The effects of wearing facemasks on oxygenation and ventilation at rest and during physical activity.

BACKGROUND: Facemasks are recommended to reduce the spread of SARS-CoV-2, but concern about inadequate gas exchange is an often cited reason for non-compliance. RESEARCH QUESTION: Among adult volunteers, do either cloth masks or surgical masks impair oxygenation or ventilation either at rest or during physical activity? STUDY DESIGN AND METHODS: With IRB approval and informed consent, we measured heart rate (HR), transcutaneous carbon dioxide (CO2) tension and oxygen levels (SpO2) at the conclusion of six 10-minute phases: sitting quietly and walking briskly without a mask, sitting quietly and walking briskly while wearing a cloth mask, and sitting quietly and walking briskly while wearing a surgical mask. Brisk walking required at least a 10bpm increase in heart rate. Occurrences of hypoxemia (decrease in SpO2 of ≥3% from baseline to a value of ≤94%) and hypercarbia (increase in CO2 tension of ≥5 mmHg from baseline to a value of ≥46 mmHg) in individual subjects were collected. Wilcoxon signed-rank was used for pairwise comparisons among values for the whole cohort (e.g. walking without a mask versus walking with a cloth mask). RESULTS: Among 50 adult volunteers (median age 33 years; 32% with a co-morbidity), there were no episodes of hypoxemia or hypercarbia (0%; 95% confidence interval 0-1.9%). In paired comparisons, there were no statistically significant differences in either CO2 or SpO2 between baseline measurements without a mask and those while wearing either kind of mask mask, both at rest and after walking briskly for ten minutes. INTERPRETATION: The risk of pathologic gas exchange impairment with cloth masks and surgical masks is near-zero in the general adult population.

Randomized pilot trial of ipratropium versus placebo in children with critical asthma.

OBJECTIVE: To test the effects of inhaled ipratropium on clinical outcomes of critical asthma in the first randomized trial of this adjunctive therapy in critically ill children. DESIGN: Pilot, placebo-controlled, double-blinded, and randomized-controlled trial PATIENTS: Thirty children (15 per group) with critical asthma receiving high-intensity albuterol per a standardized pathway utilizing objective assessments to wean patients to less frequent albuterol administration. INTERVENTIONS: Subjects were randomized to receive either nebulized ipratropium bromide (500 µg in 0.9% saline per dose) or an equivalent volume of nebulized 0.9% saline every 6 h until the patient was successfully weaned to albuterol doses every 2 h ("q2 albuterol"). MEASUREMENTS AND MAIN RESULTS: Demographics, initial clinical severity score, and asthma histories were similar between groups. There was no significant difference in the median duration of high-intensity albuterol between the treatment group (17.5 [10.3-22.1] h) and placebo group (14.6 [12.7-24.5] days; p = .56). Similarly, there was no significant difference in pediatric intensive care unit length of stay (22.6 [21.1-33.6] vs. 21.4 [16.1-35.8] h; p = .74) or hospital length of stay (48.0 [41.8-59.8] vs. 47.3 [37.2-63.1] h; p = .67). In multivariate linear regression adjusting for identified confounders, treatment with ipratropium was not significantly associated with any of the three outcomes. Side effects were rare and occurred with equally between both groups CONCLUSIONS: Adjunctive therapy with ipratropium was not associated with decreased duration of high-intensity albuterol or shortened length of stay when compared to placebo. A larger, multicenter trial is warranted to confirm that ipratropium does not improve clinical outcomes.

Emergency room endotracheal intubation in children with bronchiolitis: A cohort study using a multicenter database.

BACKGROUND AND AIMS: Bronchiolitis and asthma have a clinical overlap, and it has been shown that pediatric intensive care unit (PICU) patients with asthma undergoing endotracheal intubation in a community hospital emergency room (ER) have a shorter duration of mechanical ventilation (MV) and PICU length of stay (LOS) vs children undergoing intubation in a children's hospital. We aimed to determine if the setting of intubation (community vs children's hospital ER) is associated with the duration of MV and PICU LOS among children with bronchiolitis. METHODS: With IRB approval, data in the Virtual Pediatric Systems (VPS, LLC) database were queried for bronchiolitis patients <24 months of age admitted to one of 103 predominantly North American PICUs between 1/2009 and 1/2016 who had an endotracheal tube in place at PICU admission. There were no exclusion criteria. Extracted data included ER type (community/external or children's hospital/internal), demographics, and reported comorbidities. Outcomes analyzed were duration of MV and PICU LOS. Multivariable linear regression was used to evaluate if intubation location was independently associated with the outcomes of interest. RESULTS: Among 1934 patients, median age was 2.0 (IQR: 1.0-4.8) months, 51% were admitted from an external ER, 41% were White, 61% were male, and 28% had ≥1 comorbidity. Median duration of MV was 6.6 (4.6-9.5) days and the median PICU LOS was 7.0 (4.6-10.6) days. Children who underwent endotracheal intubation in a children's hospital ER had a modestly longer duration of MV (6.7 [4.4-9.4] vs 6.5 [5.2-9.6] days, P < .001, Mann-Whitney U) and longer PICU LOS (7.2 [4.8-10.8] vs 6.9 [4.2-10.1] days, P = .004, Mann-Whitney U). After adjusting for confounding variables, we did not observe a significant association between the location of endotracheal intubation and duration of MV or PICU LOS. CONCLUSION: In this cohort, and unlike outcomes of near-fatal asthma, we observed that clinical outcomes of critical bronchiolitis were similar regardless of location of endotracheal intubation.

