Pediatric Cervical Spine Injury Following Blunt Trauma in Children Younger Than 3 Years: The PEDSPINE II Study.

Importance: There is variability in practice and imaging usage to diagnose cervical spine injury (CSI) following blunt trauma in pediatric patients. Objective: To develop a prediction model to guide imaging usage and to identify trends in imaging and to evaluate the PEDSPINE model. Design, Setting, and Participants: This cohort study included pediatric patients (<3 years years) following blunt trauma between January 2007 and July 2017. Of 22 centers in PEDSPINE, 15 centers, comprising level 1 and 2 stand-alone pediatric hospitals, level 1 and 2 pediatric hospitals within an adult hospital, and level 1 adult hospitals, were included. Patients who died prior to obtaining cervical spine imaging were excluded. Descriptive analysis was performed to describe the population, use of imaging, and injury patterns. PEDSPINE model validation was performed. A new algorithm was derived using clinical criteria and formulation of a multiclass classification problem. Analysis took place from January to October 2022. Exposure: Blunt trauma. Main Outcomes and Measures: Primary outcome was CSI. The primary and secondary objectives were predetermined. Results: The current study, PEDSPINE II, included 9389 patients, of which 128 (1.36%) had CSI, twice the rate in PEDSPINE (0.66%). The mean (SD) age was 1.3 (0.9) years; and 70 patients (54.7%) were male. Overall, 7113 children (80%) underwent cervical spine imaging, compared with 7882 (63%) in PEDSPINE. Several candidate models were fitted for the multiclass classification problem. After comparative analysis, the multinomial regression model was chosen with one-vs-rest area under the curve (AUC) of 0.903 (95% CI, 0.836-0.943) and was able to discriminate between bony and ligamentous injury. PEDSPINE and PEDSPINE II models' ability to identify CSI were compared. In predicting the presence of any injury, PEDSPINE II obtained a one-vs-rest AUC of 0.885 (95% CI, 0.804-0.934), outperforming the PEDSPINE score (AUC, 0.845; 95% CI, 0.769-0.915). Conclusion and Relevance: This study found wide clinical variability in the evaluation of pediatric trauma patients with increased use of cervical spine imaging. This has implications of increased cost, increased radiation exposure, and a potential for overdiagnosis. This prediction tool could help to decrease the use of imaging, aid in clinical decision-making, and decrease hospital resource use and cost.

Injury Patterns and Outcomes at a Single Pediatric Trauma Center During the Coronavirus Disease 19 Pandemic.

INTRODUCTION: The coronavirus disease 19 (COVID-19) pandemic is reported to have changed injury patterns, prevalence, and outcomes across multiple institutions in the United States. Interpretation of aggregate data is difficult because injury patterns vary between urban and rural hospitals and the implementation of locoregional public health policies and guidelines in response to COVID-19 differed. To prepare our trauma system for future societal shutdowns, we compared injury patterns and outcomes of injured children and adolescents at a single pediatric trauma center before and during the first 2 y of the COVID-19 pandemic. METHODS: We abstracted demographic, injury, and outcome data for injured children and adolescents (age <15 y) who required admission using our hospital trauma registry and the electronic medical record. We compared differences prior to and during the COVID-19 pandemic using univariate analysis. To address confounding variables, we also analyzed in-hospital mortality using a multivariable regression. RESULTS: We observed an increase in the number of injured children requiring admission during the first year of the COVID-19 pandemic compared to the prepandemic era. Among injury types sustained, we observed an increase in firearm and nonfirearm related penetrating injuries (P < 0.001) during the first year, but not the second year, of the COVID-19 pandemic. Controlling for several confounding variables, we also observed an increase in in-hospital mortality (P = 0.04) during the first year of the COVID-19 pandemic. CONCLUSIONS: The psychosocial and socioeconomic burden of the COVID-19 pandemic may have contributed to the rise in penetrating injuries and the odds of in-hospital mortality among a cohort of children and adolescents who were admitted to our hospital following injury. This data may be used to prepare our trauma system for future societal shutdowns through data informed resource utilization.

The Role of Pulmonary Function Testing in the Diagnosis and Management of COPD.

