Giovanna Chidini

Noninvasive ventilation for treating acute respiratory failure in AIDS patients with Pneumocystis carinii pneumonia

Objective. To compare noninvasive positive pressure ventilation (NPPV) vs. invasive mechanical ventilation in AIDS patients with Pneumocystis carinii pneumonia (PCP)-related acute respiratory failure (ARF).Design: A single-center, prospective, case-control trial.Setting: An ICU of a private tertiary hospital specialized in infectious disease.Patients: Forty-eight AIDS patients with severe PCP-related ARF needing mechanical ventilation.Interventions: Twenty-four patients treated with NPPV by a facial mask strictly matched with 24 patients treated with invasive ventilation by endotracheal intubation.Results: Use of NPPV avoided intubation in 67% of patients, and avoidance of intubation was associated with improved survival (100% vs. 38%; P=0.003). NPPV-treated patients required fewer invasive devices (P<0.001) and had a lower incidence of pneumothoraces (8.3% vs. 37.5%; P=0.039). The NPPV-treated group required a nurse workload similar to that of the conventional ventilation group, but this group had a shorter duration of stay in the ICU (P=0.013). The NPPV-treated group had a lower mortality in the ICU, the hospital and within 2 months of study entry. Differences in mortality between the two groups disappeared after 6 months.Conclusions: The findings of this study seem to provide further support for applying NPPV in AIDS patients with severe PCP-related ARF as a first-line therapeutic choice, but randomized controlled trials are required to confirm our results.

Noninvasive Continuous Positive Airway Pressure in Acute Respiratory Failure: Helmet Versus Facial Mask

OBJECTIVE: Noninvasive continuous positive airway pressure (nCPAP) is applied through different interfaces to treat mild acute respiratory failure (ARF) in infants. Recently a new pediatric helmet was introduced in clinical practice to deliver nCPAP. The objective of this study was to compare the feasibility of the delivery of nCPAP by the pediatric helmet with delivery by a conventional facial mask in infants with ARF. PATIENTS AND METHODS: We conducted a single-center physiologic, randomized, controlled study with a crossover design on 20 consecutive infants with ARF. All patients received nCPAP by helmet and facial mask in random order for 90 minutes. In infants in both trials, nCPAP treatment was preceded by periods of unassisted spontaneous breathing through a Venturi mask. The primary end point was the feasibility of nCPAP administered with the 2 interfaces (helmet and facial mask). Feasibility was evaluated by the number of trial failures defined as the occurrence of 1 of the following: intolerance to the interface; persistent air leak; gas-exchange derangement; or major adverse events. nCPAP application time, number of patients who required sedation, and the type of complications with each interface were also recorded. The secondary end point was gas-exchange improvement. RESULTS: Feasibility of nCPAP delivery was enhanced by the helmet compared with the mask, as indicated by a lower number of trial failures (P < .001), less patient intolerance (P < .001), longer application time (P < .001), and reduced need for patient sedation (P < .001). For both delivery methods, no major patient complications occurred. CONCLUSIONS: The results of this current study revealed that the helmet is a feasible alternative to the facial mask for delivery of nCPAP to infants with mild ARF.

Treatment of acute hypoxemic respiratory failure with continuous positive airway pressure delivered by a new pediatric helmet in comparison with a standard full face mask: A prospective pilot study

Objectives: To evaluate the feasibility and efficacy of continuous positive airway pressure delivered by a new pediatric helmet in comparison with a standard facial mask in infants with acute hypoxemic respiratory failure. Design: A single-center prospective case–control study. Setting: Pediatric intensive care unit in a tertiary children hospital. Patients and Interventions: Twenty consecutive infants treated with continuous positive airway pressure by a helmet matched with a control patient treated with continuous positive airway pressure by facial mask and selected by age, weight, PaO2:Fio2, and PaCO2 on pediatric intensive care unit admission. Measurements and Main Results: Feasibility was defined as the incidence of continuous positive airway pressure protocol failure secondary to 1) failure to administer continuous positive airway pressure because of intolerance to the interface; 2) deterioration in gas exchange soon after continuous positive airway pressure institution; and 3) major clinical adverse events such as pneumothorax or any hemodynamic instability related to the continuous positive airway pressure safety system devices failure. Evaluation of feasibility included also the total application time of respiratory treatment, the number of continuous positive airway pressure discontinuations/first 24 hrs. Interface-related complications included air leaks, cutaneous pressure sores, eye irritation, inhalation, and gastric distension. The 20 patients and control subjects had similar matching characteristics. Continuous positive airway pressure delivered by a helmet compared with a facial mask reduced continuous positive airway pressure trial failure rate (p = .02), increased application time (p = .001) with less discontinuations (p = .001), and was not associated with an increased rate of major adverse events, resulting in decreased air leaks (p = .04) and pressure sores (p = .002). Both continuous positive airway pressure systems resulted in early and sustained improvement in oxygenation. Conclusions: The helmet might be considered a viable and safe alternative to a standard facial mask to deliver continuous positive airway pressure in hypoxemic infants in the pediatric intensive care unit setting. In our study, the helmet allowed more prolonged application of continuous positive airway pressure compared with a facial mask, ensuring similar improvement in oxygenation without any adverse events and clinical intolerance.

