Kyle J. Rehder

Use of high flow nasal cannula in critically ill infants, children, and adults: a critical review of the literature

BackgroundHigh flow nasal cannula (HFNC) systems utilize higher gas flow rates than standard nasal cannulae. The use of HFNC as a respiratory support modality is increasing in the infant, pediatric, and adult populations as an alternative to non-invasive positive pressure ventilation.ObjectivesThis critical review aims to: (1) appraise available evidence with regard to the utility of HFNC in neonatal, pediatric, and adult patients; (2) review the physiology of HFNC; (3) describe available HFNC systems (online supplement); and (4) review ongoing and planned trials studying the utility of HFNC in various clinical settings.ResultsClinical neonatal studies are limited to premature infants. Only a few pediatric studies have examined the use of HFNC, with most focusing on this modality for viral bronchiolitis. In critically ill adults, most studies have focused on acute respiratory parameters and short-term physiologic outcomes with limited investigations focusing on clinical outcomes such as duration of therapy and need for escalation of ventilatory support. Current evidence demonstrates that HFNC generates positive airway pressure in most circumstances; however, the predominant mechanism of action in relieving respiratory distress is not well established.ConclusionCurrent evidence suggests that HFNC is well tolerated and may be feasible in a subset of patients who require ventilatory support with non-invasive ventilation. However, HFNC has not been demonstrated to be equivalent or superior to non-invasive positive pressure ventilation, and further studies are needed to identify clinical indications for HFNC in patients with moderate to severe respiratory distress.

Active rehabilitation and physical therapy during extracorporeal membrane oxygenation while awaiting lung transplantation: a practical approach.

Objective:Extracorporeal membrane oxygenation as a bridge to lung transplantation has traditionally been associated with substantial morbidity and mortality. A major contributor to these complications may be weakness and overall deconditioning secondary to pretransplant critical illness and immobility. In an attempt to address this issue, we developed a collaborative program to allow for active rehabilitation and physical therapy for patients requiring life support with extracorporeal membrane oxygenation before lung transplantation. Design:An interdisciplinary team responded to an acute need to develop a mechanism for active rehabilitation and physical therapy for patients awaiting lung transplantation while being managed with extracorporeal membrane oxygenation. We describe a series of three patients who benefited from this new approach. Setting:A quaternary care pediatric intensive care unit in a childrens hospital set within an 800-bed university academic hospital with an active lung transplantation program for adolescent and adult patients. Patients, Interventions, and Main Results:Three patients (ages 16, 20, and 24 yrs) with end-stage respiratory failure were rehabilitated while on extracorporeal membrane oxygenation awaiting lung transplantation. These patients were involved in active rehabilitation and physical therapy and, ultimately, were ambulatory on extracorporeal membrane oxygenation before successful transplantation. Following lung transplantation, the patients were liberated from mechanical ventilation, weaned to room air, transitioned out of the intensive care unit, and ambulatory less than 1 wk posttransplant. Conclusions:A comprehensive, multidisciplinary system can be developed to safely allow for active rehabilitation, physical therapy, and ambulation of patients being managed with extracorporeal membrane oxygenation. Such programs may lead to a decreased threshold for the utilization of extracorporeal membrane oxygenation before transplant and have the potential to improve conditioning, decrease resource utilization, and lead to better outcomes in patients who require extracorporeal membrane oxygenation before lung transplantation.

Active Rehabilitation During Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplantation

BACKGROUND: Patients with end-stage lung disease often progress to critical illness, which dramatically reduces their chance of survival following lung transplantation. Pre-transplant deconditioning has a significant impact on outcomes for all lung transplant patients, and is likely a major contributor to increased mortality in critically ill lung transplant recipients. The aim of this report is to describe a series of patients bridged to lung transplant with extracorporeal membrane oxygenation (ECMO) and to examine the potential impact of active rehabilitation and ambulation during pre-transplant ECMO. METHODS: This retrospective case series reviews all patients bridged to lung transplantation with ECMO at a single tertiary care lung transplant center. Pre-transplant ECMO patients receiving active rehabilitation and ambulation were compared to those patients who were bridged with ECMO but did not receive pre-transplant rehabilitation. RESULTS: Nine consecutive subjects between April 2007 and May 2012 were identified for inclusion. One-year survival for all subjects was 100%, with one subject alive at 4 months post-transplant. The 5 subjects participating in pre-transplant rehabilitation had shorter mean post-transplant mechanical ventilation (4 d vs 34 d, P = .01), ICU stay (11 d vs 45 d, P = .01), and hospital stay (26 d vs 80 d, P = .01). No subject who participated in active rehabilitation had post-transplant myopathy, compared to 3 of 4 subjects who did not participate in pre-transplant rehabilitation on ECMO. CONCLUSIONS: Bridging selected critically ill patients to transplant with ECMO is a viable treatment option, and active participation in physical therapy, including ambulation, may provide a more rapid post-transplantation recovery. This innovative strategy requires further study to fully evaluate potential benefits and risks.

Extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure: an evidence-based review of the past decade (2002-2012).

Objective: To provide a comprehensive evidence-based review of extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure. Data Source: A thorough computerized bibliographic search of the clinical literature regarding the use of extracorporeal membrane oxygenation in the neonatal and pediatric populations. Study Selection: Clinical trials published between January 1, 2002, and October 1, 2012, including “extracorporeal membrane oxygenation” or “ECMO” and limited to studies involving humans aged 0–18 years. Trials focused on extracorporeal membrane oxygenation for cardiac indications were excluded from this study, unless the study was evaluating ancillary therapies in conjunction with extracorporeal membrane oxygenation. Data Extraction: Studies were evaluated for inclusion based on reporting of patient outcomes and/or strategic considerations, such as cannulation strategies, timing of extracorporeal membrane oxygenation utilization, and ancillary therapies. Data Synthesis: Pertinent data are summarized, and the available data are objectively classified based on the value of the study design from which the data are obtained. Conclusions: Despite a large number of published extracorporeal membrane oxygenation studies, there remains a paucity of high-quality clinical trials. The available data support continued use of extracorporeal membrane oxygenation for respiratory failure refractory to conventional therapy for neonatal and pediatric patients without significant comorbidities. Further research is needed to better quantify the benefit of extracorporeal membrane oxygenation and the utility of many therapies commonly applied to extracorporeal membrane oxygenation patients.