Pulmonary function testing (PFT) has a long and rich history in the definition, diagnosis, and management of COPD. For decades, spirometry has been regarded as the standard for diagnosing COPD; however, numerous studies have shown that COPD symptoms, pathology, and associated poor outcomes can occur, despite normal spirometry. Diffusing capacity and imaging studies have called into question the need for spirometry to put the "O" (obstruction) in COPD. The role of exercise testing and the ability of PFTs to phenotype COPD are reviewed. Although PFTs play an important role in diagnosis, treatment decisions are primarily determined by symptom intensity and exacerbation history. Although a seminal study positioned FEV1 as the primary predictor of survival, numerous studies have shown that tests other than spirometry are superior predictors of mortality. In years past, using spirometry to screen for COPD was promulgated; however, this only seems appropriate for individuals who are symptomatic and at risk for developing COPD.

Real-world diffusing capacity simulation data: how well do they fit current European Respiratory Society/American Thoracic Society acceptability criteria?

ERS/ATS D LCO standards recommend acceptability ranges for weekly D LCO simulation testing performed with a 3-L syringe. On some devices, the ERS/ATS limits may exceed or not fit a 3-sd range, in which case, simulation ranges based on 3 sd may be appropriate. https://bit.ly/3Z0YoZL.

Effect of Race and Ethnicity on Pulmonary Function Testing Interpretation: An American College of Chest Physicians (CHEST), American Association for Respiratory Care (AARC), American Thoracic Society (ATS), and Canadian Thoracic Society (CTS) Evidence Review and Research Statement.

BACKGROUND: Calls have been made to discontinue the routine use of race and ethnicity in medicine. Specific to respiratory medicine, the use of race- and ethnicity-specific reference equations for the interpretation of pulmonary function test (PFT) results has been questioned. RESEARCH QUESTIONS: Three key questions were addressed: (1) What is the current evidence supporting the use of race- and ethnicity-specific reference equations for the interpretation of PFTs? (2) What are the potential clinical implications of the use or nonuse of race and ethnicity in interpreting PFT results? and (3) What research gaps and questions must be addressed and answered to understand better the effect of race and ethnicity on PFT results interpretation and potential clinical and occupational health implications? STUDY DESIGN AND METHODS: A joint multisociety (American College of Chest Physicians, American Association for Respiratory Care, American Thoracic Society, and Canadian Thoracic Society) expert panel was formed to undertake a comprehensive evidence review and to develop a statement with recommendations to address the research questions. RESULTS: Several assumptions and gaps, both in the published literature and in our evolving understanding of lung health, were identified. It seems that many past perceptions and practices regarding the effect of race and ethnicity on PFT results interpretation are based on limited scientific evidence and measures that lack reliability. INTERPRETATION: A need exists for more and better research that will inform our field about these many uncertainties and will serve as a foundation for future recommendations in this area. The identified shortcomings should not be discounted or dismissed because they may enable flawed conclusions, unintended consequences, or both. Addressing the identified research gaps and needs would allow a better-a more informed-understanding of the effects of race and ethnicity on PFT results interpretation.

A Race-neutral Approach to the Interpretation of Lung Function Measurements.

Rationale: The use of self-reported race and ethnicity to interpret lung function measurements has historically assumed that the observed differences in lung function between racial and ethnic groups were because of thoracic cavity size differences relative to standing height. Very few studies have considered the influence of environmental and social determinants on pulmonary function. Consequently, the use of race and ethnicity-specific reference equations may further marginalize disadvantaged populations. Objectives: To develop a race-neutral reference equation for spirometry interpretation. Methods: National Health and Nutrition Examination Survey (NHANES) III data (n = 6,984) were reanalyzed with sitting height and the Cormic index to investigate whether body proportions were better predictors of lung function than race and ethnicity. Furthermore, the original GLI (Global Lung Function Initiative) data (n = 74,185) were reanalyzed with inverse-probability weights to create race-neutral GLI global (2022) equations. Measurements and Main Results: The inclusion of sitting height slightly improved the statistical precision of reference equations compared with using standing height alone but did not explain observed differences in spirometry between the NHANES III race and ethnic groups. GLI global (2022) equations, which do not require the selection of race and ethnicity, had a similar fit to the GLI 2012 "other" equations and wider limits of normal. Conclusions: The use of a single global spirometry equation reflects the wide range of lung function observed within and between populations. Given the inherent limitations of any reference equation, the use of GLI global equations to interpret spirometry requires careful consideration of an individual's symptoms and medical history when used to make clinical, employment, and insurance decisions.

Validation of the clinical utility of sGaw as a response variable in methacholine challenge testing.

