In-line miniature 3D-printed pressure-cycled ventilator maintains respiratory homeostasis in swine with induced acute pulmonary injury.

The COVID-19 pandemic demonstrated the need for inexpensive, easy-to-use, rapidly mass-produced resuscitation devices that could be quickly distributed in areas of critical need. In-line miniature ventilators based on principles of fluidics ventilate patients by automatically oscillating between forced inspiration and assisted expiration as airway pressure changes, requiring only a continuous supply of pressurized oxygen. Here, we designed three miniature ventilator models to operate in specific pressure ranges along a continuum of clinical lung injury (mild, moderate, and severe injury). Three-dimensional (3D)-printed prototype devices evaluated in a lung simulator generated airway pressures, tidal volumes, and minute ventilation within the targeted range for the state of lung disease each was designed to support. In testing in domestic swine before and after induction of pulmonary injury, the ventilators for mild and moderate injury met the design criteria when matched with the appropriate degree of lung injury. Although the ventilator for severe injury provided the specified design pressures, respiratory rate was elevated with reduced minute ventilation, a result of lung compliance below design parameters. Respiratory rate reflected how well each ventilator matched the injury state of the lungs and could guide selection of ventilator models in clinical use. This simple device could help mitigate shortages of conventional ventilators during pandemics and other disasters requiring rapid access to advanced airway management, or in transport applications for hands-free ventilation.

Effect of Vibrating Mesh Nebulizer Aerosol Technology on the In Vitro Activity of Ribavirin Against Respiratory Syncytial Virus.

BACKGROUND: Ribavirin is an antiviral drug that for many years has been administered to the lungs by aerosolization. Despite advancements in oral delivery routes, there has been a renewed interested in delivering ribavirin via the pulmonary system in select patients and the severely ill. The vibrating mesh nebulizer was previously demonstrated to be an effective alternative to the small-particle aerosol generator in particle size, chemical makeup, and concentrations of the ribavirin before and after nebulization. However, the antiviral activity of ribavirin has never been examined. We sought to study ribavirin's activity before and after nebulization via vibrating mesh nebulizer. METHODS: We grew and infected human epithelial type 2 cells and primary airway epithelial cells with respiratory syncytial virus (RSV). We then compared the antiviral effect of non-nebulized (control) and aerosolized ribavirin to untreated controls. We used traditional plaque assay and real-time polymerase chain reaction to determine the quantity of virus. RESULTS: Both non-nebulized (control) and nebulized ribavirin reduced the size of RSV plaques compared to untreated controls. Additionally, the non-nebulized and nebulized ribavirin equally inhibited RSV replication. There were no statistically significant differences between the non-nebulized and nebulized ribavirin across all time points. CONCLUSIONS: The vibrating mesh nebulizer did not affect the antiviral properties of nebulized ribavirin when compared to non-nebulized drug. Our findings add supporting evidence for the use of the vibrating mesh nebulizer in the administration of inhaled ribavirin.

AARC Clinical Practice Guideline: Management of Pediatric Patients With Oxygen in the Acute Care Setting.

Oxygen therapy is one of the most important therapeutics offered in the clinical management of pediatric patients with cardiopulmonary disease. As the medical community seeks to ensure evidence-based management of clinical interventions, we conducted a systematic review with the goal of providing evidence-based clinical practice guidelines to answer questions surrounding the use of simple oxygen therapy to improve oxygenation, including a comparison of delivery devices, the efficacy of humidification, comparison of flows, and goals for use in children. Using a modification of the RAND/UCLA Appropriateness Method, we developed 4 recommendations to assist clinicians in the utilization of oxygen therapy in hospitalized children: (1) the use of an oxygen hood or tent in lieu of a low-flow oxygen device for consistent oxygen delivery is not recommended; (2) the use of high-flow nasal cannula therapy is safe and more effective than low-flow oxygen to treat infants with moderate to severe bronchiolitis; (3) the application of humidification with low-flow oxygen delivery is not recommended; (4) targeting [Formula: see text] 90-97% for infants and children with bronchiolitis is recommended; however, no specific target can be recommended for pediatric patients with respiratory diseases outside of bronchiolitis, and establishing a patient/disease oxygen therapy target upon admission is considered best practice.

Multidisciplinary Safety Recommendations After Tracheostomy During COVID-19 Pandemic: State of the Art Review.

