Diagnostic accuracy of airway ultrasound in confirming the endotracheal tube depth in critically ill children.

BACKGROUND: Chest X-ray, the established standard of confirming endotracheal tube (ETT) position, has important drawbacks including radiation exposure. Point-of-care airway ultrasound, which has been insufficiently studied in children, can overcome these problems. MATERIALS AND METHODS: This was a prospective cross-sectional study done on children aged 2 months to 17 years undergoing intubation with cuffed ETT in the PICU. The ETT cuff was filled with saline and three ultrasonographic techniques were used- 1) Suprasternal (SS) method 2) Cricoid (CC) metho and 3) Tracheal ring (TR) method. Position of the ETT as determined by ultrasound and X-ray were compared. The main outcomes were sensitivity, specificity, and area under curve (AUC) for ultrasound-based methods vs. X-ray. For the TR method, concordance between the X-ray and ultrasound categories were taken. RESULTS: Total 62 patients were enrolled. The sensitivity and specificity of SS method were 71% (95% CI: 57-83%) and 100% (40-100%). The CC distance method had an AUC of 0.94 (95% CI: 0.86, 1.0). In the TR method, 98% of correct position on X-ray were correctly classified by USG. The agreement between X-ray and ultrasound categories with the cuff between the first and third tracheal rings, was very good [kappa (95% CI): 0.87 (0.70, 1.00), p ≤0.001)]. CONCLUSION: Bedside ultrasound is a good method to confirm ETT depth in children. The tracheal ring method had the best diagnostic accuracy and is easy to perform. The new method using cricoid cuff distance needs further validation in different ICU settings.

Risk Factors for Procedural Complications of Pediatric Flexible Bronchoscopy: Experience From a Tertiary Care Centre in Northern India.

We analyzed the records of 869 children who underwent flexible bronchoscopy. We found procedural complications in 6.7% (n = 59), with severe events in 3.2% (n = 28). Age < 1 y, recurrent respiratory papillomatosis, and finding lower airway malacia on bronchoscopy were identified as independent risk factors for developing complications with adjusted odds ratio (95% CI) of 2.6 (1.3, 4.9); P = 0.004; 5.4 (1.7, 17.6); P = 0.005 and 2.1 (1.1, 4.0); P = 0.031, respectively.

Pulmonary Tuberculosis in Severely Malnourished Children Admitted to Nutrition Rehabilitation Centers: A Multicenter Study.

OBJECTIVES: To identify prevalence of pulmonary tuberculosis (TB) in severely malnourished children admitted to nutritional rehabilitation centers. METHODS: A multicenter cross-sectional study involving 41 nutrition rehabilitation centres (NRCs) across India was carried out to document prevalence of pulmonary tuberculosis in acute severe malnourished children admitted in NRCs. After training of the NRC staff to follow algorithm provided by national tuberculosis elimination program, children admitted to NRCs were screened for pulmonary tuberculosis. RESULTS: A total of 4356 children were enrolled across all the sites. Gastric aspirate for Cartridge based nucleic acid amplification test (CBNAAT), tuberculin skin test (TST) and X-ray film of chest were done in more than 99% of enrolled subjects. A total of 189 children (4.3%) had pulmonary tuberculosis. Eighty-seven (1.99%) were microbiologically confirmed by positive CBNAAT. On multivariate analysis, only significant association was with history of contact with TB patient in family. CONCLUSIONS: The present results suggest that a significant proportion (>4%) of children admitted in NRCs suffer from pulmonary tuberculosis. It is feasible to improve diagnosis of tuberculosis as a whole and microbiologically confirmed TB.

A "Cool" extraction technique for difficult pediatric airway foreign bodies: Report of two cases.

Foreign body (FB) aspiration is a potentially life-threatening accident in children. Traditionally, rigid bronchoscopy has been the procedure of choice for FB removal, however it may miss distally lodged FBs. We report two pediatric cases with distal impacted FBs that could not be retrieved by rigid bronchoscopy (RB) and were mobilised using Fogarty balloon followed by flexible bronchoscopic cryoextraction. The advantage of a cryoprobe is lower risk of fragmentation of FB that may occur with forceps. Cryoextraction is particularly advantageous for removing water-containing FBs. In both patients, FB was removed more than 2 weeks following aspiration, leading to the formation of granulation tissue around the FB, which considerably hampered the process. Using a laryngeal mask airway to secure the airway, FB removal by flexible bronchoscopy may be a safe and effective technique in skilled hands, especially for FBs impacted in distal airways with granulation tissue where RB fails.

