑃 < 0.001 for all. The highest likelihood of PAC use occurred with ≥11 vs no chronic conditions (odds ratio [OR] 11.7 [95% CI, 8.0- 17.2]), ≥9 vs no therapeutic medication classes (OR 4.8 [95% CI, 1.8-13.0]), and existing tracheostomy (OR 3.0, 95% confidence interval [CI], 2.6-3.5). Median (interquartile range [IQR]) acute-care length of stay (LOS) for children most likely to use PAC was 19 (8-56) days; LOS remained long (median 13 [6-41] days) for children with the same attributes (n = 9448) not transferred to PAC. CONCLUSIONS: Children with RI who are most likely to use PAC have a high prevalence of multiple chronic conditions, multiple medications, and medical technology. Future investigations should assess the supply of PAC against the demand of hospitalized children with RI who might need it.

Successful venoarterial extracorporeal membrane oxygenation for prolonged hepatopulmonary syndrome following pediatric liver transplantation: A case report and review of the literature.

HPS is a major complicating feature of end-stage liver disease. Diagnosis is clinical, and LT is the only definitive treatment. While the general impression is that HPS improves quickly after transplantation, it may not always be the case. We describe the smallest reported child with HPS prior to LT and requiring prolonged venoarterial extracorporeal membrane oxygenation after LT; especially as it is a rare occurrence, physician managing such cases should be aware of the circumstances under which HPS may require specific treatment.

Healing, spirituality and integrative medicine.

Spirituality plays a prominent role in the lives of most palliative patients whether or not they formally adhere to a specific religion and belief. As a result, the palliative care team is frequently called upon to support families who are experiencing their "dark night of the soul" and struggling to make sense of their lives during a healthcare crisis. While conventional religious practices provide a source of comfort and guidance for many of our patients, a significant number of our patients do not have a strong religious community to which to turn. Over the last two decades, more people in Western countries identify themselves as spiritual but not religious and do not belong to an organized faith community. For those patients who express a strong spiritual connection or sense of 'something greater' or 'a higher power', encouraging the exploration of those feelings and beliefs through chaplains, clergypersons, or members of the interdisciplinary palliative care team can help provide context, meaning and purpose in their lives impacted by serious illness. One of the goals of effective palliative care is the facilitation of personal growth and psychological resilience in dealing with one's health challenges. Integrative medicine, also referred to as complementary and alternative medicine, provides a set of tools and philosophies intended to enhance wellness and a sense of wellbeing. Many of the modalities are derived from disciplines such as massage, acupuncture, Rei Ki, aromatherapy, and dietary supplements. The use of integrative medicine in North America is widespread and frequently not shared with one's clinician due to many patients' concerns that clinicians will disapprove of the patient's use of them. In addition to its efficacy in reducing symptoms commonly experienced by patients receiving palliative care (e.g., nausea, pain, depression, and existential suffering), integrative medicine offers non-verbal, non-cognitive avenues for many to achieve a peaceful and calm inner state. The calm state often achieved during integrative medicine treatments is similar to that seen during deep prayer or meditation. In such a transcendent or non-ordinary state of consciousness, many people experience new insights or understanding of their lives and choices they must make. Thus, integrative approaches facilitate patients attaining greater self-awareness and may meet their spiritual needs without the religious overtones that accompany traditional prayer. In so doing, patients may gain greater insight and find inner peace through simple, non-verbal approaches.

ICU-Acquired Weakness Is Associated With Differences in Clinical Outcomes in Critically Ill Children.