OBJECTIVE: In the chronic phase of the COVID-19 pandemic, questions have arisen regarding the care of patients with a tracheostomy and downstream management. This review addresses gaps in the literature regarding posttracheostomy care, emphasizing safety of multidisciplinary teams, coordinating complex care needs, and identifying and managing late complications of prolonged intubation and tracheostomy. DATA SOURCES: PubMed, Cochrane Library, Scopus, Google Scholar, institutional guidance documents. REVIEW METHODS: Literature through June 2020 on the care of patients with a tracheostomy was reviewed, including consensus statements, clinical practice guidelines, institutional guidance, and scientific literature on COVID-19 and SARS-CoV-2 virology and immunology. Where data were lacking, expert opinions were aggregated and adjudicated to arrive at consensus recommendations. CONCLUSIONS: Best practices in caring for patients after a tracheostomy during the COVID-19 pandemic are multifaceted, encompassing precautions during aerosol-generating procedures; minimizing exposure risks to health care workers, caregivers, and patients; ensuring safe, timely tracheostomy care; and identifying and managing laryngotracheal injury, such as vocal fold injury, posterior glottic stenosis, and subglottic stenosis that may affect speech, swallowing, and airway protection. We present recommended approaches to tracheostomy care, outlining modifications to conventional algorithms, raising vigilance for heightened risks of bleeding or other complications, and offering recommendations for personal protective equipment, equipment, care protocols, and personnel. IMPLICATIONS FOR PRACTICE: Treatment of patients with a tracheostomy in the COVID-19 pandemic requires foresight and may rival procedural considerations in tracheostomy in their complexity. By considering patient-specific factors, mitigating transmission risks, optimizing the clinical environment, and detecting late manifestations of severe COVID-19, clinicians can ensure due vigilance and quality care.

AARC Clinical Practice Guideline: Management of Pediatric Patients With Tracheostomy in the Acute Care Setting.

Children requiring a tracheostomy to maintain airway patency or to facilitate long-term mechanical ventilatory support require comprehensive care and committed, trained, direct caregivers to manage their complex needs safely. These guidelines were developed from a comprehensive review of the literature to provide guidance for the selection of the type of tracheostomy tube (cuffed vs uncuffed), use of communication devices, implementation of daily care bundles, timing of first tracheostomy change, type of humidification used (active vs passive), timing of oral feedings, care coordination, and routine cleaning. Cuffed tracheostomy tubes should only be used for positive-pressure ventilation or to prevent aspiration. Manufacturer guidelines should be followed for cuff management and tracheostomy tube hygiene. Daily care bundles, skin care, and the use of moisture-wicking materials reduce device-associated complications. Tracheostomy tubes may be safely changed at postoperative day 3, and they should be changed with some regularity (at a minimum of every 1-2 weeks) as well as on an as-needed basis, such as when an obstruction within the lumen occurs. Care coordination can reduce length of hospital and ICU stay. Published evidence is insufficient to support recommendations for a specific device to humidify the inspired gas, the use of a communication device, or timing for the initiation of feedings.

Inhaled Pulmonary Vasodilators in the Neonatal and Pediatric ICU.

Inhaled pulmonary vasodilators are a powerful tool in the arsenal of therapies designed to treat pulmonary hypertension in pediatrics. Yet only 1 inhaled vasodilator, inhaled nitric oxide (INO), has been approved by the Food and Drug Administration for use in neonates > 34 weeks gestational age with persistent pulmonary hypertension of the newborn. Off-label use of inhaled vasodilators is common in the neonatal and pediatric population despite a lack of evidence. Growing focus on providing evidence-based therapies combined with the increasing cost of INO has led to the exploration of other inhaled pulmonary vasoactive agents. Advancements in technology have led to the creation of nitric oxide generation devices that do not require tanks. This review evaluates the current evidence regarding the use of inhaled vasodilators and INO delivery devices in the neonatal and pediatric intensive care population.

Adding Continuous Vital Sign Information to Static Clinical Data Improves the Prediction of Length of Stay After Intubation: A Data-Driven Machine Learning Approach.