Transition Care in Cystic Fibrosis.

Cystic fibrosis (CF) is a chronic childhood illness with gradually improving survival and significant burden of disease during adult life. Transition of CF care from pediatric to an adult based multidisciplinary team is a complex process and careful coordination with a transition key worker is necessary for successful transition without adverse outcome. Transition is associated with a key change in CF management with shift from family-centred care to self-reliance and independence on part of the patient. Readiness and skills of self-managed care play central part in successful transition. Resource materials for transition are available online for different countries for improved readiness and smooth transition. Situation is worse in resource-limited settings as facilities of fully functional adult multidisciplinary care for CF is not readily available.

Interventional Bronchoscopy in Children: The Way Forward.

Bronchoscopy in children has been utilized primarily to diagnose airway anomalies and obtain bronchoalveolar lavage. Gradual development of thinner bronchoscopes and instruments has opened the gates to the world of bronchoscopic interventions in children. Endobronchial ultrasound guided mediastinal aspiration has been used in adults and children. In younger children, esophageal approach has also been used for sampling of mediastinal lymph nodes. Lung biopsies using cryoprobe have been increasingly used in children. Other bronchoscopic interventions discussed include dilatation of tracheobronchial stenosis, airway stenting, foreign body removal, hemoptysis control, re-expansion of atelectasis etc. Patient safety during the procedure is of paramount importance. Expertise and availability of equipment to handle complications is of huge significance.

Development of algorithm for diagnosis of cystic fibrosis in absence of sweat chloride testing in resource-limited setting.

OBJECTIVE: To develop a diagnostic algorithm for cystic fibrosis (CF) in the setting of unavailability of sweat chloride, based on clinical features and basic laboratory investigations. METHODS: In a prospective observational study, we enrolled children with recurrent/persistent pneumonia with either malabsorption or poor growth, undergoing a sweat chloride test, between January 2019 and December 2020. They were simultaneously evaluated for aquagenic wrinkling of hands, stool fat globules, sputum for bacterial culture, blood gas, and serum electrolytes. Sensitivity and specificity were calculated for parameters having a significant difference between CF and non-CF groups. Scoring systems and algorithms for the diagnosis of CF were developed. RESULTS: Of 134 children enrolled, 46 (34%) had CF. The sensitivity and specificity of various parameters to diagnose CF was: sibling death due to respiratory illness (30.43%, 96.59%), aquagenic wrinkling (76.74%, 47.67%), metabolic alkalosis (17.78%, 94.12%), hyponatremia (28.89%, 89.41%), stool fat globules (38.46%, 81.18%), and presence of Pseudomonas in sputum culture (23.68%, 98.80%). Using coefficients of significant parameters on stepwise logistic regression, the composite score for diagnosis of CF was calculated as: 3X sibling death due to respiratory illness + 1.5X hyponatremia + 1.5X metabolic alkalosis + 1.5X aquagenic wrinkling + 1X stool fat globules + 2.5X presence of Pseudomonas in sputum culture (each of the variables scores 0 or 1 for absence and presence, respectively). The cut-off of ≥2.5 had sensitivity and specificity of 81.82% and 76.83%, respectively. CONCLUSIONS: In resource-limited settings, the proposed diagnostic algorithm can be used for the diagnosis of presumptive CF with fair sensitivity and specificity.

Humoral cross-reactivity towards SARS-CoV-2 in young children with acute respiratory infection with low-pathogenicity coronaviruses.

Background: SARS-CoV-2 infection in children frequently leads to only asymptomatic and mild infections. It has been suggested that frequent infections due to low-pathogenicity coronaviruses in children, impart immunity against SARS-CoV-2 in this age group. Methods: From a prospective birth cohort study prior to the pandemic, we identified children with proven low-pathogenicity coronavirus infections. Convalescent sera from these children were tested for antibodies against respective seasonal coronaviruses (OC43, NL63, and 229E) and SARS-CoV-2 by immunofluorescence and virus microneutralization assay respectively. Results: Forty-two children with proven seasonal coronavirus infection were included. Convalescent sera from these samples demonstrated antibodies against the respective seasonal coronaviruses. Of these, 40 serum samples showed no significant neutralization of SARS-CoV-2, while 2 samples showed inconclusive results. Conclusion: These findings suggest that the antibodies generated in low-pathogenicity coronavirus infections offer no protection from SARS-CoV-2 infection in young children.

Poor Respiratory Health Following Relapsing SARS-CoV-2 Infection in Children with Cystic Fibrosis.

