Adherence to Lung-Protective Ventilation Principles in Pediatric Acute Respiratory Distress Syndrome:A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study

OBJECTIVES: To describe mechanical ventilation management and factors associated with nonadherence to lung-protective ventilation principles in pediatric acute respiratory distress syndrome. DESIGN: A planned ancillary study to a prospective international observational study. Mechanical ventilation management (every 6 hr measurements) during pediatric acute respiratory distress syndrome days 0-3 was described and compared with Pediatric Acute Lung Injury Consensus Conference tidal volume recommendations (< 7 mL/kg in children with impaired respiratory system compliance, < 9 mL/kg in all other children) and the Acute Respiratory Distress Syndrome Network lower positive end-expiratory pressure/higher FIO2 grid recommendations. SETTING: Seventy-one international PICUs. PATIENTS: Children with pediatric acute respiratory distress syndrome. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Analyses included 422 children. On pediatric acute respiratory distress syndrome day 0, median tidal volume was 7.6 mL/kg (interquartile range, 6.3-8.9 mL/kg) and did not differ by pediatric acute respiratory distress syndrome severity. Plateau pressure was not recorded in 97% of measurements. Using delta pressure (peak inspiratory pressure - positive end-expiratory pressure), median tidal volume increased over quartiles of median delta pressure (p = 0.007). Median delta pressure was greater than or equal to 18 cm H2O for all pediatric acute respiratory distress syndrome severity levels. In severe pediatric acute respiratory distress syndrome, tidal volume was greater than or equal to 7 mL/kg 62% of the time, and positive end-expiratory pressure was lower than recommended by the positive end-expiratory pressure/FIO2 grid 70% of the time. In multivariable analysis, tidal volume nonadherence was more common with severe pediatric acute respiratory distress syndrome, fewer PICU admissions/yr, non-European PICUs, higher delta pressure, corticosteroid use, and pressure control mode. Adherence was associated with underweight stature and cuffed endotracheal tubes. In multivariable analysis, positive end-expiratory pressure/FIO2 grid nonadherence was more common with higher pediatric acute respiratory distress syndrome severity, ventilator decisions made primarily by the attending physician, pre-ICU cardiopulmonary resuscitation, underweight stature, and age less than 2 years. Adherence was associated with respiratory therapist involvement in ventilator management and longer time from pediatric acute respiratory distress syndrome diagnosis. Higher nonadherence to tidal volume and positive end-expiratory pressure recommendations were independently associated with higher mortality and longer duration of ventilation after adjustment for confounding variables. In stratified analyses, these associations were primarily influenced by children with severe pediatric acute respiratory distress syndrome. CONCLUSIONS: Nonadherence to lung-protective ventilation principles is common in pediatric acute respiratory distress syndrome and may impact outcome. Modifiable factors exist that may improve adherence

Executive Summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2)

OBJECTIVES: We sought to update our 2015 work in the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) guidelines for the diagnosis and management of pediatric acute respiratory distress syndrome (PARDS), considering new evidence and topic areas that were not previously addressed. DESIGN: International consensus conference series involving 52 multidisciplinary international content experts in PARDS and four methodology experts from 15 countries, using consensus conference methodology, and implementation science. SETTING: Not applicable. PATIENTS: Patients with or at risk for PARDS. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Eleven subgroups conducted systematic or scoping reviews addressing 11 topic areas: 1) definition, incidence, and epidemiology; 2) pathobiology, severity, and risk stratification; 3) ventilatory support; 4) pulmonary-specific ancillary treatment; 5) nonpulmonary treatment; 6) monitoring; 7) noninvasive respiratory support; 8) extracorporeal support; 9) morbidity and long-term outcomes; 10) clinical informatics and data science; and 11) resource-limited settings. The search included MEDLINE, EMBASE, and CINAHL Complete (EBSCOhost) and was updated in March 2022. Grading of Recommendations, Assessment, Development, and Evaluation methodology was used to summarize evidence and develop the recommendations, which were discussed and voted on by all PALICC-2 experts. There were 146 recommendations and statements, including: 34 recommendations for clinical practice; 112 consensus-based statements with 18 on PARDS definition, 55 on good practice, seven on policy, and 32 on research. All recommendations and statements had agreement greater than 80%. CONCLUSIONS: PALICC-2 recommendations and consensus-based statements should facilitate the implementation and adherence to the best clinical practice in patients with PARDS. These results will also inform the development of future programs of research that are crucially needed to provide stronger evidence to guide the pediatric critical care teams managing these patients.</p