BACKGROUND AND OBJECTIVE: Airway hyperresponsiveness (AHR) is commonly assessed by a methacholine challenge test (MCT), during which a provocative concentration causing a 20% reduction in forced expiratory volume in 1 second (FEV1 ) (PC20 ) < 8 mg/ml is considered a positive response. However, a fall in specific airway conductance (sGaw) may also have clinical significance. The purpose of this study was to assess whether AHR determined by a provocative concentration causing a 40% reduction in sGaw (PC40 ) < 8 mg/ml corresponds to a clinical diagnosis of asthma. METHODS: We analysed the changes in spirometry, lung volumes and sGaw during MCT in 211 randomly selected patients being evaluated for AHR to support a clinical diagnosis of asthma. RESULTS: The mean (SD) age of the group was 53 (15) years, with 141 women (67%). Overall lung function was normal, with FEV1  = 92 (15) % predicted, total lung capacity = 97 (13) % predicted and sGaw = 0.19 (0.15-0.23) L/s/cm H2 O/L, (median, 25-75 IQR). There were many more patients who responded by PC40 only (n = 120) than who responded by PC20 (n = 52). There was no significant difference in asthma diagnosis between the PC20 (98%) and PC40 (93%) groups, and we estimate 34% of patients with a diagnosis of asthma would have been classified as having no AHR if only the FEV1 criterion was used. CONCLUSION: Changes in sGaw during MCT indicate clinically significant AHR in support of a clinical diagnosis of asthma among patients being evaluated for asthma.

Management of pediatric appendicitis during the COVID-19 pandemic: A nationwide multicenter cohort study.

BACKGROUND: The COVID-19 pandemic has impacted timely access to care for children, including patients with appendicitis. This study aimed to evaluate the effect of the COVID-19 pandemic on management of appendicitis and patient outcomes. METHODS: A multicenter retrospective study was performed including 19 children's hospitals from April 2019-October 2020 of children (age≤18 years) diagnosed with appendicitis. Groups were defined by each hospital's city/state stay-at-home orders (SAHO), designating patients as Pre-COVID (Pre-SAHO) or COVID (Post-SAHO). Demographic, treatment, and outcome data were obtained, and univariate and multivariable analysis was performed. RESULTS: Of 6,014 patients, 2,413 (40.1%) presented during the COVID-19 pandemic. More patients were managed non-operatively during the COVID-19 pandemic compared to before the pandemic (147 (6.1%) vs 144 (4.0%), p < 0.001). Despite this change, there was no difference in the proportion of complicated appendicitis between groups (1,247 (34.6%) vs 849 (35.2%), p = 0.12). COVID era non-operative patients received fewer additional procedures, including interventional radiology (IR) drain placements, compared to pre-COVID non-operative patients (29 (19.7%) vs 69 (47.9%), p < 0.001). On adjusted analysis, factors associated with increased odds of receiving non-operative management included: increasing duration of symptoms (OR=1.01, 95% CI: 1.01-1.012), African American race (OR=2.4, 95% CI: 1.3-4.6), and testing positive for COVID-19 (OR=10.8, 95% CI: 5.4-21.6). CONCLUSION: Non-operative management of appendicitis increased during the COVID-19 pandemic. Additionally, fewer COVID era cases required IR procedures. These changes in the management of pediatric appendicitis during the COVID pandemic demonstrates the potential for future utilization of non-operative management.

Association between COVID-19 related elective surgery cancellations and pediatric inguinal hernia complications: A nationwide multicenter cohort study.

BACKGROUND: Optimal inguinal hernia repair timing remains controversial. It remains unclear how COVID-19 related elective surgery cancellations impacted timing of inguinal hernia repair and whether any delays led to complications. This study aims to determine whether elective surgery cancellations are safe in pediatric inguinal hernia. METHODS: This multicenter retrospective cohort study at 14 children's hospitals included patients ≤18 years who underwent inguinal hernia repair between September 13, 2019, through September 13, 2020. Patients were categorized by whether their inguinal hernia repair occurred before or after their hospital's COVID-19 elective surgery cancellation date. Incarceration and emergency department encounters were compared between pre and postcancellation. RESULTS: Of 1,404 patients, 604 (43.0%) underwent inguinal hernia repair during the postcancellation period, 92 (6.6%) experienced incarceration, and 213 (15.2%) had an emergency department encounter. The postcancellation period was not associated with incarceration (odds ratio 1.54; 95% confidence interval 0.88-2.71; P = .13) or emergency department encounters (odds ratio 1.53; 95% confidence interval 0.94-2.48; P = .09) despite longer median times to inguinal hernia repair (precancellation 29 days [interquartile range 13-55 days] versus postcancellation 31 days [interquartile range 14-73 days], P = .01). Infants were more likely to have the emergency department be their index presentation in the postcancellation period (odds ratio 1.69; 95% confidence interval 1.24-2.31; P < .01). CONCLUSION: Overall, COVID-19 elective surgery cancellations do not appear to increase the likelihood of incarceration or emergency department encounters despite delays in inguinal hernia repair, suggesting that cancellations are safe in children with inguinal hernia. Assessment of elective surgery cancellation safety has important implications for health policy.