OBJECTIVE: ICU-acquired weakness, comprised critical illness myopathy and critical illness neuropathy, occurs in a significant proportion of critically ill adults and is associated with high morbidity and mortality. Little is known about ICU-acquired weakness among critically ill children. We investigated the incidence of ICU-acquired weakness among PICUs participating in the Virtual PICU Systems database. We also sought to identify associated risk factors for ICU-acquired weakness and evaluate the hypothesis that ICU-acquired weakness is associated with poor clinical outcomes. DESIGN: Retrospective cohort study. SETTING: PICU. MEASUREMENTS AND MAIN RESULTS: Virtual PICU System was queried for critical illness myopathy and critical illness neuropathy between January 2009 and November 2013. Demographic, admission, and clinical outcome variables including mechanical ventilation days, PICU length of stay, and discharge disposition were analyzed. The Pediatric Index of Mortality-2 was used to evaluate and control for illness severity and risk of mortality. Among 203,875 admissions, there were 55 cases of critical illness myopathy reported and no cases of critical illness neuropathy, resulting in an incidence of 0.02%. Mechanical ventilation days were higher among patients with ICU-acquired weakness versus those who did not develop ICU-acquired weakness (31.6 ± 28.9 vs 9.3 ± 20.6; p < 0.001). In our multivariable analysis, when controlling for Pediatric Index of Mortality-2, ICU-acquired weakness was more frequently reported in those with admission diagnoses of respiratory illness and infection and the need for mechanical ventilation, renal replacement therapy, extracorporeal life support, and tracheostomy. ICU-acquired weakness was associated with a longer PICU length of stay, episodes requiring mechanical ventilation, and discharge to an intermediate, chronic care, and rehabilitation care unit. ICU-acquired weakness was not independently associated with mortality. CONCLUSIONS: ICU-acquired weakness is uncommonly diagnosed among PICU patients reported in Virtual PICU System. ICU-acquired weakness is associated with critical care therapies, invasive procedures, and resource utilization. Limitations of our retrospective study include underrecognition of ICU-acquired weakness and lack of standardized diagnostic criteria within Virtual PICU System. Prospective studies are needed to better understand the true incidence, risk factors, and clinical course for patients who develop ICU-acquired weakness.

Families' Views of Pediatric Palliative Aquatics: A Qualitative Study.

Although pediatric palliative care policies and services have been developed, research in this area continues to lag. An integrated model of palliative care has been suggested by the American Academy of Pediatrics and includes complementary and alternative services aimed at improving the well-being of children and their families. The first-known pediatric palliative aquatics program (PPAP) in California uses several techniques to decrease pain and promote well-being through relaxation and interaction between patients, specialists, and family members. This study investigates the perceptions of family members of their children's experiences with a PPAP. Researchers from an outside institution conducted focus groups and interviews. Themes were extracted from the focus group transcripts using Braun and Clarke's method of inductive thematic analysis. Data were collected at the host site, local libraries, and participant homes. Participants were primary caregivers and siblings (n = 23) of children in a PPAP, an independent children's respite, transitional, and end-of-life care facility in California. The research described and drew implications from the diverse perceptions that family members expressed about the benefits of having a child in the PPAP, including sensory, physical, and social experiences. Although the PPAP aims to promote well-being through relaxation, several other benefits were expressed by family members of children going through the program, including pain relief.

Use of a noninvasive electromagnetic device to place transpyloric feeding tubes in critically ill children.

BACKGROUND: The start of transpyloric feedings is often delayed because of challenges in reliably placing tubes blindly at the bedside. OBJECTIVE: To determine whether tube placement with the guidance of a noninvasive computerized electromagnetic device shortens the time needed to achieve accurate placement of transpyloric feeding tubes in critically ill children. METHODS: In a prospective, randomized trial in a tertiary-care, university-affiliated pediatric intensive care unit, 49 children requiring transpyloric feeding tube placement were randomized to have their tube placed by using conventional blind technique or with the assistance of a noninvasive electromagnetic device. RESULTS: Twenty-seven patients were randomized to blind placement, and 22 were randomized to the electromagnetic device group. The time required to place the tubes successfully was significantly longer (P < .03) in the electromagnetic device group (median, 9.5 minutes; 95% confidence interval, 7-13 minutes) compared with the conventional placement group (median, 5 minutes; 95% confidence interval, 4.0-7.0 minutes). CONCLUSIONS: Placement of transpyloric feeding tubes with the guidance of a noninvasive electromagnetic device significantly increases the time required for accurate placement. Because placement of transpyloric feeding tubes in critically ill children is common practice in many pediatric intensive care units, technology that delays satisfactory placement may be counterproductive in experienced hands.

