Respiratory care
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CPAP and noninvasive ventilation (NIV) offer an alternative to intubation and mechanical ventilation in the treatment of acute and chronic respiratory disorders commonly encountered in infants and children. There are many distinct challenges associated with the application, management, and safety of CPAP and NIV in the pediatric population. ⋯ More recently, high-flow nasal cannula (HFNC) has emerged as an alternative to CPAP and NIV. Evidence related to the use of CPAP, NIV, and HFNC is included in this review.
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The Pediatric Acute Lung Injury Consensus Conference (PALICC) has provided the critical care community with the first pediatric-focused definition for ARDS. The PALICC recommendations provide guidance on conventional ventilator management, gas exchange goals, use of high-frequency ventilation, adjunct management approaches, and the application of extracorporeal membrane oxygenation for pediatric ARDS (PARDS). Although outcomes for PARDS have improved over the past decade, mortality and morbidity remain significant. ⋯ Improvements in prognostication and stratification of disease severity may help to guide therapeutic interventions. Improved comparisons between patients and studies may help to promote future clinical investigations. Hopefully, the recommendations provided by PALICC, in terms of defining and managing ARDS, will stimulate additional research to better guide therapy and further improve outcomes for critically ill infants and children with ARDS.
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Asthma exacerbation is a common reason for children to present to the emergency department. If primary therapies fail to halt the progression of an asthma flare, status asthmaticus often leads to hospital, and potentially ICU, admission. ⋯ This review will present the physiologic basis and summarize the supporting data for a host of adjunct therapies, including ipratropium, intravenous β agonists, methylxanthines, intravenous and inhaled magnesium, heliox (helium-oxygen mixture), ketamine, antibiotics, noninvasive ventilation, inhaled anesthetics, and extracorporeal membrane oxygenation. Finally, we present a suggested care map for escalating to these therapies in children with refractory status asthmaticus.
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Over the last decade, tracheostomy has been increasingly performed in children, aligned with the improvements in neonatal and pediatric ICU care. Nowadays, the majority of children with tracheostomy represent a very complex cohort of patients with sustained reliance on tracheostomy and related medical technology for long-term survival. Tracheostomy is one of the most commonly performed procedures in the adult ICU. ⋯ There is a recognized need for improvement and coordination of care of pediatric patients with tracheostomy. A multidisciplinary coordinated approach to tracheostomy care has already shown promising results. This paper seeks to review the pertinent literature regarding quality improvement initiatives for tracheostomy care, including review of the recently established Global Tracheostomy Collaborative.
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Inhaled nitric oxide (INO) is only FDA-cleared for neonates (> 34 weeks gestation) with hypoxic respiratory failure-associated pulmonary hypertension. Off-label use of INO is common in the pediatric population despite a lack of evidence regarding survival benefit, questioning whether the therapy should be considered outside the neonatal period. A lack of definitive evidence combined with increasing health-care costs has led to the use of less costly inhaled prostacyclin as an alternative to INO, presenting unique patient safety concerns. We evaluate the current evidence and patient safety considerations regarding inhaled pulmonary vasodilators in the pediatric population.