Characteristics and predictors of intensive care unit admission in pediatric blunt abdominal trauma.

BACKGROUND: Pediatric trauma patients sustaining blunt abdominal trauma (BAT) with intra-abdominal injury (IAI) are frequently admitted to the intensive care unit (ICU). This study was performed to identify predictors for ICU admission following BAT. METHODS: Prospective study of children (< 16 years) who presented to 14 Level-One Pediatric Trauma Centers following BAT over a 1-year period. Patients were categorized as ICU or non-ICU patients. Data collected included vitals, physical exam findings, laboratory results, imaging, and traumatic injuries. A multivariable hierarchical logistic regression model was used to identify predictors of ICU admission. Predictive ability of the model was assessed via tenfold cross-validated area under the receiver operating characteristic curves (cvAUC). RESULTS: Included were 2,182 children with 21% (n = 463) admitted to the ICU. On univariate analysis, ICU patients were associated with abnormal age-adjusted shock index, increased injury severity scores (ISS), lower Glasgow coma scores (GCS), traumatic brain injury (TBI), and severe solid organ injury (SOI). With multivariable logistic regression, factors associated with ICU admission were severe trauma (ISS > 15), anemia (hematocrit < 30), severe TBI (GCS < 8), cervical spine injury, skull fracture, and severe solid organ injury. The cvAUC for the multivariable model was 0.91 (95% CI 0.88-0.92). CONCLUSION: Severe solid organ injury and traumatic brain injury, in association with multisystem trauma, appear to drive ICU admission in pediatric patients with BAT. These results may inform the design of a trauma bay prediction rule to assist in optimizing ICU resource utilization after BAT. STUDY DESIGN: Prognosis study.

Verification of Assayed Blood Gas Quality Control Ranges.

BACKGROUND: Blood gas quality control (QC) is an essential and mandatory part of a laboratory's quality plan. The acceptable QC range should be 2 SD from the mean value. The use of assayed QC material does not negate the responsibility of the laboratory to calculate the mean and 2 SD ranges of QC measurements for verification. Verifying assayed QC ranges is a Clinical Laboratory Improvement Amendment (CLIA) requirement. This study shows the results of assayed QC mean and 2 SD range verification from a blood gas analyzer. METHODS: QC data from a blood gas analyzer were compared to manufacturer-provided mean and ranges. The percent difference between the measured mean and the manufacturer-provided mean was calculated to assess agreement. The measured SD was used to determine how many SD the manufacturer-provided ranges were from the measured mean. RESULTS: The largest difference in mean values was 2.27% > the manufacturer-provided mean. Forty-eight percent of all mean value comparisons showed a difference of 0%, and 71% were < 1%. The manufacturer-provided ranges were considerably wider than the measured 2 SD range, ranging from 2.4-75 SD. None of the manufacturer-provided ranges were deemed acceptable for clinical use. CONCLUSIONS: Our analysis validates the CLIA mandate and American Association for Respiratory Care Clinical Practice Guideline recommendation that laboratories must verify manufacturer-provided QC means and ranges and adjust QC means and ranges to match the performance of their blood gas analyzer.

Prevalence of Burnout Among Respiratory Therapists Amidst the COVID-19 Pandemic.

