• Mark J Peters, Rachel Agbeko, Peter Davis, Nigel Klein, Zohra Zenasni, Amy Jones, Christine Mackerness, Susan George, Paul Veys, Samiran Ray, Paul R Mouncey, David A Harrison, Kathy Rowan, and SCARF Study Investigators and the Pediatric Intensive Care Society Study Group (PICS-SG).
• Respiratory Critical Care and Anaesthesia Unit, UCL Great Ormond Street Institute of Child Health, London, United Kingdom.
• Pediatr Crit Care Me. 2018 Oct 1; 19 (10): 939-948.

ObjectivesPrevious trials in adults with impaired immunity and respiratory failure suggest that early noninvasive ventilation avoids endotracheal intubation and improves survival. No randomized clinical trials have addressed this question in children.DesignWe undertook an open, parallel-group randomized trial in three pediatric hospitals.SubjectsChildren with impaired immunity and acute respiratory failure defined as tachypnoea (> 90th centile); a new requirement for supplemental oxygen; and new chest radiograph infiltrates.InterventionsChildren were randomly assigned to early PICU admission for continuous positive airways pressure (early continuous positive airways pressure) or to standard care. The primary outcome was endotracheal intubation by 30 days.Measurements And Main ResultsOne-hundred fourteen children met inclusion criteria of whom 42 were randomized between January 2013 and January 2016. There was no significant difference in endotracheal intubation by 30 days with early continuous positive airways pressure (10/21; 48%) compared with standard care (5/21; 24%), odds ratio 2.9 (0.8-10.9), p value equals to 0.11. However, 30-day mortality was significantly higher with early continuous positive airways pressure (7/21; 33%) compared with standard care (1/21; 5%), odds ratio 10.0 (1.1-90.6), p value equals to 0.041. Mortality at 90 days was early continuous positive airways pressure (11/21; 52%) versus standard care (4/21; 19%), odds ratio 4.7 (1.2-18.6), p value equals to 0.029, whereas mortality at 1 year was similar early continuous positive airways pressure (13/21; 61.9%) versus standard care (9/21; 42.7%), odds ratio 2.2 (0.6-7.4), p value equals to 0.22. There were two serious adverse events: early continuous positive airways pressure (pneumothorax) and standard care (hemothorax).ConclusionsThis study provided no evidence to support early PICU admission for continuous positive airways pressure in children with acute respiratory failure and impaired immunity. There was a trend toward increased endotracheal intubation and a higher early mortality in the early continuous positive airways pressure group.

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