What are the current indications for noninvasive ventilation in children

Purpose of review The aims of this paper are to examine the physiological rationale for noninvasive respiratory support (NRS) in children older than 1 month with acute respiratory failure, to review clinical available data and to give some practical recommendations for the safe application of NRS. Recent findings NRS is the delivery of ventilatory support without the need for an invasive airway. Two types of NRS are commonly used in the pediatric population: noninvasive continuous positive airway pressure and noninvasive positive pressure ventilation. In general, the evidence to support the use of NRS in children with acute respiratory failure is scarce. However, two randomized studies have been recently published suggesting that noninvasive positive pressure ventilation ameliorates clinical signs and gas exchange while reducing the need for endotracheal intubation. Moreover, noninvasive continuous positive airway pressure and heliox may improve clinical scores and carbon dioxide washout in infants with severe bronchiolitis, without major complications. Data from noncontrolled studies show that NRS unloads the respiratory muscles and that the helmet can be a valid alternative to a facial and/or nasal mask when noninvasive continuous positive airway pressure is administered to children in the early stage of acute respiratory failure. Summary Preliminary clinical data show that NRS is safe and effective in children with acute respiratory failure.

Reduction in catheter-related infections after switching from povidone-iodine to chlorhexidine for the exit-site care of tunneled central venous catheters in children on hemodialysis.

Only a few studies have investigated the optimal exit site management of tunneled central venous catheters (CVCs) in pediatric patients on chronic hemodialysis (HD). The aim of this study was to assess the efficacy of chlorhexidine solutions and a 5% povidone‐iodine solution on the incidence of CVC‐related infections in children on HD. The incidence of exit‐site infection (ESI), tunnel infection (TI), and bloodstream infection (BSI) was assessed in two groups of tunneled CVCs. The iodopovidone group consisted of 14 CVCs used between 1 January 2011 and 30 June 2012 in 10 children, whose median age at the time of CVC placement was 11.8 years (range 1.2–19.2): 5% povidone‐iodine was used for CVC exit‐site care. From 1 August 2012 to 31 January 2014, 0.5% chlorhexidine gluconate/70% isopropyl alcohol was used for the exit site, and 2% chlorhexidine gluconate/70% isopropyl alcohol spray for the hub in 13 CVCs was used in 10 patients (chlorhexidine group), whose median age at the time of CVC placement was 10 years (range 1.2–19.2). Ten episodes of ESI were diagnosed in the iodopovidone group (incidence 3.4/1000 CVC days), and only one in the chlorhexidine group (incidence 0.36/1000 CVC days, P = 0.008). One TI was observed in the iodopovidone group (0.34/1000 CVC days), and none in the chlorhexidine group. The incidence of BSIs decreased from 1.7/1000 CVC days (5 cases) to 0.36/1000 CVC days (1 case, P = 0.06) after switching to chlorhexidine. Two CVCs were lost due to CVC‐related infections in the iodopovidone group, whereas no CVC was lost due to infections in the chlorhexidine group. In comparison with 5% povidone‐iodine, the use of chlorhexidine gluconate was associated with a reduction in the incidence of ESI, TI, and BSI in children on HD.

Continuous Positive Airway Pressure With Helmet Versus Mask in Infants With Bronchiolitis: An RCT

BACKGROUND: Noninvasive continuous positive airway pressure (CPAP) is usually applied with a nasal or facial mask to treat mild acute respiratory failure (ARF) in infants. A pediatric helmet has now been introduced in clinical practice to deliver CPAP. This study compared treatment failure rates during CPAP delivered by helmet or facial mask in infants with respiratory syncytial virus-induced ARF. METHODS: In this multicenter randomized controlled trial, 30 infants with respiratory syncytial virus-induced ARF were randomized to receive CPAP by helmet (n = 17) or facial mask (n = 13). The primary endpoint was treatment failure rate (defined as due to intolerance or need for intubation). Secondary outcomes were CPAP application time, number of patients requiring sedation, and complications with each interface. RESULTS: Compared with the facial mask, CPAP by helmet had a lower treatment failure rate due to intolerance (3/17 [17%] vs 7/13 [54%], P = .009), and fewer infants required sedation (6/17 [35%] vs 13/13 [100%], P = .023); the intubation rates were similar. In successfully treated patients, CPAP resulted in better gas exchange and breathing pattern with both interfaces. No major complications due to the interfaces occurred, but CPAP by mask had higher rates of cutaneous sores and leaks. CONCLUSIONS: These findings confirm that CPAP delivered by helmet is better tolerated than CPAP delivered by facial mask and requires less sedation. In addition, it is safe to use and free from adverse events, even in a prolonged clinical setting.

