Executive Summary:International Clinical Practice Guidelines for Pediatric Ventilator Liberation, A Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network Document

Rationale: Pediatric-specific ventilator liberation guidelines are lacking despite the many studies exploring elements of extubation readiness testing. The lack of clinical practice guidelines has led to significant and unnecessary variation in methods used to assess pediatric patients’ readiness for extubation. Methods: Twenty-six international experts comprised a multiprofessional panel to establish pediatrics-specific ventilator liberation clinical practice guidelines, focusing on acutely hospitalized children receiving invasive mechanical ventilation for more than 24 hours. Eleven key questions were identified and first prioritized using the Modified Convergence of Opinion on Recommendations and Evidence. A systematic review was conducted for questions that did not meet an a priori threshold of &gt;80% agreement, with Grading of Recommendations, Assessment, Development, and Evaluation methodologies applied to develop the guidelines. The panel evaluated the evidence and drafted and voted on the recommendations. Measurements and Main Results: Three questions related to systematic screening using an extubation readiness testing bundle and a spontaneous breathing trial as part of the bundle met Modified Convergence of Opinion on Recommendations criteria of &gt;80% agreement. For the remaining eight questions, five systematic reviews yielded 12 recommendations related to the methods and duration of spontaneous breathing trials, measures of respiratory muscle strength, assessment of risk of postextubation upper airway obstruction and its prevention, use of postextubation noninvasive respiratory support, and sedation. Most recommendations were conditional and based on low to very low certainty of evidence. Conclusions: This clinical practice guideline provides a conceptual framework with evidence-based recommendations for best practices related to pediatric ventilator liberation.</p

Executive Summary: International Clinical Practice Guidelines for Pediatric Ventilator Liberation, A PALISI Network Document

RATIONALE: Pediatric specific ventilator liberation guidelines are lacking despite the many studies exploring elements of extubation readiness testing. The lack of clinical practice guidelines has led to significant and unnecessary variation in methods used to assess pediatric patients' readiness for extubation. METHODS: Twenty-six international experts comprised a multi-professional panel to establish pediatric specific ventilator liberation clinical practice guidelines, focusing on acutely hospitalized children receiving invasive mechanical ventilation for more than 24 hours. Eleven key questions were identified and first prioritized using the Modified Convergence of Opinion on Recommendations and Evidence. Systematic review was conducted for questions which did not meet an a-priori threshold of ≥80% agreement, with Grading of Recommendations, Assessment, Development, and Evaluation methodologies applied to develop the guidelines. The panel evaluated the evidence, drafted, and voted on the recommendations. MEASUREMENTS AND MAIN RESULTS: Three questions related to systematic screening, using an extubation readiness testing bundle and use of a spontaneous breathing trial as part of the bundle met Modified Convergence of Opinion on Recommendations criteria of ≥80% agreement. For the remaining 8 questions, 5 systematic reviews yielded 12 recommendations related to the methods and duration of spontaneous breathing trials; measures of respiratory muscle strength; assessment of risk of post-extubation upper airway obstruction and its prevention; use of post-extubation non-invasive respiratory support; and sedation. Most recommendations were conditional and based on low to very low certainty of evidence. CONCLUSION: This clinical practice guideline provides a conceptual framework with evidence-based recommendations for best practices related to pediatric ventilator liberation.The project was funded by Eunice Kennedy Shriver National Institute of Child Health (NICHD) and Human Development National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) (R13HD102137), in addition to funds from department of pediatrics at Indiana University School of Medicine, Indianapolis, Indiana