BACKGROUND: Bedside monitors in the ICU routinely measure and collect patients' physiologic data in real time to continuously assess the health status of patients who are critically ill. With the advent of increased computational power and the ability to store and rapidly process big data sets in recent years, these physiologic data show promise in identifying specific outcomes and/or events during patients' ICU hospitalization. METHODS: We introduced a methodology designed to automatically extract information from continuous-in-time vital sign data collected from bedside monitors to predict if a patient will experience a prolonged stay (length of stay) on mechanical ventilation, defined as >4 d, in a pediatric ICU. RESULTS: Continuous-in-time vital signs information and clinical history data were retrospectively collected for 284 ICU subjects from their first 24 h on mechanical ventilation from a medical-surgical pediatric ICU at Boston Children's Hospital. Multiple machine learning models were trained on multiple subsets of these subjects to predict the likelihood that each of these subjects would experience a long stay. We evaluated the predictive power of our models strictly on unseen hold-out validation sets of subjects. Our methodology achieved model performance of >83% (area under the curve) by using only vital sign information as input, and performances of 90% (area under the curve) by combining vital sign information with subjects' static clinical data readily available in electronic health records. We implemented this approach on 300 independently trained experiments with different choices of training and hold-out validation sets to ensure the consistency and robustness of our results in our study sample. The predictive power of our approach outperformed recent efforts that used deep learning to predict a similar task. CONCLUSIONS: Our proposed workflow may prove useful in the design of scalable approaches for real-time predictive systems in ICU environments, exploiting real-time vital sign information from bedside monitors. (ClinicalTrials.gov registration NCT02184208.).

Tracheostomy in the COVID-19 era: global and multidisciplinary guidance.

Global health care is experiencing an unprecedented surge in the number of critically ill patients who require mechanical ventilation due to the COVID-19 pandemic. The requirement for relatively long periods of ventilation in those who survive means that many are considered for tracheostomy to free patients from ventilatory support and maximise scarce resources. COVID-19 provides unique challenges for tracheostomy care: health-care workers need to safely undertake tracheostomy procedures and manage patients afterwards, minimising risks of nosocomial transmission and compromises in the quality of care. Conflicting recommendations exist about case selection, the timing and performance of tracheostomy, and the subsequent management of patients. In response, we convened an international working group of individuals with relevant expertise in tracheostomy. We did a literature and internet search for reports of research pertaining to tracheostomy during the COVID-19 pandemic, supplemented by sources comprising statements and guidance on tracheostomy care. By synthesising early experiences from countries that have managed a surge in patient numbers, emerging virological data, and international, multidisciplinary expert opinion, we aim to provide consensus guidelines and recommendations on the conduct and management of tracheostomy during the COVID-19 pandemic.

Alarm Strategies and Surveillance for Mechanical Ventilation.

Clinical alarms, including those for mechanical ventilation, have been one of the leading causes of health technology hazards. It has been reported that < 15% of alarms studied rose to the level of being clinically relevant or actionable. Most alarms in health care, whether by default or intention, are set to a hypothetical average patient, which is essentially a one size fits most approach. A method of tuning to individual patient characteristics is possible, similar to the treatment philosophy of precision medicine. The excessive amount of alarms in a clinical environment is thought to be the largest contributing factor to alarm-related adverse events. All these factors come to bear on human perception and response to mechanical ventilation and clinical alarms. Observations of human response to stimuli suggest that response to alarms is closely matched to the perceived reliability and value of the alarm system. This paper provides a review examining vulnerabilities in the current management of mechanical ventilation alarms and summarizes best practices identified to help prevent patient injury. This review examines the factors that affect alarm utility and provides recommendations for applying research findings to improve safety for patients, clinician efficiency, and clinician well-being.

Distribution of Ventilation Measured by Electrical Impedance Tomography in Critically Ill Children.