Corticosteroid Therapy During Acute Bronchiolitis in Patients Who Later Develop Asthma.

BACKGROUND AND OBJECTIVE: Meta-analyses show that corticosteroids are not effective in patients with bronchiolitis. However, risk factors for asthma such as eczema or familial atopy prompt some practitioners to prescribe corticosteroids for bronchiolitis. We assessed if corticosteroid prescription is associated with shorter hospitalization for bronchiolitis among patients who later develop asthma. METHODS: The Pediatric Health Information System database was interrogated for patients with bronchiolitis aged <2 years hospitalized between 2006 and 2015. Only patients who also later had a hospitalization for asthma and prescription of inhaled corticosteroids were included. For the initial bronchiolitis admission, use of mechanical ventilation defined "severe illness," and ICU admission without mechanical ventilation defined "moderate illness"; all other patients were deemed to have "mild illness." Variables associated (P < .10) with length of stay (LOS) in bivariate analysis were included in linear regression analysis. RESULTS: During the bronchiolitis admission of 2479 children who were later hospitalized for asthma, corticosteroid prescription (n = 857) was associated with longer LOS in bivariate analysis (3 [2-4] vs 2 [2-4] days; P < .01) but not the multivariate model (P = .18) that included age, sex, comorbid conditions, bacterial pneumonia, and illness severity. Corticosteroid prescription was associated with shorter LOS among previously healthy children with moderate illness (4 [2-6] vs 5 [3-7] days; P = .02) but not those with mild or severe illness. CONCLUSIONS: Corticosteroids were not associated with improved outcome in patients with bronchiolitis who were later hospitalized with asthma. Moderately ill patients with no comorbidities may warrant further study.

Hyponatremia and Hypotonic Intravenous Fluids Are Associated With Unfavorable Outcomes of Bronchiolitis Admissions.

OBJECTIVES: Hyponatremia has been associated with unfavorable outcomes when present at admission in children with bronchiolitis. Delayed hyponatremia may be a modifiable risk factor for severe disease that is influenced by intravenous fluid (IVF) tonicity. We hypothesized that both hyponatremia and prescription of severely hypotonic IVF are associated with unfavorable outcomes, and that prescription of severely hypotonic IVF is associated with subsequent hyponatremia. METHODS: Data were retrospectively extracted for 1557 pediatric inpatients with bronchiolitis. Any day on which a subject was prescribed IVF with sodium <70 mEq/L was termed "IVF <70." All other days on which IVF was prescribed were termed "IVF ≥70." Any blood sodium ≤135 mEq/L defined hyponatremia for that day. All other days with sodium available were labeled normonatremia. Variables were compared with Spearman correlation, Wilcoxon rank test, or χ2. Significant results had P < .05. RESULTS: Blood sodium levels correlated negatively with hospital length of stay (r = -0.477, P < .0001). On each of the first 4 days of hospitalization, significantly increased hospital length of stay was observed in patients with hyponatremia (n = 134 [25.7% of subjects with available sodium data]) versus patients with normonatremia (n = 387 [74.3%]), and in patients prescribed IVF <70 (n = 348 [46.3% of subjects prescribed IVF]) versus patients prescribed IVF ≥70 (n = 403 [53.7%]). Patients prescribed IVF <70 had increased rates of hyponatremia on the subsequent day versus patients prescribed IVF ≥70 (50.0% vs 26.9%, P < .001). CONCLUSIONS: In children hospitalized with bronchiolitis, hyponatremia may be a modifiable risk factor for severe disease that may be mitigated by avoiding use of severely hypotonic IVF.