Operational Definitions related to Pediatric Ventilator Liberation

BACKGROUND: Common, operational definitions are crucial to assess interventions and outcomes related to pediatric mechanical ventilation. These definitions can reduce unnecessary variability amongst research and quality improvement efforts, to ensure findings are generalizable and can be pooled to establish best practices. RESEARCH QUESTION: Can we establish operational definitions for key elements related to pediatric ventilator liberation using a combination of detailed literature review and consensus-based approaches? STUDY DESIGN AND METHODS: A panel of 26 international experts in pediatric ventilator liberation, two methodologists and two librarians conducted systematic reviews on eight topic areas related to pediatric ventilator liberation. Through a series of virtual meetings, we established draft definitions which were voted upon using an anonymous web-based process. Definitions were revised by incorporating extracted data gathered during the systematic review and discussed in another consensus meeting. A second round of voting was conducted to confirm the final definitions. RESULTS: In eight topic areas identified by the experts, 16 preliminary definitions were established. Based on initial discussion and the first round of voting, modifications were suggested for 11 of the 16 definitions. There was significant variability in how these items were defined in the literature reviewed. The final round of voting achieved ≥80% agreement for all 16 definitions in the following areas: what constitutes respiratory support (invasive mechanical ventilation and non-invasive respiratory support), liberation and failed attempts to liberate from invasive mechanical ventilation, liberation from respiratory support, duration of non-invasive respiratory support, total duration of invasive mechanical ventilation, spontaneous breathing trials, extubation readiness testing, 28-ventilator free days, and planned vs rescue use of post-extubation non-invasive respiratory support. INTERPRETATION: We propose these consensus-based definitions for elements of pediatric ventilator liberation, informed by evidence, be used for future quality improvement initiatives and research studies to improve generalizability, and facilitate comparison.The project was funded by Eunice Kennedy Shriver National Institute of Child Health (NICHD) and Human Development National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) (R13HD102137), in addition to funds from the Department of Pediatrics at Indiana University School of Medicine, Indianapolis, Indiana

Evaluation d'une nouvelle pratique (la CPAP dans les broncholites sévères,aspect clinique et impact économique)

LE KREMLIN-B.- PARIS 11-BU Méd (940432101) / SudocSudocFranceF

Insuffisance respiratoire aiguë hypercapnique de l enfant (bases physiopathologiques et implications pour la ventilation mécanique noninvasive)

La ventilation noninvasive (VNI) a de nombreuses indications potentielles en pédiatrie mais elle reste sous-utilisée en raison des difficultés techniques. Il y a par ailleurs un manque crucial de données physiologiques et d études cliniques. L objet de ce travail est d évaluer les conséquences physiologiques de détresses respiratoires fréquentes en pédiatrie et de préciser les bénéfices de la VNI. Sur une population de 10 jeunes nourrissons présentant une obstruction sévère des voies aériennes supérieures, nous avons constaté une augmentation très importante du travail respiratoire en ventilation spontanée. La VNI permet une réduction de ce travail et une amélioration des échanges gazeux. Cette étude a mit en évidence les problèmes d interaction du patient avec son ventilateur lors d une VNI à 2 niveaux de pressions. Le problème du réglage des paramètres de ventilation a fait l objet d un travail sur des patients atteints de mucoviscidose chez lesquels la VNI a démontré son efficacité. Nous avons montré que, quel que soit le mode de réglage, clinique ou physiologique, la VNI s accompagne d une amélioration significative du travail respiratoire. Chez 13 enfants présentant une insuffisance respiratoire aiguë hypercapnique nécessitant une ventilation assistée, la VNI diminue significativement le travail respiratoire de ces patients et améliore la ventilation alvéolaire et les échanges gazeux. Un réglage clinique, basé sur des paramètres noninvasifs, s est avéré être aussi efficace qu un réglage invasif basé sur l enregistrement des pressions oesophagienne et transdiaphragmatique. Des résultats préliminaires sur 6 nourrissons atteints de bronchiolite sévère montrent qu une pression positive continue administrée de manière noninvasive permet de diminuer le travail respiratoire et d améliorer la ventilation alvéolaire. En conclusion, ces études physiologiques permettent de mieux comprendre la physiopathologie de l insuffisance respiratoire aiguë et la place de la VNI.Noninvasive ventilation (NIV) has numerous potential indications in childhood. The aim of the present work was to analyse the physiological consequences of some common causes of respiratory failure in children and to evaluate the benefit of NIV. We analysed the work of breathing in 10 infants, mean age 8 months, presenting with severe upper airway obstruction due to structural abnomalities of the upper airway. Their work of breathing was dramatically increased and decreased significantly with NIV, which translated in an improvement of breathing pattern and gas exchange. In 13 children hospitalised in the pediatric intensive care unit (PICU) for an acute hypercapnic respiratory failure, NIV was associated with a reduction in the work of breathing and an improvement of alveolar ventilation and gas exchange. Moreover, a clinical setting of NIV was as efficient as a physiological setting. A preliminary study on 6 infants hospitalised in the PICU for severe bronchiolitis, NIV decreased the work of breathing and improved alveolar ventilation. In conclusion, the measurement of the work of breathing in various causes of respiratory failure in children improves our understanding of the pathophysiology of respiratory failure and the benefit of NIV.PARIS12-Bib. électronique (940280011) / SudocSudocFranceF