BACKGROUND: Electrical impedance tomography (EIT) is a noninvasive, portable lung imaging technique that provides functional distribution of ventilation. We aimed to describe the relationship between the distribution of ventilation by mode of ventilation and level of oxygenation impairment in children who are critically ill. We also aimed to describe the safety of EIT application. METHODS: A prospective observational study of EIT images obtained from subjects in the pediatric ICU. Images were categorized by whether the subjects were on intermittent mandatory ventilation (IMV), continuous spontaneous ventilation, or no positive-pressure ventilation. Images were categorized by the level of oxygenation impairment when using [Formula: see text]/[Formula: see text]. Distribution of ventilation is described by the center of ventilation. RESULTS: Sixty-four images were obtained from 25 subjects. Forty-two images obtained during IMV with a mean ± SD center of ventilation of 55 ± 6%, 14 images during continuous spontaneous ventilation with a mean ± SD center of ventilation of 48.1 ± 11%, and 8 images during no positive-pressure ventilation with a mean ± SD center of ventilation of 47.5 ± 10%. Seventeen images obtained from subjects with moderate oxygenation impairment with a mean ± SD center of ventilation of 59.3 ± 1.9%, 12 with mild oxygenation impairment with a mean ± SD center of ventilation of 52.6 ± 2.3%, and 4 without oxygenation impairment with a mean ± SD center of ventilation of 48.3 ± 4%. There was more ventral distribution of ventilation with IMV versus continuous spontaneous ventilation (P = .009), with IMV versus no positive-pressure ventilation (P = .01) cohorts, and with moderate oxygenation impairment versus cohorts without oxygenation impairment (P = .009). There were no adverse events related to the placement and use of EIT in our study. CONCLUSIONS: Children who had worse oxygen impairment or who received controlled modes of ventilation had more ventral distribution of ventilation than those without oxygen impairment or the subjects who were spontaneously breathing. The ability of EIT to detect changes in the distribution of ventilation in real time may allow for distribution-targeted mechanical ventilation strategies to be deployed proactively; however, future studies are needed to determine the effectiveness of such a strategy.

Fully automated, real-time, calibration-free, continuous noninvasive estimation of intracranial pressure in children.

OBJECTIVE: In the search for a reliable, cooperation-independent, noninvasive alternative to invasive intracranial pressure (ICP) monitoring in children, various approaches have been proposed, but at the present time none are capable of providing fully automated, real-time, calibration-free, continuous and accurate ICP estimates. The authors investigated the feasibility and validity of simultaneously monitored arterial blood pressure (ABP) and middle cerebral artery (MCA) cerebral blood flow velocity (CBFV) waveforms to derive noninvasive ICP (nICP) estimates. METHODS: Invasive ICP and ABP recordings were collected from 12 pediatric and young adult patients (aged 2-25 years) undergoing such monitoring as part of routine clinical care. Additionally, simultaneous transcranial Doppler (TCD) ultrasonography-based MCA CBFV waveform measurements were performed at the bedside in dedicated data collection sessions. The ABP and MCA CBFV waveforms were analyzed in the context of a mathematical model, linking them to the cerebral vasculature's biophysical properties and ICP. The authors developed and automated a waveform preprocessing, signal-quality evaluation, and waveform-synchronization "pipeline" in order to test and objectively validate the algorithm's performance. To generate one nICP estimate, 60 beats of ABP and MCA CBFV waveform data were analyzed. Moving the 60-beat data window forward by one beat at a time (overlapping data windows) resulted in 39,480 ICP-to-nICP comparisons across a total of 44 data-collection sessions (studies). Moving the 60-beat data window forward by 60 beats at a time (nonoverlapping data windows) resulted in 722 paired ICP-to-nICP comparisons. RESULTS: Greater than 80% of all nICP estimates fell within ± 7 mm Hg of the reference measurement. Overall performance in the nonoverlapping data window approach gave a mean error (bias) of 1.0 mm Hg, standard deviation of the error (precision) of 5.1 mm Hg, and root-mean-square error of 5.2 mm Hg. The associated mean and median absolute errors were 4.2 mm Hg and 3.3 mm Hg, respectively. These results were contingent on ensuring adequate ABP and CBFV signal quality and required accurate hydrostatic pressure correction of the measured ABP waveform in relation to the elevation of the external auditory meatus. Notably, the procedure had no failed attempts at data collection, and all patients had adequate TCD data from at least one hemisphere. Last, an analysis of using study-by-study averaged nICP estimates to detect a measured ICP > 15 mm Hg resulted in an area under the receiver operating characteristic curve of 0.83, with a sensitivity of 71% and specificity of 86% for a detection threshold of nICP = 15 mm Hg. CONCLUSIONS: This nICP estimation algorithm, based on ABP and bedside TCD CBFV waveform measurements, performs in a manner comparable to invasive ICP monitoring. These findings open the possibility for rational, point-of-care treatment decisions in pediatric patients with suspected raised ICP undergoing intensive care.

Empirical Probability of Positive Response to PEEP Changes and Mechanical Ventilation Factors Associated With Improved Oxygenation During Pediatric Ventilation.