Lack of irrefutable validation does not negate clinical utility of near-infrared spectroscopy monitoring: learning to trust new technology.

Reliance on new monitoring device technology is based upon an understanding of how the device operates and its reliability in a specific clinical setting. The introduction of new monitoring devices will therefore elicit either distrust of the new technology and the data presented or adoption of new devices. The use of near-infrared spectroscopy (NIRS) technology to monitor vital organs in postoperative pediatric cardiac surgery patients has been extensively described yet controversy remains as to the use of this monitoring device. The following retrospective case series demonstrates how learning from trends in data elicited from 2-site NIRS monitoring provided important bedside insights. These insights led to changes in clinician behavior and reliance on NIRS monitoring for early recognition of clinically silent deteriorations. Disregard for the NIRS data may have led to a fatal outcome in an unstable patient who might have received more timely intervention if the NIRS data had been acknowledged earlier. This case series demonstrates that 2-site NIRS monitoring accurately reflects situations in which poor clinical outcomes may occur when declining trends in somatic tissue oxygen saturations are not corrected. Physician management of the postoperative pediatric cardiac surgery patient can change based upon the insights gained through the application of NIRS monitoring.

Massage therapy in outpatient pediatric chronic pain patients: do they facilitate significant reductions in levels of distress, pain, tension, discomfort, and mood alterations?

BACKGROUND AND OBJECTIVES: This study was designed to look at the efficacy of adjuvant massage therapy in children and adolescents who presented to a chronic pediatric pain clinic for management. METHODS: After Institutional Review Board approval and informed consent and assent was obtained, all pediatric patients who presented to the outpatient chronic pain clinic at Children's Memorial Hospital from July 2006 to May 2007 were invited to participate in a study that offered massage therapy as an adjunct to conventional pain treatment. Patients (n = 80 sessions, 57 patients) were asked to rate their levels of distress, pain, tension, discomfort, and degree of upset mood on a scale of 1-5 (e.g. for distress 1 = very calm; 5 = very distressed) before and after massage therapy. Paired t-tests were used to compare pre- and postmassage ratings and probability values were corrected for multiple comparisons using the Bonferroni procedure. RESULTS: After massage therapy, patients reported highly significant improvement in their levels of distress, pain, tension, discomfort, and mood compared with their premassage ratings (all t-values >6.1, ****P < 1 x 10(-8). To control for the possible effects of patients reporting improvements simply as a result of rating their symptoms, we collected control ratings before and after a comparable 'no intervention' time period in a subset of 25 patients. The 'no intervention' time period typically took place in the treatment room with the therapist present. Approximately 60% of the control ratings were obtained before the intervention and 40% were obtained after the massage therapy. None of the differences between the pre- and postratings associated with the 'no intervention' control time period were significant. In these same patients, the difference between the pre- and postmassage ratings were significant, all t-values >3.8, **P < 0.001.

Conventional mechanical ventilation in pediatrics.

OBJECTIVE: To review the various challenges of providing mechanical ventilation to pediatric patients with diseases of increased airway resistance, diseases of abnormal lung compliance or normal lungs. SOURCES: Original data from our pediatric intensive care unit and animal research laboratory. Relevant articles included in the MEDLINE electronic database during the last 10 years. Also included were book chapters and definitive studies, as judged by the authors, in the fields of asthma, acute respiratory distress syndrome, mechanical ventilation, ventilator-induced lung injury and permissive hypercapnia. SUMMARY OF THE FINDINGS: Mechanical ventilation of patients with diseases of increased airway resistance should center on avoidance of dynamic hyperinflation, allowing complete exhalation prior to the initiation of a subsequent breath and permissive hypercapnia. Positive end-expiratory pressure should be used sparingly to prevent atelectasis and facilitate synchrony in spontaneously breathing patients. Mechanical ventilation of patients with diseases of abnormal lung compliance should take into consideration the inhomogeneous distribution of lung disease. Focus should be on avoidance of volutrauma and atelectrauma that could result in ventilator-associated lung injury. CONCLUSIONS: The last decade was marked by significant advances in the management of pediatric respiratory failure. The choice of mechanical ventilation strategy can significantly influence the subsequent course of lung injury. Mechanical ventilation can no longer be viewed simply as a harmless support modality that is employed to keep patients alive while disease-specific treatments are used to ameliorate the underlying pathology.

