Impact of different nebulisation systems on patient comfort in bronchiolitis: a randomised controlled cross-over trial.

OBJECTIVE: To test the hypothesis that greater comfort is achieved using a nebuliser integrated into a high-flow nasal cannula (nebulisation system integrated in high-flow nasal cannula (NHF)) than using a jet nebuliser (JN), and to explore differences in analgesia requirement and the possibility of feeding during nebulisation. DESIGN: Randomised cross-over trial. SETTING: Paediatric intensive care unit. PATIENTS: Children aged <24 months diagnosed with bronchiolitis between November 2016 and May 2017. INTERVENTIONS: Nebulisations using NHF and JN. MAIN OUTCOME MEASURES: COMFORT-Behaviour Scale (CBS) and Numerical Rating Comfort Scale (NRSc) were used to measure comfort, and Numerical Rating Satisfaction Scale (NRSs) was used to assess satisfaction before, during and after nebulisation. Other variables included feeding, analgesia, need for being held and respiratory and heart rates. RESULTS: Thirty-three children with 233 nebulisations were included in the study. The median age was 3.0 (IQR 2-9) months. Comfort and satisfaction were greater with NHF than with JN. The median staff-recorded CBS, NRSc and NRSs scores for NHF versus JN were 13 (IQR 9-15) vs 17 (IQR 13-23), 8 (IQR 7-0) vs 7 (IQR 4-8), and 4 (IQR 3-4) vs 2 (IQR 2-3), respectively; and caregiver-recorded scores were 12 (IQR 10-15) vs 19 (IQR 13-24), 9 (IQR 7-10) vs 4 (IQR 1-6), and 4 (IQR 3-4) vs 2 (IQR 1-3), respectively (p<0.001). Children who received NHF had lower cardiac and respiratory rates, needed to be held less often during therapy and required less analgesia (p<0.001). CONCLUSION: Nebulisation through NHF appears to be a better alternative to JN in terms of comfort and satisfaction as well as making feeding possible during nebulisation.

Effectiveness of Two Targeted Temperature Management Methods After Pediatric Postcardiac Arrest: A Multicenter International Study.

OBJECTIVES: It is currently recommended that after return of spontaneous circulation following cardiac arrest, fever should be prevented using TTM through a servo-controlled system. This technology is not yet available in many global settings, where manual physical measures without servo-control is the only option. Our aim was to compare feasibility, safety and quality assurance of servo-controlled system versus no servo-controlled system cooling, TTM protocols for cooling, maintenance and rewarming following return of spontaneous circulation after cardiac arrest in children. DESIGN: Prospective, multicenter, nonrandomized, study. SETTING: PICUs of 20 hospitals in South America, Spain, and Italy, 2012-2014. PATIENTS: Under 18 years old with a cardiac arrest longer than 2 minutes, in coma and surviving to PICU admission requiring mechanical ventilation were included. METHODS: TTM to 32-34°C was performed by prospectively designed protocol across 20 centers, with either servo-controlled system or no servo-controlled system methods, depending on servo-controlled system availability. We analyzed clinical data, cardiac arrest, temperature, mechanical ventilation duration, length of hospitalization, complications, survival, and neurologic outcomes at 6 months. PRIMARY OUTCOME: feasibility, safety and quality assurance of the cooling technique and secondary outcome: survival and Pediatric Cerebral Performance Category at 6 months. MEASUREMENTS AND MAIN RESULTS: Seventy patients were recruited, 51 of 70 TTM (72.8%) with servo-controlled system. TTM induction, maintenance, and rewarming were feasible in both groups. Servo-controlled system was more effective than no servo-controlled system in maintaining TTM (69 vs 60%; p = 0.004). Servo-controlled system had fewer temperatures above 38.1°C during the 5 days of TTM (0.1% vs 2.9%; p < 0.001). No differences in mortality, complications, length of mechanical ventilation and of stay, or neurologic sequelae were found between the two groups. CONCLUSIONS: TTM protocol (for cooling, maintenance and rewarming) following return of spontaneous circulation after cardiac arrest in children was feasible and safe with both servo-controlled system and no servo-controlled system techniques. Achieving, maintaining, and rewarming within protocol targets were more effective with servo-controlled system versus no servo-controlled system techniques.