Individual patient data meta-analysis on awake pediatric extracorporeal life support: Feasibility and safety of analgesia, sedation and respiratory support weaning, and physiotherapy.

OBJECTIVE: Awake Extracorporeal Life Support (aECLS) with active mobilization has gained consensus over time, also within the pediatric community. This individual patient data (IPD) meta-analysis summarizes available evidence on pediatric aECLS, its feasibility, and safety regarding sedation weaning, extubation, and physiotherapy. METHODS: PubMed/Medline and Cochrane Database were screened until February 2022. Articles reporting on children (≤18 years) undergoing aECLS were selected. IPD were requested, pooled in a single database, and analyzed using descriptive statistics. Primary outcome was survival to hospital discharge. Secondary outcomes included extubation during ECLS, physiotherapy performed, tracheostomy, and complications. RESULTS: Nineteen articles and 65 patients (males:n = 30/59,50.8%) were included. Age ranged from 2 days to 17 years. ECLS configurations included veno-venous (n = 42/65, 64.6%), veno-arterial (n = 18/65, 27.7%) and other ECLS settings (n = 5/65, 7.7%). Exclusive neck cannulation was performed in 51/65 (78.5%) patients. Extubation or tracheostomy during ECLS was reported in 66.2% (n = 43/65) and 27.7% (n = 18/65) of patients, respectively. Physiotherapy was reported as unspecified physical activity (n = 34/63, 54%), mobilization in bed (n = 15/63, 23.8%), ambulation (n = 14/63, 22.2%). Complications were reported in 60.3% (n = 35/58) of patients, including hemorrhagic (36.2%), mechanical (17.2%), or pulmonary (17.2%) issues, and need for reintubation (15.5%). Survival at discharge was 81.5% (n = 53/65). CONCLUSION: Awake ECLS strategy with active physiotherapy can be applied in children from neonatal age. Ambulation is also possible in selected cases. Complications related to such management were limited. Further studies on aECLS are needed to evaluate safety and efficacy of early physiotherapy and define patient selection.

Physiotherapy-led lung ultrasound in neonatal extra-corporeal membrane oxygenation: A case-study.

There is a growing body of evidence to support the use of point of care lung ultrasound (LUS) in adult patients receiving extra-corporeal membrane oxygenation (ECMO). However, literature supporting the use of LUS in neonatal and paediatric ECMO patients is limited. We report the use of physiotherapy-led LUS in a neonatal ECMO patient. The baby required veno-arterial ECMO for long-segment tracheal stenosis and presented with complete right lung collapse. In this situation real time, bedside imaging enabled timely and specific physiotherapy treatment to be implemented. LUS also allowed immediate reassessment and subsequent improvement to be determined. This negated the requirement for an additional, pre-surgery chest X-ray, reducing radiation exposure. This case-study highlights LUS as an important tool for health professionals caring for neonatal and paediatric ECMO patients. Future research should include further development of population specific LUS scoring systems.

Awake extracorporeal life support and physiotherapy in adult patients: A systematic review of the literature.

OBJECTIVE: The Awake Extracorporeal Life Support (ECLS) practice combined with physiotherapy is increasing. However, available evidence for this approach is limited, with unclear indications on timing, management, and protocols. This review summarizes available literature regarding Awake ECLS and physiotherapy application rates, practices, and outcomes in adults, providing indications for future investigations. METHODS: Four databases were screened from inception to February 2021, for studies reporting adult Awake ECLS with/without physiotherapy. Primary outcome was hospital discharge survival, followed by Extracorporeal Membrane Oxygenation (ECMO) duration, extubation, Intensive Care Unit stay. RESULTS: Twenty-nine observational studies and one randomized study were selected, including 1,157 patients (males n = 611/691, 88.4%) undergoing Awake ECLS. Support type was reported in 1,089 patients: Veno-Arterial ECMO (V-A = 39.6%), Veno-Venous ECMO (V-V = 56.8%), other ECLS (3.6%). Exclusive upper body cannulation and femoral cannulation were applied in 31% versus 69% reported cases (n = 931). Extubation was successful in 63.5% (n = 522/822) patients during ECLS. Physiotherapy details were given for 676 patients: exercises confined in bed for 47.9% (n = 324) patients, mobilization until standing in 9.3% (n = 63) cases, ambulation performed in 42.7% (n = 289) patients. Femoral cannulation, extubation and V-A ECMO were mostly correlated to complications. Hospital discharge survival observed in 70.8% (n = 789/1114). CONCLUSION: Awake ECLS strategy associated with physiotherapy is performed regardless of cannulation approach. Ambulation, as main objective, is achieved in almost half the population examined. Prospective studies are needed to evaluate safety and efficacy of physiotherapy during Awake ECLS, and suitable patient selection. Guidelines are required to identify appropriate assessment/evaluation tools for Awake ECLS patients monitoring.

Early rehabilitation and mobilisation of neonatal and paediatric extracorporeal membrane oxygenation patients: A UK and Ireland consensus document.