Background: Burnout is a major challenge in health care, but its prevalence has not been evaluated in practicing respiratory therapist (RTs). The purpose of this study was to identify RT burnout prevalence and factors associated with RT burnout.Methods: An online survey was administered to 26 centers in the United States and between January and March 2021. Validated, quantitative, cross-sectional surveys were used to measure burnout and leadership domains. The survey was sent to department directors and distributed by the department directors to staff. Data analysis was descriptive and logistic regression analysis was performed to evaluate risk factors, expressed as odds ratios (OR), for burnout.Results: The survey was distributed to 3,010 RTs, and the response rate was 37%. Seventy-nine percent of respondents reported burnout, 10% with severe, 32% with moderate, and 37% with mild burnout. Univariate analysis revealed those with burnout worked more hours per week, worked more hours per week in the ICU, primarily cared for adult patients, primarily delivered care via RT protocols, reported inadequate RT staffing, reported being unable to complete assigned work, were more frequently exposed to COVID-19, had a lower leadership score, and fewer had a positive view of leadership. Logistic regression revealed burnout climate (OR 9.38, p<0.001), inadequate RT staffing (OR 2.08 to 3.19, p=0.004 to 0.05), being unable to complete all work (OR 2.14 to 5.57, p=0.003 to 0.20), and missing work for any reason were associated with increased risk of burnout (OR 1.96, p=0.007). Not providing patient care (OR 0.18, p=0.02) and a positive leadership score (0.55, p=0.02) were associated with decreased risk of burnout.Conclusion: Burnout was common among RTs in the midst of the COVID-19 pandemic. Good leadership was protective against burnout while inadequate staffing, inability to complete work, and burnout climate were associated with burnout.

Use of neurally adjusted ventilatory assist (NAVA) in a patient with severe SARS-CoV-2 pneumonia: A case report.

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia may necessitate intubation and prolonged mechanical ventilation. Early in the course of mechanical ventilation neuromuscular blocking agents may be used to allow synchronous lung protective ventilation. However, patients with SARS-CoV-2 pneumonia tend to have an intense respiratory drive resulting in patient-ventilator asynchrony when neuromuscular blocking agents are discontinued. Case and Outcomes: A 75-year-old male was admitted to the hospital with SARS-CoV-2 pneumonia requiring invasive mechanical ventilation. By ventilator day 5 the neuromuscular blocking agent had been discontinued, and the patient was markedly asynchronous in the volume control mode despite receiving continuous intravenous sedatives. The ventilator mode was changed to the neurally adjusted ventilatory assist (NAVA) mode. Initially NAVA resulted in improved synchrony and reduced work of breathing. However, a few days later the patient's tidal volume had fallen to <300 mL on NAVA despite increases in the NAVA level. It appeared that the inspiratory phase was prematurely terminating, and the expiratory threshold in NAVA is not adjustable. The ventilator mode was changed to pressure support resulting in an increased tidal volume and reduced respiratory frequency. Conclusion: In patients with SARS-CoV-2 pneumonia and intense respiratory drive, the performance of NAVA may be variable. NAVA may result in hypopnea and tachypnea when compared with pressure support. An assessment of the impact of an adjustable expiratory threshold in NAVA is warranted.

Restoring Pulmonary and Sleep Services as the COVID-19 Pandemic Lessens. From an Association of Pulmonary, Critical Care, and Sleep Division Directors and American Thoracic Society-coordinated Task Force.

Background: In March 2020, many elective medical services were canceled in response to the coronavirus disease 2019 (COVID-19) pandemic. The daily case rate is now declining in many states and there is a need for guidance about the resumption of elective clinical services for patients with lung disease or sleep conditions.Methods: Volunteers were solicited from the Association of Pulmonary, Critical Care, and Sleep Division Directors and American Thoracic Society. Working groups developed plans by discussion and consensus for resuming elective services in pulmonary and sleep-medicine clinics, pulmonary function testing laboratories, bronchoscopy and procedure suites, polysomnography laboratories, and pulmonary rehabilitation facilities.Results: The community new case rate should be consistently low or have a downward trajectory for at least 14 days before resuming elective clinical services. In addition, institutions should have an operational strategy that consists of patient prioritization, screening, diagnostic testing, physical distancing, infection control, and follow-up surveillance. The goals are to protect patients and staff from exposure to the virus, account for limitations in staff, equipment, and space that are essential for the care of patients with COVID-19, and provide access to care for patients with acute and chronic conditions.Conclusions: Transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a dynamic process and, therefore, it is likely that the prevalence of COVID-19 in the community will wax and wane. This will impact an institution's mitigation needs. Operating procedures should be frequently reassessed and modified as needed. The suggestions provided are those of the authors and do not represent official positions of the Association of Pulmonary, Critical Care, and Sleep Division Directors or the American Thoracic Society.

Weight-based reference equations for the 6-min walk test can be misleading in obese patients.

Weight-based reference equations for the 6-min walk test can produce normal results despite poor performance. Using ideal body weight- or non-weight-based reference equations for the 6-min walk test may produce more clinically meaningful results. https://bit.ly/2wE9Sdn.