Children with cystic fibrosis (CF) constitute a high-risk group for COVID-19 with underlying chronic lung disease. COVID-19 severity varying from mild infection to need of intensive care has been described in children with CF. Two children with significant underlying pulmonary morbidity are described here, who developed severe disease following SARS-CoV-2 infection. Case 1 (a 9-y-old boy) had pneumonia with respiratory failure requiring noninvasive ventilation support. He had delayed clearance of SARS-CoV-2, with recurrence of symptomatic disease with short asymptomatic period in between. He was also diagnosed with CF-related diabetes and allergic bronchopulmonary aspergillosis during the second episode. Case 2 (an 18-mo-old boy) had two episodes of SARS-CoV-2-related severe lower respiratory infection within a period of 2 mo, requiring high-flow nasal oxygen support. Both children had 3rd pulmonary exacerbation but SARS-CoV-2 was not detected in respiratory secretions. To conclude, children with CF with underlying pulmonary morbidity, can develop severe COVID-19 and prolonged SARS-CoV-2 shedding.

Positive Expiratory Pressure Oxygen Therapy for Respiratory Distress: A Single-arm Feasibility Trial.

Background: Oxygen delivery devices with positive end-expiratory pressure (PEEP) valves have been described, but high inspiratory flows may lead to poor tolerance in tachypneic patients. Positive expiratory pressure oxygen therapy (PEP-OT) using an occlusive face mask, oxygen reservoir, and PEEP valve has not been evaluated in clinical settings. Materials and methods: In a single-arm intervention trial, patients aged 19-55 years admitted with acute respiratory illness with oxygen support were enrolled. PEP-OT trial was given with PEEP of 5 and 7 cm of water over 45 minutes. Feasibility was assessed as uninterrupted completion of the PEP-OT trial. The effects of PEP-OT on cardiopulmonary physiology and adverse effects of therapy were recorded. Results: Fifteen patients (6 males) were enrolled. Fourteen patients had pneumonia and one patient had pulmonary edema. Twelve patients (80%) completed the PEP-OT trial. There was significant improvement in respiratory rate (RR) and heart rate (HR) at the end of the 45-minute PEP-OT trial (p-values 0.048 and 0.003, respectively). There was a trend toward improved SpO2 and perceived dyspnea. None of the patients developed desaturation, shock, or air leaks. Positive expiratory pressure oxygen therapy is a feasible oxygen therapy in patients with acute hypoxia. Conclusion: Positive expiratory pressure oxygen therapy seems to be safe and has a positive impact on respiratory mechanics in parenchymal respiratory pathology. How to cite this article: Dhochak N, Ray A, Soneja M, Wig N, Kabra SK, Lodha R. Positive Expiratory Pressure Oxygen Therapy for Respiratory Distress: A Single-arm Feasibility Trial. Indian J Crit Care Med 2022;26(11):1169-1174.

Acute gastrointestinal injury in critically ill children: Impact on clinical outcome.

AIM: To estimate acute gastrointestinal injury (AGI) in critically ill children and association of its severity with mortality. METHODS: In a prospective cohort study, critically ill children (1 month-18 years) were enrolled. Gastrointestinal symptoms over the first week of admission were classified into AGI grades 1 through 4, using a paediatric adaptation of European Society of Intensive Care Medicine AGI definitions. Performance of AGI grades in predicting 28-day mortality was evaluated. RESULTS: Of 151 children enrolled, 71 (47%, 95% confidence interval (CI): 38.9-55.3%) developed AGI, with AGI grades 1, 2, 3 and 4 in 22.5%, 15.9%, 6.6% and 2%, respectively. The 28-day mortality progressively increased with AGI grade 0 (15%), 1 (35%), 2 (50%), 3 (70%), through 4 (100%), P < 0.001. Association of AGI grades with 28-day mortality was significant even after adjustment for disease severity, age and nutritional status (odds ratio (OR) = 2.152, 95% CI: 1.455, 3.184). Among AGI grades, and paediatric logistic organ dysfunction-2 score components, cardiovascular (OR = 1.525, 95% CI: 1.142, 2.037) and haematological (OR = 1.719, 95% CI: 1.067, 2.772) components of paediatric logistic organ dysfunction-2 score and AGI grades (OR = 1.565, 95% CI: 1.001, 2.449) showed significant association with 28-day mortality. CONCLUSIONS: Nearly half of the critically ill children developed AGI. AGI grades were independently associated with increased mortality, and mortality progressively increased with AGI grade.