Despite increasing early rehabilitation and mobilisation (ERM) in paediatric intensive care, current evidence for ERM of neonatal and paediatric patients receiving extracorporeal membrane oxygenation (ECMO) is limited. The proposed benefits of ERM in neonatal and paediatric ECMO patients are multifaceted, including reduced immobility related issues and maintenance of functional ability. However, ECMO presents additional safety and logistical challenges, and currently there are no published neonatal or paediatric guidelines. A consensus document was developed to provide guidance for ERM with neonatal and paediatric ECMO patients. The document was developed by specialist physiotherapists from nine ECMO centres within the UK and Ireland, together with the UK Paediatric Critical Care Society ECMO group and members of the multidisciplinary team. The document covers key considerations and practicalities for completing ERM in this population including, acuity level measurement, activity level guidance, safety and risk assessment, and goal setting. Risk assessment and safety checklist bedside tools are also included and designed to be adapted as required to meet specific unit policies and protocols.

Inhaled hypertonic saline after pediatric lung transplant-Caution required?

Management of pulmonary infection following lung transplant is multifaceted and includes respiratory physiotherapy. Inhaled hypertonic saline (HTS) has been introduced as an adjunct to physiotherapy in pediatric transplant patients. There are no published studies investigating the use of HTS in this population. This study aimed to evaluate the effect of inhaled HTS, in the acute post-operative period, in pediatric lung transplant patients. A retrospective case-note review was completed at a single UK pediatric transplant center. An intervention group who received HTS was compared to a historical control group. Participants were frequency matched for age, gender, and diagnosis (14 per group); median age in years was 13.7(IQR 12.7-15.3) in the controls and 14.8(IQR 12.4-16.1) in the intervention group. Primary outcome was the requirement of invasive and non-invasive ventilation. Secondary outcomes included oxygen use and length of stay. Median days of invasive ventilation were shorter in the control group (1, 95% CI 1-1) compared to the intervention group (2, 95% CI 1-2.5) (P < .05). Days of non-invasive ventilation and oxygen were higher in the HTS group, but this was not statistically significant. The controls displayed shorter median length of stay (23 days, 95% CI 20-24) compared to the intervention group (31 days, 95% CI 24.5-39) (P < .05). The results of this small study provide uncertainty regarding the safety of inhaled hypertonic saline after lung transplant. There was a trend of poorer acute outcomes in patients who received HTS. However, the findings should be interpreted with caution and further investigation using larger samples is required.

Chest Physiotherapy for Mechanically Ventilated Children: A Systematic Review.

The aim of this study was to appraise and summarize the effects of chest physiotherapy in mechanically ventilated children. A systematic review was completed by searching Medline, Embase, Cinahl Plus, PEDro, and Web of Science from inception to February 9, 2021. Studies investigating chest physiotherapy for mechanically ventilated children (0-18 years), in a pediatric intensive care unit were included. Chest physiotherapy was defined as any intervention performed by a qualified physiotherapist. Measurements of effectiveness and safety were included. Exclusion criteria included preterm infants, children requiring noninvasive ventilation, and those in a nonacute setting. Thirteen studies met the inclusion criteria: two randomized controlled trials, three randomized crossover trials, and eight observational studies. The Cochrane risk of bias and the Critical Appraisal Skills Program tools were used for quality assessment. Oxygen saturations decreased after physiotherapy involving manual hyperinflations (MHI) and chest wall vibrations (CWV). Although statistically significant, these results were not of clinical importance. In contrast, oxygen saturations improved after the expiratory flow increase technique; however, this was not clinically significant. An increase in expiratory tidal volume was demonstrated 30 minutes after MHI and CWV. There was no sustained change in tidal volume following a physiotherapy-led recruitment maneuver. Respiratory compliance and dead-space increased immediately after MHI and CWV. Atelectasis scores improved following intrapulmonary percussive ventilation, and MHI and CWV. Evidence to support chest physiotherapy in ventilated children remains inconclusive. There are few high-quality studies, with heterogeneity in interventions and populations. Future studies are required to investigate multiple physiotherapy interventions and the impact on long-term outcomes.

Chest physiotherapy for mechanically ventilated children: a survey of current UK practice.

OBJECTIVES: Chest physiotherapy is a treatment option for mechanically ventilated children. However, there is a lack of consensus regarding its value and informal discussions suggest variation in practice. This study describes chest physiotherapy practices for mechanically ventilated children in the UK and explores clinical decision making related to its delivery. DESIGN: Cross-sectional study, using an anonymous, electronic survey. PARTICIPANTS: Qualified physiotherapists working in UK NHS paediatric intensive care units (PICUs). RESULTS: The response rate was 61% (72/118), this included physiotherapists from 26/27 (96%) PICUs. All participants reported using manual hyperinflations and position changes 'always' or 'often'. Variation in practice was evident for some techniques, including Metaneb® and percussion. DNase (99%, 71/72) and hypertonic saline (90%, 65/72) were the most frequently used mucoactives: 91% (59/65) of physiotherapists reported only nebulising hypertonic saline and 69% (49/71) use both nebulised and instilled DNase. Use and delivery of N-acetylcysteine was inconsistent (nebulised only 55%, 26/47; instilled only 15%, 7/47; both 30%, 14/47). Chest physiotherapy was most commonly delivered with a nurse (67%, 48/72). Clinical decision making processes were comparable between physiotherapists and encompassed three main elements: individual patient assessment, involvement of the multidisciplinary team, and risk versus benefit analysis. CONCLUSIONS: A range of chest physiotherapy treatments and adjuncts were used with ventilated children. Variation was apparent and may be due to individual preferences of those training staff or local policies. Pragmatic, interventional studies are required to determine best practice. Further exploration is necessary to understand the variation in practice and intricacies of decision making.