Outcomes of children with life-threatening status asthmaticus requiring isoflurane therapy and extracorporeal life support.

BACKGROUND: Severe, refractory asthma is a life-threatening emergency that may be treated with isoflurane and extracorporeal life support. The objective of this study was to describe the clinical response to isoflurane and outcomes after discharge of children who received isoflurane and/or extracorporeal life-support for near-fatal asthma. METHODS: This was a retrospective descriptive study using electronic medical record data from two pediatric intensive care units within a single healthcare system in Atlanta, GA. RESULTS: Forty-five children received isoflurane, and 14 children received extracorporeal life support, 9 without a trial of isoflurane. Hypercarbia and acidosis improved within four hours of starting isoflurane. Four children died during the index admission for asthma. Twenty-seven percent had a change in Functional Status Score of three or more points from baseline to PICU discharge. Patients had median percent predicted FEV1 and FEV1/FVC ratios pre- and post-bronchodilator values below normal pediatric values. CONCLUSION: Children who received isoflurane and/or ECLS had a high frequency of previous PICU admission and intubation. Improvement in ventilation and acidosis occurred within the first four hours of starting isoflurane. Children who required isoflurane or ECLS may develop long-lasting deficits in their functional status. Children with near-fatal asthma are a high-risk group and require improved follow-up in the year following PICU discharge.

Outpatient Utilization of the RAM Cannula for Nasal Noninvasive Ventilation in Children.

Background: The RAM cannula® consists of nasal prongs that can be used to administer oxygen, continuous, and bilevel positive airway pressure therapies. Studies have reported the efficacy and utility of the RAM cannula in inpatients requiring noninvasive ventilation (NIV); however, there is limited literature on the use of the RAM cannula to provide NIV in the outpatient setting. Objectives: This study aimed to describe the clinical features and outcomes of children who used NIV via RAM cannula in the outpatient setting. Design: Retrospective review. Methods: We conducted a retrospective review of children treated with outpatient NIV via RAM cannula at our institution between January 2010 and March 2023. The analyzed data included age, diagnoses, indications for NIV, duration of RAM cannula use, complications, and outcomes at 6 months. Results: We identified 20 patients who used outpatient NIV via RAM cannula during the study period. The median age at initiation of NIV via RAM cannula was 5.8 months (IQR 2.4-9.9 months). Indications for NIV included sleep-related hypoventilation (15%), restrictive lung disease (25%), obstructive sleep apnea (45%), and chronic respiratory failure (50%), with 6 patients having ⩾2 indications for NIV. RAM cannula was utilized for inability to tolerate conventional NIV interfaces (80%), to alleviate dyspnea (60%), and to avoid tracheostomy (55%). Patients used NIV via RAM cannula for a median duration of 7.7 months (IQR 3.7-20.6 months). Patient outcomes included ongoing usage of RAM cannula (55%), changing to conventional NIV interfaces (15%) or oxygen (10%), weaning off respiratory support (5%), and death (15%). There were no complications related to using the RAM cannula. Conclusion: Our study demonstrates the utility of outpatient NIV via RAM cannula in children with a variety of diagnoses until clinical improvement or tolerance of conventional interfaces, and for avoidance of tracheostomy.

Cryoextraction via flexible bronchoscopy in children with tracheobronchial obstruction.

BACKGROUND: Cryoextraction via flexible bronchoscopy (FB) can be used to alleviate airway obstruction due to blood clots, casts, mucus, and foreign bodies. There is limited literature regarding the utility of cryoextraction to restore airway patency in critically ill children, especially on extracorporeal membrane oxygenation (ECMO). The aims of this study were to describe the clinical course and outcomes of children who underwent cryoextraction via FB. METHODS: A singlecenter retrospective review of children who underwent cryoextraction via FB between 2017 and 2021 was conducted. The analyzed data included diagnoses, indications for cryoextraction, respiratory support modalities, FB and chest imaging results, and outcomes. RESULTS: Eleven patients aged 3-17 years underwent a total of 33 cryoextraction sessions via FB. Patients required ECMO (n = 9) or conventional mechanical ventilation (CMV) for pneumonia, pulmonary hemorrhage, pulmonary embolism, asthma exacerbation, and cardiorespiratory failure following cardiac surgery. One patient underwent elective FB and cryoextraction for plastic bronchitis. Indications for cryoextraction included airway obstruction due to tracheobronchial thrombi (n = 8), mucus plugs (n = 1), or plastic bronchitis (n = 2). Cryoextraction via FB was performed on patients on ECMO (n = 9) and CMV (n = 2) with 6 patients requiring ≥3 cryoextraction sessions for airway obstruction. There were no complications related to cryoextraction. Patient outcomes included partial (n = 5) or complete (n = 6) restoration of airway patency with ECMO decannulation (n = 5) and death (n = 4) due to critical illness. CONCLUSIONS: Cryoextraction via FB is an effective intervention that can be utilized in critically ill children with refractory tracheobronchial obstruction to restore airway patency and to facilitate liberation from ECMO.