Anoopindar Ghuman

The association between the end tidal alveolar dead space fraction and mortality in pediatric acute hypoxemic respiratory failure

Objective: To investigate the relationship of markers of oxygenation, PaO2/FIO2 ratio, SpO2/FIO2 ratio, oxygenation index, oxygen saturation index, and dead space (end tidal alveolar dead space fraction) with mortality in children with acute hypoxemic respiratory failure. Design: Retrospective. Setting: Single-center tertiary care pediatric intensive care unit. Patients: Ninety-five mechanically ventilated children with a PaO2/FIO2 ratio <300 within 24 hrs of the initiation of mechanical ventilation. Interventions: None. Main Results: The end tidal alveolar dead space fraction, PaO2/FIO2 ratio, SpO2/FIO2 ratio, oxygenation index, and oxygen saturation index were all associated with mortality (p < .02). There was a small correlation between the end tidal alveolar dead space fraction and decreasing PaO2/FIO2 (r2 = .21) and SpO2/FIO2 ratios (r2 = .22), and increasing oxygenation index (r2 = .25) and oxygen saturation index (r2 = .24). In multivariate logistic regression modeling, the end tidal alveolar dead space fraction was independently associated with mortality (p < .02). Oxygenation index, oxygen saturation index, and the end tidal alveolar dead space fraction were all acceptable discriminators of mortality with receiver operating characteristic plot area under the curves ≥0.7. Conclusions: In pediatric acute hypoxemic respiratory failure, easily obtainable pulmonary specific markers of disease severity (SpO2/FIO2 ratio, oxygen saturation index, and the end tidal alveolar dead space fraction) may be useful for the early identification of children at high risk of death. Furthermore, the end tidal alveolar dead space fraction should be considered for risk stratification of children with acute hypoxemic respiratory failure, given that it was independently associated with mortality.

Effort of breathing in children receiving high-flow nasal cannula.

Objective: High-flow humidified nasal cannula is often used to provide noninvasive respiratory support in children. The effect of high-flow humidified nasal cannula on effort of breathing in children has not been objectively studied, and the mechanism by which respiratory support is provided remains unclear. This study uses an objective measure of effort of breathing (Pressure. Rate Product) to evaluate high-flow humidified nasal cannula in critically ill children. Design: Prospective cohort study. Setting: Quaternary care free-standing academic children’s hospital. Patients: ICU patients younger than 18 years receiving high-flow humidified nasal cannula or whom the medical team planned to extubate to high-flow humidified nasal cannula within 72 hours of enrollment. Interventions: An esophageal pressure monitoring catheter was placed to measure pleural pressures via a Bicore CP-100 pulmonary mechanics monitor. Change in pleural pressure (&Dgr;Pes) and respiratory rate were measured on high-flow humidified nasal cannula at 2, 5, and 8 L/min. &Dgr;Pes and respiratory rate were multiplied to generate the Pressure.Rate Product, a well-established objective measure of effort of breathing. Baseline Pes, defined as pleural pressure at end exhalation during tidal breathing, reflected the positive pressure generated on each level of respiratory support. Measurements and Main Results: Twenty-five patients had measurements on high-flow humidified nasal cannula. Median age was 6.5 months (interquartile range, 1.3–15.5 mo). Median Pressure,Rate Product was lower on high-flow humidified nasal cannula 8 L/min (median, 329 cm H2O·min; interquartile range, 195–402) compared with high-flow humidified nasal cannula 5 L/min (median, 341; interquartile range, 232–475; p = 0.007) or high-flow humidified nasal cannula 2 L/min (median, 421; interquartile range, 233–621; p < 0.0001) and was lower on high-flow humidified nasal cannula 5 L/min compared with high-flow humidified nasal cannula 2 L/min (p = 0.01). Baseline Pes was higher on high-flow humidified nasal cannula 8 L/min than on high-flow humidified nasal cannula 2 L/min (p = 0.03). Conclusions: Increasing flow rates of high-flow humidified nasal cannula decreased effort of breathing in children, with the most significant impact seen from high-flow humidified nasal cannula 2 to 8 L/min. There are likely multiple mechanisms for this clinical effect, including generation of positive pressure and washout of airway dead space.