Tratamento atual de crianças com asma crítica e quase fatal / Contemporary treatment of children with critical and near-fatal asthma

RESUMO A asma é a mais comum das doenças da infância. Embora a maioria das crianças com exacerbações agudas de asma não demanda cuidados críticos, algumas delas não respondem ao tratamento padrão e necessitam de cuidados mais intensos. Crianças com asma crítica ou quase fatal precisam de monitoramento estrito quanto à deterioração e podem requerer estratégias terapêuticas agressivas. Esta revisão examinou as evidências disponíveis que dão suporte a terapias para asma crítica e quase fatal, e resumiu o cuidado clínico atual para essas crianças. O tratamento típico inclui uso parenteral de corticosteroides e fármacos beta-agonistas, por via inalatória ou intravenosa. Para crianças com resposta inadequada ao tratamento padrão, pode-se lançar mão do uso inalatório de brometo de ipratrópio ou intravenoso de sulfato de magnésio, metilxantinas e misturas gasosas com hélio, além de suporte ventilatório mecânico não invasivo. Pacientes com insuficiência respiratória progressiva se beneficiam de ventilação mecânica com uma estratégia que emprega grandes volumes correntes e baixas frequências do ventilador, para minimizar a hiperinsuflação dinâmica, o barotrauma e a hipotensão. Sedativos, analgésicos e bloqueadores neuromusculares são frequentemente necessários na fase inicial do tratamento para facilitar um estado de hipoventilação controlada e hipercapnia permissiva. Pacientes que não conseguem melhorar com a ventilação mecânica podem ser considerados para abordagens menos comuns, como inalação de anestésicos, broncoscopia e suporte extracorpóreo à vida. Esta abordagem atual resultou em taxas de mortalidade extremamente baixas, mesmo em crianças com necessidade de suporte mecânico.

ABSTRACT Asthma is the most common chronic illness in childhood. Although the vast majority of children with acute asthma exacerbations do not require critical care, some fail to respond to standard treatment and require escalation of support. Children with critical or near-fatal asthma require close monitoring for deterioration and may require aggressive treatment strategies. This review examines the available evidence supporting therapies for critical and near-fatal asthma and summarizes the contemporary clinical care of these children. Typical treatment includes parenteral corticosteroids and inhaled or intravenous beta-agonist drugs. For children with an inadequate response to standard therapy, inhaled ipratropium bromide, intravenous magnesium sulfate, methylxanthines, helium-oxygen mixtures, and non-invasive mechanical support can be used. Patients with progressive respiratory failure benefit from mechanical ventilation with a strategy that employs large tidal volumes and low ventilator rates to minimize dynamic hyperinflation, barotrauma, and hypotension. Sedatives, analgesics and a neuromuscular blocker are often necessary in the early phase of treatment to facilitate a state of controlled hypoventilation and permissive hypercapnia. Patients who fail to improve with mechanical ventilation may be considered for less common approaches, such as inhaled anesthetics, bronchoscopy, and extracorporeal life support. This contemporary approach has resulted in extremely low mortality rates, even in children requiring mechanical support.

Validation of a pediatric bedside tool to predict time to death after withdrawal of life support.

AIM: To evaluate the accuracy of a tool developed to predict timing of death following withdrawal of life support in children. METHODS: Pertinent variables for all pediatric deaths (age ≤ 21 years) from 1/2009 to 6/2014 in our pediatric intensive care unit (PICU) were extracted through a detailed review of the medical records. As originally described, a recently developed tool that predicts timing of death in children following withdrawal of life support (dallas predictor tool [DPT]) was used to calculate individual scores for each patient. Individual scores were calculated for prediction of death within 30 min (DPT30) and within 60 min (DPT60). For various resulting DPT30 and DPT60 scores, sensitivity, specificity and area under the receiver operating characteristic curve were calculated. RESULTS: There were 8829 PICU admissions resulting in 132 (1.5%) deaths. Death followed withdrawal of life support in 70 patients (53%). After excluding subjects with insufficient data to calculate DPT scores, 62 subjects were analyzed. Average age of patients was 5.3 years (SD: 6.9), median time to death after withdrawal of life support was 25 min (range; 7 min to 16 h 54 min). Respiratory failure, shock and sepsis were the most common diagnoses. Thirty-seven patients (59.6%) died within 30 min of withdrawal of life support and 52 (83.8%) died within 60 min. DPT30 scores ranged from -17 to 16. A DPT30 score ≥ -3 was most predictive of death within that time period, with sensitivity = 0.76, specificity = 0.52, AUC = 0.69 and an overall classification accuracy = 66.1%. DPT60 scores ranged from -21 to 28. A DPT60 score ≥ -9 was most predictive of death within that time period, with sensitivity = 0.75, specificity = 0.80, AUC = 0.85 and an overall classification accuracy = 75.8%. CONCLUSION: In this external cohort, the DPT is clinically relevant in predicting time from withdrawal of life support to death. In our patients, the DPT is more useful in predicting death within 60 min of withdrawal of life support than within 30 min. Furthermore, our analysis suggests optimal cut-off scores. Additional calibration and modifications of this important tool could help guide the intensive care team and families considering DCD.

