Respiratory care
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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.
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This article reviews the common pulmonary complications seen in the pediatric oncology population and our approach to diagnosis, management, and therapy considerations in this specialized population, including patients receiving chemotherapy, radiation, and hematopoietic stem cell transplantation. Although infections cause the most significant complications in this population, non-infectious complications, including acute lung injury from chemotherapy or radiation, idiopathic interstitial pneumonia, diffuse alveolar hemorrhage, bronchiolitis obliterans, and cryptogenic organizing pneumonia, also occur commonly. With improvements in survival of childhood cancer, there are now a growing number of adults who are childhood cancer survivors who may be encountered by therapists in adult hospitals. We also review the growing literature on the emerging late pulmonary findings in these adult childhood cancer survivors.
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Extracorporeal membrane oxygenation (ECMO) was developed initially in the 1960s to support refractory respiratory failure in addition to the cardiac support inherent in a venoarterial bypass circuit. Early successes occurred predominantly in the neonatal population with subsequent randomized controlled trials and comprehensive reviews concluding therapeutic efficacy for ECMO in neonatal respiratory failure. In contrast, the evidence supporting ECMO for respiratory failure in children is less definitive. ⋯ However, the Pediatric Acute Lung Injury Consensus Conference recommendations supporting the use of ECMO for pediatric ARDS highlight the lack of evidence-based selection criteria when determining ECMO candidacy in pediatric patients with ARDS. Ultimately, decisions to proceed with ECMO and the concomitant risk of potential life-threatening complications must consider multiple factors that balance potential risks and likelihood of benefit, pre-morbid conditions and impact on potential post-ECMO quality of life, candidacy for lung transplantation, and patient and family goals of care. This review will discuss ECMO for the support of pediatric respiratory failure, ventilator management during ECMO, considerations impacting timing of decannulation, and developing techniques.
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Oxygen is a colorless, odorless, tasteless gas that is utilized by the body for respiration. Oxygen has played a major role in respiratory care. Oxygen therapy is useful in treating hypoxemia but is often thought of as a benign therapy. ⋯ However, oxygen therapy risk, cost, and benefits should be considered in the same way as other drugs and titrated to a measured end point to avoid excessive or inadequate dosing. Withholding oxygen can have a detrimental effect, yet continuing to provide oxygen therapy when it is no longer indicated can prolong hospitalization and increase the cost of care. This comprehensive review begins with an assessment of need and a review of physiologic effects, potential toxicities, and common delivery devices, and it ends with advances in oxygen therapy with a focus on the pediatric patient.
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Children with progressive neuromuscular weakness undergo a stereotypical progression of respiratory involvement, beginning with impaired airway clearance and progressing to nocturnal and then diurnal ventilatory failure. This review examines issues related to airway clearance and mucus mobilization, sleep problems, and use of assisted ventilation in children with neuromuscular diseases. Interventions for each of these problems have been created or adapted for the pediatric population. ⋯ Questions regarding the best time to introduce some therapies, the therapeutic utility of certain interventions, and the cost-effectiveness of various treatments demand further investigation. Studies that assess the potential to improve quality of life and reduce hospitalizations and frequency of lower-respiratory tract infections will help clinicians to decide which techniques are best suited for use in children. As children with neuromuscular disease survive longer, coordinated programs for transitioning these patients to adult care must be developed to enhance their quality of life.