The large area detector onboard the eXTP mission

The Large Area Detector (LAD) is the high-throughput, spectral-timing instrument onboard the eXTP mission, a flagship mission of the Chinese Academy of Sciences and the China National Space Administration, with a large European participation coordinated by Italy and Spain. The eXTP mission is currently performing its phase B study, with a target launch at the end-2027. The eXTP scientific payload includes four instruments (SFA, PFA, LAD and WFM) offering unprecedented simultaneous wide-band X-ray timing and polarimetry sensitivity. The LAD instrument is based on the design originally proposed for the LOFT mission. It envisages a deployed 3.2 m2 effective area in the 2-30 keV energy range, achieved through the technology of the large-area Silicon Drift Detectors - offering a spectral resolution of up to 200 eV FWHM at 6 keV - and of capillary plate collimators - limiting the field of view to about 1 degree. In this paper we will provide an overview of the LAD instrument design, its current status of development and anticipated performance

Mechanical ventilation in obstructive lung diseases in children : pathophysiology of ventilatory and non-ventilatory procedures

Les pathologies respiratoires obstructives de l’enfant (asthme et broncho-alvéolites) sont l’une des principales causes d’admission en réanimation pédiatrique. Depuis plusieurs années, des progrès ont été faits pour réduire l’invasivité des soins se traduisant par une réduction de la morbidité. L’objectif de ce travail de thèse est de s’appuyer sur des mécanismes physiopathologiques pour proposer des stratégies d’optimisation ventilatoire et non ventilatoire chez ces enfants. Nous avons évalué l’impact du décubitus ventral couplé à la ventilation non invasive chez les nourrissons atteints de bronchiolite grave. Le décubitus ventral permet de réduire significativement l’effort inspiratoire et d’améliorer le couplage électromécanique du diaphragme. Ensuite nous avons évalué la « neurally adjusted ventilatory assist » (NAVA) qui est un mode ventilatoire proportionnel basé sur l’activité électrique du diaphragme. Nous avons démontré que la NAVA améliorait la synchronisation patient-respirateur et réduisait le travail respiratoire en comparaison à la « nasal continuous positive airway pressure » (nCPAP). Enfin, dans la pathologie asthmatique nous avons également décrit la faisabilité du haut débit nasal dans cette population. Ces stratégies nécessitent maintenant d’être validées sur des critères cliniques et feront l’objet de deux études multicentriques randomiséesObstructive lung disease in children (asthma and bronchiolitis) are one of the main causes of admission to pediatric intensive care units. For several years, progress has been made to reduce the invasiveness of care resulting in a decrease in associated morbidity. The main objective of the thesis was to propose new ventilatory and non-ventilatory strategies based on physiopathology to optimize the care of such children.In children with severe bronchiolitis we evaluated the impact of prone position associated with non-invasive ventilation. The prone position decreases significantly the inspiratory work of breathing and improves the neuromechanical efficiency of the diaphragm. We also evaluated the effect of neurally adjusted ventilatory assist (NAVA) that is a proportional ventilatory mode based on the electrical activity of the diaphragm. We demonstrated that NAVA improved the patient-ventilator interactions and decrease the work of breathing in comparison with nasal continuous positive airway pressure (nCPAP). We also evaluated the feasibility of high flow nasal cannula as a respiratory support in children with severe asthma attack. These strategies need now to be validated on clinical outcomes and are the subject of two ongoing multicenter randomized trial

Ventilation mécanique dans les pathologies obstructives de l'enfant : physiopathologie des interventions ventilatoires et non ventilatoires

Obstructive lung disease in children (asthma and bronchiolitis) are one of the main causes of admission to pediatric intensive care units. For several years, progress has been made to reduce the invasiveness of care resulting in a decrease in associated morbidity. The main objective of the thesis was to propose new ventilatory and non-ventilatory strategies based on physiopathology to optimize the care of such children.In children with severe bronchiolitis we evaluated the impact of prone position associated with non-invasive ventilation. The prone position decreases significantly the inspiratory work of breathing and improves the neuromechanical efficiency of the diaphragm. We also evaluated the effect of neurally adjusted ventilatory assist (NAVA) that is a proportional ventilatory mode based on the electrical activity of the diaphragm. We demonstrated that NAVA improved the patient-ventilator interactions and decrease the work of breathing in comparison with nasal continuous positive airway pressure (nCPAP). We also evaluated the feasibility of high flow nasal cannula as a respiratory support in children with severe asthma attack. These strategies need now to be validated on clinical outcomes and are the subject of two ongoing multicenter randomized trialsLes pathologies respiratoires obstructives de l’enfant (asthme et broncho-alvéolites) sont l’une des principales causes d’admission en réanimation pédiatrique. Depuis plusieurs années, des progrès ont été faits pour réduire l’invasivité des soins se traduisant par une réduction de la morbidité. L’objectif de ce travail de thèse est de s’appuyer sur des mécanismes physiopathologiques pour proposer des stratégies d’optimisation ventilatoire et non ventilatoire chez ces enfants. Nous avons évalué l’impact du décubitus ventral couplé à la ventilation non invasive chez les nourrissons atteints de bronchiolite grave. Le décubitus ventral permet de réduire significativement l’effort inspiratoire et d’améliorer le couplage électromécanique du diaphragme. Ensuite nous avons évalué la « neurally adjusted ventilatory assist » (NAVA) qui est un mode ventilatoire proportionnel basé sur l’activité électrique du diaphragme. Nous avons démontré que la NAVA améliorait la synchronisation patient-respirateur et réduisait le travail respiratoire en comparaison à la « nasal continuous positive airway pressure » (nCPAP). Enfin, dans la pathologie asthmatique nous avons également décrit la faisabilité du haut débit nasal dans cette population. Ces stratégies nécessitent maintenant d’être validées sur des critères cliniques et feront l’objet de deux études multicentriques randomisée