Extracorporeal membrane oxygenation for severe refractory respiratory failure secondary to 2009 H1N1 influenza A.

BACKGROUND: Respiratory failure and acute respiratory distress syndrome secondary to H1N1 influenza infection is a source of substantial morbidity and mortality, having caused over 265,000 hospitalizations in the United States in 2009. During the H1N1 pandemic, up to 31% of the H1N1 patients required intensive care unit admission, and many were refractory to maximal conventional therapies. These most critically ill patients may require extracorporeal membrane oxygenation (ECMO) for survival. METHODS: We retrospectively reviewed the medical records of the 7 patients with refractory hypoxemia due to H1N1 influenza who were treated with ECMO in our pediatric intensive care unit. RESULTS: Five of the 7 patients survived to hospital discharge. The cohorts mean age was 21 years, and 4 were female. At admission to the pediatric intensive care unit, 6 had at least one comorbid condition, 6 were mechanically ventilated, and one was in shock. All 7 patients were treated with oral oseltamivir, high-frequency oscillatory ventilation, and inhaled nitric oxide prior to ECMO. Five received intravenous steroids, and 2 were treated with compassionate-use intravenous zanamivir. The mean duration of pre-ECMO ventilation was 8.7 days (range 14 h to 25 d). Mean oxygenation index was 50 (range 26–73) at ECMO cannulation. Six received venovenous ECMO, and one received venoarterial ECMO. The mean duration of ECMO was 432 hours (range 192–890 h). CONCLUSIONS: This series suggests that ECMO is a viable treatment for refractory hypoxemia secondary to H1N1 influenza infection in both pediatric and adult patients.

Standardizing postoperative PICU handovers improves handover metrics and patient outcomes.

Objectives: To improve handover communication and patient outcomes for postoperative admissions to a multidisciplinary PICU. Design: Prospective cohort study. Setting: Multidisciplinary PICU in a university hospital. Subjects: The multidisciplinary team responsible for postoperative PICU admissions and patient care, including attending, fellow, house staff physicians, and nurses from pediatric critical care medicine, surgery, and anesthesia. Interventions: An online survey distributed to PICU, surgery, and anesthesia providers identified existing barriers and challenges to effective postoperative PICU handovers and guided the formation of a standard protocol. Handovers for postoperative PICU admissions were then directly observed for 3 months pre- and postimplementation of the protocol, with data collected on communication, metrics, and patient outcomes. Observations and data collection, as well as the online provider survey, were repeated approximately 1 year after handover protocol implementation. Measurements and Main Results: Survey data demonstrated increases in provider ratings of handover attendance, communication, and quality after implementation of the handover protocol (p < 0.001). Surgical report errors were eliminated (p = 0.03), and the prevalence of provider attendance for the handover duration increased from 39.3% to 68.2% (p = 0.01). Following protocol implementation, fewer patients experienced antibiotic delays (34.5% to 13.9%; p = 0.03) or required hemodynamic or respiratory interventions within the first 6 hours of PICU admission (24.6% to 9.1%; p = 0.04). Patients received their first dose of analgesia (62.3 to 17.4 min; p = 0.01) and had their admission laboratory studies sent (42.3 to 32.9 min; p = 0.04) more quickly. Data collected at 12 months postimplementation demonstrated sustained reductions in analgesia timing, antibiotic delays, and handover barriers. Conclusions: Postoperative communication and patient outcomes can be improved and sustained over time with implementation of a standardized handover protocol.

Technological advances in extracorporeal membrane oxygenation for respiratory failure

Extracorporeal membrane oxygenation (ECMO) for neonatal and pediatric cardiac and/or respiratory failure is well established, and its use for adult respiratory failure is rapidly increasing. Management strategies developed over the past 30 years coupled with significant recent technological advances have led to improved ECMO survival. These new technologies are expanding the potential applications for ECMO in exciting ways, including new patient populations and the ability to make ECMO mobile for both intra- and inter-hospital transport. In this article, we highlight some of the recent technological advances and their impact on the utilization of ECMO in increasingly diverse patient populations.

Economic Outcomes of Extracorporeal Membrane Oxygenation With and Without Ambulation as a Bridge to Lung Transplantation

BACKGROUND: An increasing number of centers are using active rehabilitation and ambulation for critically ill patients on extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation. This investigation assessed the economic impact at a single center of ambulatory versus non-ambulatory ECMO strategies as a bridge to lung transplantation. METHODS: We conducted a single-center retrospective cohort analysis of all subjects supported with ECMO as a bridge to lung transplantation (N = 9) from 2007 to 2012. Subjects who were rehabilitated while supported with ECMO before lung transplantation were compared with those who were not rehabilitated during ECMO. Hospital cost data for the month before transplantation through 12 months after the initial post-transplant hospital discharge were compared. RESULTS: The median cost (interquartile range [IQR]) in the 30 d before transplant for the ambulatory cohort was

Development of a Quality Improvement Bundle to Reduce Tracheal Intubation–Associated Events in Pediatric ICUs

88,137 (IQR

Ambulatory ECMO as a Bridge to Lung Transplant in a Previously Well Pediatric Patient With ARDS

38,589-