A computer vision method for respiratory monitoring in intensive care environment using RGB-D cameras

This paper presents a novel computer vision method to measure the breathing pattern in intensive care environment. The proposed system uses depth information captured by two RGB-D cameras in order to reconstruct a 3D surface of a patient's torso with a high spatial coverage. The optimal positioning for the sensors is a key step to perform an accurate 3D reconstruction without interfering with patient care. In this context, our hardware setup meets the clinical requirements while allowing accurate estimation of respiratory parameters including respiratory rate, tidal volume and inspiratory time. Our system provides the motion information not only for the top of the torso surface but also for its both lateral sides. Our method was tested in an environment designed for critically ill children, where it was compared to the gold standard method currently used in intensive care units. The performed experiments yielded high accuracy and showed significant agreement with gold standard method

Noninvasive support and ventilation for pediatric acute respiratory distress syndrome:proceedings from the Pediatric Acute Lung Injury Consensus Conference

OBJECTIVE: Despite the widespread use of noninvasive ventilation in children and in children with acute lung injury and pediatric acute respiratory distress syndrome, there are few scientific data on the utility of this therapy. In this review, we examine the literature regarding noninvasive positive pressure ventilation and use the Research ANd Development/University of California, Los Angeles appropriateness methodology to provide strong or weak recommendations for the use of noninvasive positive pressure ventilation in children with pediatric acute respiratory distress syndrome. DATA SOURCES: Electronic searches were made in PubMed, EMBASE, Web of Science, Cochrane Library, and Scopus with the following specific keywords: noninvasive ventilation, noninvasive positive pressure ventilation, continuous positive airway pressure, and high-flow nasal cannula. STUDY SELECTION: Studies were eligible for inclusion if they included 10 or more children between 1 month and 18 years old. Randomized and nonrandomized controlled trials, controlled before-and-after studies, concurrent cohort studies, interrupted time series studies, historically controlled studies, cohort studies, cross-sectional studies, and uncontrolled longitudinal studies were included for data synthesis. DATA SYNTHESIS: The literature provides a solid physiological rationale for the use of noninvasive positive pressure ventilation in children with pediatric acute respiratory distress syndrome. The addition of noninvasive positive pressure ventilation can improve gas exchange and potentially prevent intubation and mechanical ventilation in some children with mild pediatric acute respiratory distress syndrome. Noninvasive positive pressure ventilation is not indicated in severe pediatric acute respiratory distress syndrome. Noninvasive positive pressure ventilation should be performed only in acute care setting with experienced team, and patient-ventilator synchrony is crucial for success. An oronasal interface provides superior support, but close monitoring of children is required due to the risk of progressive respiratory failure and the potential need for intubation. The use of high-flow nasal cannula is a promising treatment for respiratory disease; however, at this time, the efficacy of high-flow nasal cannula compared with noninvasive positive pressure ventilation is unknown. CONCLUSION: Noninvasive positive pressure ventilation can be beneficial in children with pediatric acute respiratory distress syndrome, particularly in those with milder disease. However, further research is needed into the use of noninvasive positive pressure ventilation in children