Viral Bronchiolitis in PICUs: Looking Further Than the Acute Phase!

Acute viral bronchiolitis (AVB) is the leading cause of acute respiratory distress and is a serious global public health problem, not because of mortality but rather by the sheer number of children infected and requiring hospitalization in all developed countries

High-Flow Nasal Cannula in the Pediatric ICU: Popular or Efficient?

High-flow nasal cannula (HFNC) delivers a heated and humidified gas mixture at a flow greater than patient inspiratory flow demand. Several physiological studies have evaluated HFNC in neonates, infants, children, and adults. These found that HFNC improves gas exchange, applies positive pressure, flushes anatomical dead space, and decreases work of breathing. In adults, the FLORALI trial3 was the first to provide evidence of HFNC superiority over noninvasive ventilation (NIV) and standard oxygenation, which places the HFNC as the primary respiratory support for adults with hypoxemic acute respiratory failure

Infections invasives à méningocoque

Invasive meningococcal infections (MSI) include meningitis, septicemia and septic shock associated with Neisseria meningitidis. In France, serogroup B dominates, followed by serogroups C, Y and W. Their lethality is 10%, or even 25% if septic shock. The diagnosis is evoked in front of a fever associated withmeningeal signs (headache, bulging fontanelle, vomiting, meningeal stiffness) and / or signs of poor peripheral perfusion (mottling, prolonged skin recollection, cold extremities) and / or limb pain, and secondarily an eruption (morbilliform erythema) or purpura).Les infections invasives à méningocoque (IIM) regroupent les méningites, septicémies et chocs septiques liés à Neisseiria meningitidis. En France, le sérogroupe B domine, suivi des sérogroupes C, Y et W. Leur létalité est de 10 %, voire 25 % si choc septique. Le diagnostic est évoqué devant une fièvre associée àdes signes méningés (céphalée, fontanelle bombée, vomissements, raideur méningée) et/ou des signes de mauvaise perfusion périphérique (marbrures, temps de recoloration cutanée allongé, extrémités froides) et/ou des douleurs des membres, et secondairement une éruption (érythème morbilliforme ou purpura)

SCHEMATEC : une méthodologie utilisant des outils basés sur le virtuel et une base de données au service de la conservation-restauration des objets scientifiques et techniques patrimoniaux

National audienceAvec le projet SCHEMATEC nous avons souhaité combler une lacune : celle de l’absence de méthodologie descriptive des objets fonctionnels scientifiques et techniques patrimoniaux adaptée à leur conservation-restauration.Les neuf niveaux de lecture créés permettent de passer intuitivement de la compréhension globale de l’usage des objets à celle plus détaillée de ses composants, organes fonctionnels jusqu’au modèle complet en systémique. Basés sur des représentations 2D, complétées parfois de représentations 3D ainsi que d’animations des mécanismes complexes, ils bénéficient également de l’apport des diagrammes SADT permettant de visualiser l’impact des altérations sur les chaînes fonctionnelles. Ainsi c’est l’ensemble des outils virtuels de l’ingénierie technique qui ont été analysés, optimisés et adaptés.La méthodologie de représentation schématique de la fonctionnalité des objets scientifiques et techniques ne se limite pas seulement à améliorer la compréhension de leur fonctionnement, mais couvre l’ensemble du projet de conservation-restauration (constat d’état, diagnostic, propositions d’interventions adéquates en vue d’éventuelles remises en fonction). Ainsi les schémas techniques réalisés ne sont pas seulement des outils d’observation et de description mais également des moyens essentiels d’analyse entre les acteurs du projet.Afin de pouvoir encapsuler, stocker et valoriser ces connaissances, une base de données en ligne SCHEMATEC (schematec.he-arc.ch) a été créée dans le cadre du projet. Elle permet la sauvegarde complète des projets construits selon la méthodologie SCHEMATEC mais également leur consultation. A terme elle devrait devenir le support du savoir partageable entre plusieurs communautés concernées par la conservation-restauration des objets scientifiques et techniques patrimoniaux fonctionnels