BACKGROUND: PEEP is titrated to improve oxygenation during mechanical ventilation. It is clinically desirable to identify factors that are associated with a clinical improvement or deterioration following a PEEP change. However, these factors have not been adequately described in the literature. Therefore, we aimed to quantify the empirical probability of PEEP changes having a positive effect upon oxygenation, compliance of the respiratory system (CRS), and the ratio of dead space to tidal volume (VD/VT). Further, clinical factors associated with positive response during pediatric mechanical ventilation are described. METHODS: Mechanically ventilated pediatric subjects in the ICU were eligible for inclusion in the study. During PEEP increases (PEEPincrease), a responder was defined as having an improved SpO2 /FIO2 ratio; non-responders demonstrated a worsening SpO2 /FIO2 ratio in the following hour. When PEEP was decreased (PEEPdecrease), a responder was anyone who maintained or increased the SpO2 /FIO2 ratio; non-responders demonstrated a worsening SpO2 /FIO2 ratio. Features from continuous mechanical ventilation variables were extracted, and differences between responders and non-responders were identified. RESULTS: 286 PEEP change cases were eligible for analysis in 76 subjects. For PEEPincrease cases, the empirical probability of positive response was 56%, 67%, and 54% for oxygenation, CRS, and VD/VT, respectively. The median SpO2 /FIO2 increase was 13. For PEEPdecrease, the empirical probability of response was 46%, 53%, and 46% for oxygenation, CRS, and VD/VT, respectively. PEEPincrease responders had higher FIO2 requirements (70.8 vs 52.5%, P < .001), mean airway pressure (14.0 vs 12.9 cm H2O, P = .03), and oxygen saturation index (9.9 vs 7.5, P = .002) versus non-responders. For PEEPdecrease, VD/VT was lower in responders (0.46 vs 0.50, P = .031). CONCLUSIONS: In children requiring mechanical ventilation, the responder rate was modest for both PEEPincrease and PEEPdecrease cases. These data suggest that PEEP titration often does not have the desired clinical effect, and predicting which patients will manifest a positive response is complex, requiring more sophisticated means of assessing individual subjects.

A Comparative Analysis of Ideal Body Weight Methods for Pediatric Mechanical Ventilation.

BACKGROUND: A universal method for determining ideal body weight (IBW) for the application of appropriate tidal volumes in children on mechanical ventilation is elusive. We sought to compare 3 commonly used IBW methods for subjects between ages 2 and 20 y. METHODS: Demographic data were recorded, and the IBW was calculated based on the McLaren-Read, Moore, and body mass index methods by using growth chart data from the Centers for Disease Control and Prevention. The percentage error between each IBW method and the actual body weight were calculated and reported as median (interquartile range). We decided a priori that a ≥10% difference between the actual body weight and IBW would be clinically important. The Wilcoxon signed-rank test was used to compare the actual body weight with the IBW. Bland-Altman analysis was used to assess the individual agreement of each IBW method with the actual body weight. The Kruskal-Wallis test was used to detect differences among the IBW methods. RESULTS: A total of 58 subjects (36% female) were analyzed. The median (interquartile range) percent weight error between the actual body weight and calculated the IBW was 14.8% (1.9-22.1%, P = .038), 13.8% (4.6-23.4%, P = .008), and 12.0% (3.9-20.5%, P = .037); the mean biases were 2.7 (95% CI -13.4 to 18.9) kg, 3.9 (95% CI -15.1 to 22.9) kg, 3.2 (95% CI -16.7 to 23.1) kg; and the numbers of subjects who would have a clinically important error were 29 (55.7%), 29 (56.9%), and 30 (51.7%) for the McLaren-Read, Moore, and body mass index methods, respectively. CONCLUSIONS: The majority of the subjects demonstrated a clinically important error between the actual body weight and the IBW. The percent error increased in subjects > 25 kg actual body weight. These data underline the importance of obtaining height measurements and calculated IBW in pediatric patients who are mechanically ventilated.

A standardized, closed-loop system for monitoring pediatric tracheostomy-related adverse events.