Ventilação mecânica convencional em pediatria / Conventional mechanical ventilation in pediatrics

OBJETIVO: Revisar os vários desafios existentes na ventilação mecânica de pacientes pediátricos com doenças de resistência elevada das vias aéreas, complacência pulmonar anormal ou pulmões normais. FONTES DOS DADOS: Dados originais coletados em nossa unidade de tratamento intensivo pediátrico e em nosso laboratório de pesquisa animal. Artigos pertinentes incluídos na base de dados MEDLINE durante os últimos 10 anos. Também foram incluídos capítulos de livros e estudos definitivos, a critério dos autores, sobre asma, síndrome do desconforto respiratório agudo, ventilação mecânica, lesão pulmonar induzida pelo ventilador e hipercapnia permissiva. SíNTESE DOS DADOS: O foco da ventilação mecânica de pacientes com doenças que resultam em resistência elevada das vias aéreas deve centrar-se na hipercapnia permissiva e prevenção de hiperinsuflação dinâmica, permitindo exalação total antes do início da inspiração subseqüente. A pressão expiratória final positiva deve ser usada comedidamente para evitar atelectasia e facilitar a sincronia em pacientes com respiração espontânea. A ventilação mecânica de pacientes com doenças de complacência pulmonar anormal deve levar em consideração a distribuição heterogênea da lesão pulmonar. O enfoque deve ser na prevenção de volutrauma e atelectrauma, que podem resultar em lesão pulmonar associada ao ventilador. CONCLUSÕES: A última década foi marcada por significativos avanços no manejo de insuficiência respiratória em pacientes pediátricos. A escolha da estratégia de ventilação mecânica pode influenciar significativamente o curso subseqüente da lesão pulmonar. A ventilação mecânica não pode ser vista apenas como uma mera modalidade de suporte usada para manter os pacientes vivos enquanto que tratamentos específicos à doença são empregados para melhorar a patologia de base.

OBJECTIVE: To review the various challenges of providing mechanical ventilation to pediatric patients with diseases of increased airway resistance, diseases of abnormal lung compliance or normal lungs. SOURCES: Original data from our pediatric intensive care unit and animal research laboratory. Relevant articles included in the MEDLINE electronic database during the last 10 years. Also included were book chapters and definitive studies, as judged by the authors, in the fields of asthma, acute respiratory distress syndrome, mechanical ventilation, ventilator-induced lung injury and permissive hypercapnia. SUMMARY OF THE FINDINGS: Mechanical ventilation of patients with diseases of increased airway resistance should center on avoidance of dynamic hyperinflation, allowing complete exhalation prior to the initiation of a subsequent breath and permissive hypercapnia. Positive end-expiratory pressure should be used sparingly to prevent atelectasis and facilitate synchrony in spontaneously breathing patients. Mechanical ventilation of patients with diseases of abnormal lung compliance should take into consideration the inhomogeneous distribution of lung disease. Focus should be on avoidance of volutrauma and atelectrauma that could result in ventilator-associated lung injury. CONCLUSIONS: The last decade was marked by significant advances in the management of pediatric respiratory failure. The choice of mechanical ventilation strategy can significantly influence the subsequent course of lung injury. Mechanical ventilation can no longer be viewed simply as a harmless support modality that is employed to keep patients alive while disease-specific treatments are used to ameliorate the underlying pathology.