Mechanical Ventilation during ECMO: Best Practices.

Adults and children who require extracorporeal membrane oxygenation for respiratory failure remain at risk for ongoing lung injury if ventilator management is not optimized. This review serves as a guide to assist the bedside clinician in ventilator titration for patients on extracorporeal membrane oxygenation, with a focus on lung-protective strategies. Existing data and guidelines for extracorporeal membrane oxygenation ventilator management are reviewed, including non-conventional ventilation modes and adjunct therapies.

Respiratory Therapist Intubation Practice in Pediatric ICUs: A Multicenter Registry Study.

BACKGROUND: Tracheal intubation by respiratory therapists (RTs) is a well-established practice that has been described primarily in adult and neonatal patients. However, minimal data exist regarding RTs' intubation performance in pediatric ICUs. The purpose of this study was to describe the current landscape of intubations performed by RTs in pediatric ICUs. METHODS: A multicenter quality improvement database, the National Emergency Airway Registry for Children (NEAR4KIDS) was queried from 2015 to 2018. We performed a retrospective analysis of prospectively collected data on subject demographics, indication for intubation, difficult airway history and feature presence, provider discipline, medications, and device. Intubation outcomes included first-attempt and overall success rates, adverse events, and oxygen desaturation (ie, [Formula: see text] < 80%). Overall intubation success was defined as intubation achieved in ≤ 2 attempts. RESULTS: There were 12,056 initial intubation encounters from 46 ICUs, with 109 (0.9%) first attempts performed by RTs. Nine (20%) ICUs reported at least one intubation encounter by RTs. The number of intubations performed by RTs at individual centers ranged from 1 to 46 (RT participation rate: 0.3% to 19.6%). RTs utilized video laryngoscopy more often than other providers (53.2% for RTs vs 28.1% for others, P < .001). RTs' first attempt success (RT 60.6% vs other 69.2%, P = .051), overall success (RT 76.2 % vs other 82.4%, P = .09), and oxygen desaturation [Formula: see text] < 80% (RT 16.5% vs other 16.9%, P = .91) were similar to other providers. Adverse events were more commonly reported in intubations by RTs versus by other providers (22.9% vs 13.8%, P = .006). CONCLUSIONS: RTs infrequently intubate in pediatric ICUs, with success rates similar to other providers but higher adverse event rates. RTs were more likely to use video laryngoscopy than other providers. RTs' intubation participation, success, and adverse event rates varied greatly across pediatric ICUs.

Cricoid Pressure During Induction for Tracheal Intubation in Critically Ill Children: A Report From National Emergency Airway Registry for Children.

OBJECTIVES: Cricoid pressure is often used to prevent regurgitation during induction and mask ventilation prior to high-risk tracheal intubation in critically ill children. Clinical data in children showing benefit are limited. Our objective was to evaluate the association between cricoid pressure use and the occurrence of regurgitation during tracheal intubation for critically ill children in PICU. DESIGN: A retrospective cohort study of a multicenter pediatric airway quality improvement registry. SETTINGS: Thirty-five PICUs within general and children's hospitals (29 in the United States, three in Canada, one in Japan, one in Singapore, and one in New Zealand). PATIENTS: Children (< 18 yr) with initial tracheal intubation using direct laryngoscopy in PICUs between July 2010 and December 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Multivariable logistic regression analysis was used to evaluate the association between cricoid pressure use and the occurrence of regurgitation while adjusting for underlying differences in patient and clinical care factors. Of 7,825 events, cricoid pressure was used in 1,819 (23%). Regurgitation was reported in 106 of 7,825 (1.4%) and clinical aspiration in 51 of 7,825 (0.7%). Regurgitation was reported in 35 of 1,819 (1.9%) with cricoid pressure, and 71 of 6,006 (1.2%) without cricoid pressure (unadjusted odds ratio, 1.64; 95% CI, 1.09-2.47; p = 0.018). On multivariable analysis, cricoid pressure was not associated with the occurrence of regurgitation after adjusting for patient, practice, and known regurgitation risk factors (adjusted odds ratio, 1.57; 95% CI, 0.99-2.47; p = 0.054). A sensitivity analysis in propensity score-matched cohorts showed cricoid pressure was associated with a higher regurgitation rate (adjusted odds ratio, 1.01; 95% CI, 1.00-1.02; p = 0.036). CONCLUSIONS: Cricoid pressure during induction and mask ventilation before tracheal intubation in the current ICU practice was not associated with a lower regurgitation rate after adjusting for previously reported confounders. Further studies are needed to determine whether cricoid pressure for specific indication with proper maneuver would be effective in reducing regurgitation events.

Clinical Impact of External Laryngeal Manipulation During Laryngoscopy on Tracheal Intubation Success in Critically Ill Children.