Impact of Gender on Sepsis Mortality and Severity of Illness for Prepubertal and Postpubertal Children

OBJECTIVE To investigate differences in sepsis mortality between prepubertal and postpubertal males and females. STUDY DESIGN This was a retrospective review of the Virtual PICU Systems (VPS) database (including 74 pediatric intensive care units [PICUs]) for 2006-2008. We included prepubertal (aged 2-7 years) and postpubertal (aged 16-21 years) children with a primary diagnosis of sepsis admitted to a participating PICU. RESULTS Prepubertal females (n = 272; 9.9% mortality) and prepubertal males (n = 303; 10.9% mortality) had similar mortality and severity of illness (Pediatric Index of Mortality 2 risk of mortality [PIM 2 ROM]). Postpubertal females (n = 233; mortality, 5.6%) had lower mortality than postpubertal males (n = 212; mortality, 11.8%; P = .03). PIM 2 ROM was higher for postpubertal males than postpubertal females (P = .02). After controlling for hospital specific effects with multivariate modeling, in postpubertal children, female gender was independently associated with a lower initial severity of illness (PIM 2 ROM: OR, 0.77; 95% CI, 0.62-0.96; P = .02). CONCLUSION Sepsis mortality is similar in prepubertal males and females. However, postpubertal males have a higher sepsis mortality than postpubertal females, likely related to their greater severity of illness on PICU admission. These outcome differences in postpubertal children may reflect a hormonal influence on the response to infection or differences in underlying comorbidities, source of infection, or behavior.

Respiratory inductance plethysmography calibration for pediatric upper airway obstruction: an animal model

Background:We sought to determine optimal methods of respiratory inductance plethysmography (RIP) flow calibration for application to pediatric postextubation upper airway obstruction.Methods:We measured RIP, spirometry, and esophageal manometry in spontaneously breathing, intubated Rhesus monkeys with increasing inspiratory resistance. RIP calibration was based on: ΔµVao ≈ M[ΔµVRC + K(ΔµVAB)] where K establishes the relationship between the uncalibrated rib cage (ΔµVRC) and abdominal (ΔµVAB) RIP signals. We calculated K during (i) isovolume maneuvers during a negative inspiratory force (NIF), (ii) quantitative diagnostic calibration (QDC) during (a) tidal breathing, (b) continuous positive airway pressure (CPAP), and (c) increasing degrees of upper airway obstruction (UAO). We compared the calibrated RIP flow waveform to spirometry quantitatively and qualitatively.Results:Isovolume calibrated RIP flow tracings were more accurate (against spirometry) both quantitatively and qualitatively than those from QDC (P < 0.0001), with bigger differences as UAO worsened. Isovolume calibration yielded nearly identical clinical interpretation of inspiratory flow limitation as spirometry.Conclusion:In an animal model of pediatric UAO, isovolume calibrated RIP flow tracings are accurate against spirometry. QDC during tidal breathing yields poor RIP flow calibration, particularly as UAO worsens. Routine use of a NIF maneuver before extubation affords the opportunity to use RIP to study postextubation UAO in children.

Symposium: intensive careRespiratory support in children

Respiratory failure is defined by the inability of the respiratory system to adequately deliver oxygen or remove carbon dioxide from the pulmonary circulation resulting in hypoxaemia, hypercapnia or both. A wide variety of disease processes can lead to respiratory failure in children. Multiple interventions can support the paediatric patient with respiratory failure, from simple oxygen delivery devices to high frequency oscillatory ventilation. This article will review available devices to improve oxygenation and ventilation, their advantages and disadvantages, and help to guide physicians in the management of children with respiratory failure.