Implementation of a diuretic stewardship program in a pediatric cardiovascular intensive care unit to reduce medication expenditures.

PURPOSE: The implementation of a diuretic stewardship program in a pediatric cardiovascular intensive care unit (ICU) is described. METHODS: This retrospective study compared the use of i.v. chlorothiazide and i.v. ethacrynic acid in pediatric cardiovascular surgery patients before and after implementation of a diuretic stewardship program. All pediatric patients admitted to the pediatric cardiovascular service were included. The cardiovascular surgery service was educated on formal indications for specific diuretic agents, and the diuretic stewardship program was implemented on January 1, 2013. Under the stewardship program, i.v. ethacrynic acid was indicated in patients with a sulfonamide allergy, and i.v. chlorothiazide was considered appropriate in patients receiving maximized i.v. loop diuretic doses. A detailed review of the pharmacy database and medical records was performed for each patient to determine i.v. chlorothiazide and i.v. ethacrynic acid use and expenditures, appropriateness of use, days using a ventilator, and cardiovascular ICU length of stay. RESULTS: After implementation of diuretic stewardship, the use of i.v. chlorothiazide decreased by 74% (531 fewer doses) while i.v. ethacrynic acid use decreased by 92% (47 fewer doses), resulting in a total reduction of $91,398 in expenditures on these diuretics over the six-month study period and an estimated annual saving of over $182,000. The median number of days using a ventilator and the length of ICU stay did not differ significantly during the study period. CONCLUSION: Implementation of a diuretic stewardship program reduced the use of i.v. chlorothiazide and i.v. ethacrynic acid without adversely affecting clinical outcomes such as ventilator days and length of stay in a pediatric cardiovascular ICU.

Implementation of continuous capnography is associated with a decreased utilization of blood gases.

BACKGROUND: Capnography provides a continuous, non-invasive monitoring of the CO2 to assess adequacy of ventilation and provide added safety features in mechanically ventilated patients by allowing for quick identification of unplanned extubation. These monitors may allow for decreased utilization of blood gases. The objective was to determine if implementation of continuous capnography monitoring decreases the utilization of blood gases resulting in decreased charges. METHODS: This is a retrospective review of a quality improvement project that compares the utilization of blood gases before and after the implementation of standard continuous capnography. The time period of April 2010 to September 2010 was compared to April 2011 to September 2011. Parameters collected included total number of blood gases analyzed, cost of blood gas analysis, ventilator and patient days. RESULTS: The total number of blood gases after the institution of end tidal CO2 monitoring decreased from 12,937 in 2009 and 13,171 in 2010 to 8,070 in 2011. The average number of blood gases per encounter decreased from 20.8 in 2009 and 21.6 in 2010 to 13.8 post intervention. The blood gases per ventilator day decreased from 4.94 in 2009 and 4.76 in 2010 to 3.30 post intervention. The total charge savings over a 6-month period was $880,496. CONCLUSIONS: Continuous capnography resulted in a significant savings over a 6-month period by decreasing the utilization of blood gas measurements.

Fatalities above 30,000 feet: characterizing pediatric deaths on commercial airline flights worldwide.

OBJECTIVES: We conducted this study to characterize in-flight pediatric fatalities onboard commercial airline flights worldwide and identify patterns that would have been unnoticed through single case analysis of these relative rare events. DESIGN: Retrospective cohort study of pediatric in-flight medical emergencies resulting in fatalities between January 2010 and June 2013. SETTING: A ground-based medical support center providing remote medical support to commercial airlines worldwide. PATIENTS: Children (age 0-18 yr) who experienced a medical emergency resulting in death during a commercial airline flight. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were a total of 7,573 in-flight medical emergencies involving children reported to the ground-based medical support center, resulting in 10 deaths (0.13% of all pediatric in-flight emergencies). The median subject age was 3.5 months with 90% being younger than 2 years, the age until which children are allowed to travel sharing a seat with an adult passenger, also known as lap infants. Six patients had no previous medical history, with one suffering cardiorespiratory arrest after developing acute respiratory distress during flight and five found asystolic (including four lap infants). Four subjects had preflight medical conditions, including two children traveling for the purpose of accessing advanced medical care. CONCLUSIONS: Pediatric in-flight fatalities are rare, but death occurs most commonly in infants and in subjects with a preexisting medical condition. The number of fatalities involving seemingly previously healthy children under the age of 2 years (lap infants) is intriguing and could indicate a vulnerable population at increased risk of death related to in-flight environmental factors, sleeping arrangements, or yet another unrecognized factor.