OBJECTIVES/HYPOTHESIS: Advancement in neonatal and pediatric intensive care has increased the need for chronic-care interventions, including tracheostomy. It is well established that children with a tracheostomy are at a high risk for adverse events, many of which are preventable. Despite this, there is no standardized method of monitoring tracheostomy-related adverse events (TRAEs). Our objective was to describe and assess a standardized, closed-loop system for monitoring TRAEs. STUDY DESIGN: Prospective Study. METHODS: A specific tracheostomy-related category was established within the adverse event reporting system in January 2015. Monthly TRAE reports were supplied to the multidisciplinary tracheostomy team (MDT) with descriptions of event type, severity, and preventability. The MDT reviewed events and discussed necessary follow-up. The frequency of events was standardized by inpatient tracheostomy days (ITDs) using an automated monthly list. Adverse events were tracked using a control chart. Aggregated data were divided into biannual reports for analysis. RESULTS: Eighty-five TRAEs were reported between January 2015 and June 2017, averaging 5.75 per 1,000 ITDs. Most common events include unplanned decannulation (50%) and improper use of tracheostomy supplies (21%). The frequency of all preventable events has decreased by 76% since the second half of 2015. During this timeframe, minor events have decreased, moderate events have maintained a frequency of less than one per 1,000 ITDs, and only one severe event occurred. CONCLUSIONS: This standardized, closed-loop reporting method, modeled after other successful intensive care unit reporting systems, accurately tracks TRAEs. We have observed a decrease in preventable TRAEs without a negative impact on rates of severe events. Results suggest improved quality of care for patients with tracheostomy. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:2419-2424, 2018.

Equilibration Time Required for Respiratory System Compliance and Oxygenation Response Following Changes in Positive End-Expiratory Pressure in Mechanically Ventilated Children.

OBJECTIVES: Increases in positive end-expiratory pressure are implemented to improve oxygenation through the recruitment and stabilization of collapsed alveoli. However, the time it takes for a positive end-expiratory pressure change to have maximum effect upon oxygenation and pulmonary compliance has not been adequately described in children. Therefore, we sought to quantify the time required for oxygenation and pulmonary system compliance changes in children requiring mechanical ventilation. DESIGN: Retrospective analysis of continuous data. SETTINGS: Multidisciplinary ICU of a pediatric university hospital. PATIENTS: Mechanically ventilated pediatric subjects. INTERVENTIONS: A case was eligible for analysis if during a 90-minute window following an increase in positive end-expiratory pressure, no other changes to the ventilator were made, ventilator and physiologic data were continuously available and a positive oxygenation response was observed. Time to 90% (T90) of the maximum change in oxygenation and compliance was computed. Differences between oxygenation and compliance T90 were compared using a paired t test. The effect of severity of illness (by oxygen saturation index) upon oxygenation and compliance was analyzed. MEASUREMENTS AND MAIN RESULTS: A total of 200 subjects were enrolled and 1,150 positive end-expiratory pressure change cases were analyzed. Of these, 54 subjects with 171 positive end-expiratory pressure change case were included in the analysis (67% were responders).Changes in dynamic compliance (T90 = 38 min) preceded changes in oxygenation (T90 = 71 min; p < 0.001). Oxygenation response differed depending on severity of illness quantified by oxygen saturation index; lung dysfunction was associated with a longer response time (p = 0.001). CONCLUSIONS: T90 requires 38 and 71 minutes for dynamic pulmonary compliance and oxygenation, respectively; the latter was directly observed to be dependent upon severity of illness. To our knowledge, this is the first report of oxygenation and compliance equilibration data following positive end-expiratory pressure increases in pediatric mechanically ventilated subjects.

Pediatric Oxygen Therapy: A Review and Update.

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. After many years of study, we have learned a great deal of the benefits and potential risk of this powerful drug. Today oxygen gas is cheap, widely available, and easy to administer. Oxygen delivery devices vary in cost from a few cents for a simple nasal cannula to $25-$50 for some humidified systems. Undoubtedly, oxygen therapy is an important tool and has saved many lives and improved others. 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.

Noninvasive Monitoring of Oxygen and Ventilation.

Noninvasive monitoring of oxygenation and ventilation is an essential part of pediatric respiratory care. Carbon dioxide, gas exchange monitoring, transcutaneous monitoring, near-infrared spectroscopy, pulse oximetry, and electrical impedance tomography are examined. Although some of these technologies have been utilized for decades, incorporation into mechanical ventilators and recently developed methods may provide important clinical insights in a broader patient range. Less mature technologies (electrical impedance tomography and near-infrared spectroscopy) have been of particular interest, since they offer easy bedside application and potential for improved care of children with respiratory failure and other disorders. This article provides an overview of the principles of operation, a survey of recent and relevant literature, and important technological limitations and future research directions.