OBJECTIVES: External laryngeal manipulation is a commonly used maneuver to improve visualization of the glottis during tracheal intubation in children. However, the effectiveness to improve tracheal intubation attempt success rate in the nonanesthesia setting is not clear. The study objective was to evaluate the association between external laryngeal manipulation use and initial tracheal intubation attempt success in PICUs. DESIGN: A retrospective observational study using a multicenter emergency airway quality improvement registry. SETTING: Thirty-five PICUs within general and children's hospitals (29 in the United States, three in Canada, one in Japan, one in Singapore, and one in New Zealand). PATIENTS: Critically ill children (< 18 years) undergoing initial tracheal intubation with direct laryngoscopy in PICUs between July 1, 2010, and December 31, 2015. MEASUREMENTS AND MAIN RESULTS: Propensity score-matched analysis was performed to evaluate the association between external laryngeal manipulation and initial attempt success while adjusting for underlying differences in patient and clinical care factors: age, obesity, tracheal intubation indications, difficult airway features, provider training level, and neuromuscular blockade use. External laryngeal manipulation was defined as any external force to the neck during laryngoscopy. Of the 7,825 tracheal intubations, the initial tracheal intubation attempt was successful in 1,935/3,274 intubations (59%) with external laryngeal manipulation and 3,086/4,551 (68%) without external laryngeal manipulation (unadjusted odds ratio, 0.69; 95% CI, 0.62-0.75; p < 0.001). In propensity score-matched analysis, external laryngeal manipulation remained associated with lower initial tracheal intubation attempt success (adjusted odds ratio, 0.93; 95% CI, 0.90-0.95; p < 0.001). CONCLUSIONS: External laryngeal manipulation during direct laryngoscopy was associated with lower initial tracheal intubation attempt success in critically ill children, even after adjusting for underlying differences in patient factors and provider levels. The indiscriminate use of external laryngeal manipulation cannot be recommended.

Quality improvement in pediatrics: past, present, and future.

Almost two decades ago, the landmark report "To Err is Human" compelled healthcare to address the large numbers of hospitalized patients experiencing preventable harm. Concurrently, it became clear that the rapidly rising cost of healthcare would be unsustainable in the long-term. As a result, quality improvement methodologies initially rooted in other high-reliability industries have become a primary focus of healthcare. Multiple pediatric studies demonstrate remarkable quality and safety improvements in several domains including handoffs, catheter-associated blood stream infections, and other serious safety events. While both quality improvement and research are data-driven processes, significant differences exist between the two. Research utilizes a hypothesis driven approach to obtain new knowledge while quality improvement often incorporates a cyclic approach to translate existing knowledge into clinical practice. Recent publications have provided guidelines and methods for effectively reporting quality and safety work and improvement implementations. This review examines not only how quality improvement in pediatrics has led to improved outcomes, but also looks to the future of quality improvement in healthcare with focus on education and collaboration to ensure best practice approaches to caring for children.

Is there still a role for high-frequency oscillatory ventilation in neonates, children and adults?

Critically ill patients with respiratory pathology often require mechanical ventilation and while low tidal volume ventilation has become the mainstay of treatment, achieving adequate gas exchange may not be attainable with conventional ventilator modalities. In attempt to achieve gas exchange goals and also mitigate lung injury, high frequency ventilation is often implemented which couples low tidal volumes with sustained mean airway pressure. This manuscript presents the physiology of high-frequency oscillatory ventilation, reviews the currently available data on its use and provides strategies and approaches for this mode of ventilation.

Detection of Multiple Respiratory Viruses Associated With Mortality and Severity of Illness in Children.

OBJECTIVE: Respiratory viral infection is a common source of morbidity and mortality in children. Coinfection with multiple viruses occurs frequently; however, the clinical significance of concomitant viral pathogens is unclear. We hypothesized that presence of more than one respiratory virus is associated with increased morbidity and mortality when compared with children with a single respiratory virus. DESIGN: Retrospective cohort study. SETTING: A tertiary care hospital. PATIENTS: All children at Duke Children's Hospital over a 2-year period with isolation of a virus on an extended viral respiratory panel result. Demographic data, comorbidities, and details of hospital encounter were recorded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Two hundred thirty-five hospital encounters demonstrated positive extended viral respiratory panels. Immunocompromised status (37%) and respiratory comorbidities (23%) were common. Twenty-eight patients (12%) tested positive for multiple viruses, with adenovirus (23/28) and respiratory syncytial virus (15/28) most prevalent in patients with multiple viruses. Viral codetection was associated with increased use of noninvasive ventilation (p = 0.02), extracorporeal membrane oxygenation (p = 0.02), increased likelihood of moderate or severe illness (p = 0.005), and increased mortality (p = 0.01). Subgroup analysis demonstrated that this mortality association persisted for children with normal immune function (p = 0.003) and children with no comorbidities (p = 0.007). CONCLUSIONS: Children with multiple respiratory viruses may be at increased risk of moderate or severe illness and mortality, with previously healthy children potentially being at greatest risk. Further studies are indicated to determine the significance and generalizability of this finding and to better understand the pathophysiology of viral coinfection.

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.

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.

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 children's 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.