Alteplase use for malfunctioning central venous catheters correlates with catheter-associated bloodstream infections.

OBJECTIVES: A catheter thrombosis and the presence of a catheter-associated bloodstream infection (CBSI) often occur simultaneously, but it is unclear if or to what degree the two complications relate. Several animal and adult studies indicate a relationship between fibrin sheaths and thrombi in the development of CBSIs. To date, there has been limited human investigation in the pediatric population to determine a clear link between the presence of a thrombus and bacteremia. The use of alteplase for malfunctioning central venous catheter may indicate the formation of intraluminal thrombus or fibrin sheath. A catheter that requires alteplase is at higher risk of a CBSI. DESIGN: A retrospective chart review from July 2008 to December 2010. SETTING: PICU. PATIENTS: All patients with central catheters admitted to the PICU. INTERVENTIONS: No interventions performed with the retrospective study. MEASUREMENTS: Number of total central venous catheters, number of central venous catheters that received treatment with alteplase, and number of CBSIs. MAIN RESULTS: Preliminary data during the study period identified 3,289 central venous catheters. Twelve percent of these catheters required at least one dose of alteplase. There were 40 CBSIs during this same time period of which 28% received alteplase during the 5 days preceding the positive blood culture. The odds ratio for getting a CBSI when alteplase is administered is 2.87 (confidence interval 1.42-5.80; p = 0.002). The average age of the central venous catheters at time of infection was not statistically different, 16.1 days in the alteplase catheters compared with 25.6 days for the catheters that did not receive alteplase (p = 0.6). CONCLUSIONS: There is a positive correlation between the use of alteplase for malfunctioning central venous catheters and the development of a CASBI. This is likely associated with the presence of an intraluminal fibrin sheath or thrombus. This study adds evidence linking thrombus formation to CBSI.

Post-transplant critical care outcomes for pediatric multivisceral and intestinal transplant patients.

This study reviews the post-operative management of pediatric intestinal transplant patients at a single center with reporting of standard PICU benchmarks for quality of care. It is a retrospective, descriptive, chart review describing our institution's experience between 2006 and 2010. Twenty patients were included. Median age at transplant was 1.6 yr. Median length of PICU stay was 12 days. Median ventilation time was two days. Median time for continuous sedation infusion was two days, with median continuous pain medication infusion of three days. All patients were placed on parental nutrition and started on enteral feedings between days 3 and 4. Forty percent of patients required hemodynamic support. Only 35% of patients required insulin therapy. Diuretics were frequently used in this patient population. There were no episodes of early rejection. The survival rate to PICU discharge was 95%. Our institution's experience over the past four yr has been very successful with a short duration of mechanical ventilation, limited use of pain and sedation drips, early initiation of enteral feedings, minimal hemodynamic support, and a low mortality rate to PICU discharge despite a preponderance of complex MVTx recipients.

Oxygenation index predicts mortality in pediatric stem cell transplant recipients requiring mechanical ventilation.

The mortality in the ICU for pediatric HSCT recipients remains high. Early pulmonary complications continue to be an obstacle to the survival. We hypothesize OI is a predictor for mortality in critically ill pediatric HSCT recipients. Retrospective review of pediatric HSCT recipients between 2002 and 2010 who required intensive care during the same hospital admission as their transplant. Twenty-eight patients accounted for 31 ICU admissions. Twenty-six (84%) admissions required mechanical ventilation. Ten (38%) mechanically ventilated admissions were placed on HFOV. Mortality of those mechanically ventilated was 70%. An OI ≥ 20 at any point during ventilation was associated with 94% mortality, while an OI ≥ 25 had 100% mortality. There was a significant association between maximum OI at any point during mechanical ventilation and ICU mortality, with the odds of dying increasing by 13% for each unit increase of max OI (OR = 1.13, 95% CI = 1.01-1.26, p = 0.03). An OI of 20 had a sensitivity of 0.89 and specificity of 0.83 for predicting mortality. OI has a strong association with ICU mortality among pediatric stem cell recipients.