Ventilator-associated pneumonia in an Italian pediatric intensive care unit: a prospective study.

BackgroundThis study was undertaken to determine the prevalence, risk factors and outcomes associated with ventilator-associated pneumonia (VAP) in a European pediatric intensive care unit (PICU).MethodsA total of 451 children who had been mechanically ventilated in the PICU for ≥48 hours during a 3-year period were enrolled in this prospective study.ResultsIn comparison with children without VAP, 30 children (6.6%) who developed VAP had a longer PICU stay (P=0.0001) and hospital stay (P=0.0001), and a higher mortality rate (P=0.04). Logistic regression analysis showed that the need for re-intubation (P=0.0001), the presence of tracheostomy (P=0.04), and enteral feeding (P=0.02) were independent risk factors for VAP.ConclusionsA relevant proportion of intubated children develop VAP, which is closely related to invasive procedures. As VAP is associated with increased medical costs and death, multicenter studies are urgently needed to improve the therapeutic approach to VAP and VAP prevention.

Wegener's granulomatosis presenting with life-threatening lung hemorrhage in a 7-year-old child

Wegener’s granulomatosis (WG) is an idiopathic systemic disease that usually onsets in adolescence and is rare in young children. Its diagnosis is usually based on the presence of fever with arthralgia and weight loss, associated with symptoms of upper and/or lower respiratory tract involvement and renal disorders. We describe the appearance of a life-threatening lung hemorrhage in the absence of hemoptysis in a 7-year-old girl with a completely negative previous clinical history, who was subsequently diagnosed as having WG. The teaching message is that immediate bronchoscopy with bronchoalveolar lavage seems to be advisable in the presence of severe respiratory distress and bilateral lung as well as renal involvement. When a diffuse alveolar hemorrhage syndrome is demonstrated, WG should be considered among the main etiologies even in a relatively young child without a clinically suggestive history.

Use of Defibrotide to help prevent post-transplant endothelial injury in a genetically predisposed infant with metachromatic leukodystrophy undergoing hematopoietic stem cell gene therapy

Valeria Calbi ● Francesca Fumagalli ● Giulia Consiglieri ● Rachele Penati ● Serena Acquati ● Daniela Redaelli ● Vanessa Attanasio ● Facchini Marcella ● Maria Pia Cicalese ● Maddalena Migliavacca ● Federica Barzaghi ● Francesca Ferrua ● Andrea Assanelli ● Paolo Silvani ● Matteo Zoccolillo ● Giovanna Chidini ● Robert Chiesa ● Ruchi Arora ● Francesca Ciotti ● Marina Sarzana ● Gigliola Antonioli ● Cristina Baldoli ● Francesco Morena ● Sabata Martino ● Gian Luigi Ardissino ● Maria Grazia Natali Sora ● Luigi Naldini ● Fabio Ciceri ● Alessandro Aiuti ● Maria Ester Bernardo

Split catheters in children on chronic hemodialysis: a single-center experience.

Tunneled central venous catheters (CVCs) play an increasing role as vascular access for chronic hemodialysis (HD) in children, but limited data exist about the optimal CVC choice. We analyzed the outcome, efficacy, and complications of tunneled CVCs, placed in our unit in the last 3 years. Nineteen 10 F Split‐Cath CVCs (two separate catheters fused along their length) were placed in 10 children, median age 9.19 years (range 2.15–13.31) and body weight (BW) between 10 and 40 kg. CVCs survival at 1, 3, 6, and 12 months was 94%, 77%, 51%, and 34%, respectively. Catheter survival was higher in children with BW > 20 kg than in smaller patients. Median survival was higher than that of 11 Quinton Permcath CVCs, placed in five children in the preceding 2 years (280 vs. 45 days, P < 0.05). Median blood flow rate and indices of HD adequacy were higher in children with lower BW (<20 kg vs. 20–30 kg vs. >30 kg) than in those with higher BW. Incidence of exit site and bloodstream infections was 2.32 and 0.66/1000 CVC days, respectively. One case of hemothorax due to subclavian artery puncture occurred during CVC placement. In conclusion, Split‐Cath 10 F CVC allows for effective dialysis in children undergoing HD, particularly those between 10 and 30 kg BW. Catheter survival is acceptable, but could be improved in small children.