Contemporary Trends in Pediatric Extubation Failure and Non-Invasive Respiratory Support Use.

Background: Prolonged invasive mechanical ventilation is associated with morbidity and mortality in children. Timely extubation is essential and must balance the competing risks of extubation failure (EF) and prolonged use of post-extubation non-invasive respiratory support.

Research Question: Have EF risk factors, EF rates, post-extubation non-invasive respiratory support practices, and patient-centered outcomes changed between 2013-2022?

Study Design And Methods: Retrospective cross-sectional study of patients < 19 years old receiving invasive mechanical ventilation ≥ 24h extubated between 2013-2022 from 158 North American sites in the Virtual Pediatric Intensive Care, LLC quality improvement database STUDY RESULTS: 132,712 unique encounters were included.

Protocols and Pathways in Pediatric Critical Asthma: A Systematic Review and Meta-Analysis.

Pediatric critical asthma is one of the most frequent reasons for presentation to the emergency department and admission to the floor or pediatric ICU (PICU) in pediatric patients. Clinical pathways and protocols have been used frequently in respiratory care, and many have been associated with an improvement in outcomes. We performed a systematic review on the use of protocols or pathways in the treatment of critical asthma.

Intravenous Bronchodilators in Pediatric Critical Asthma: A Systematic Review and Network Meta-Analysis.

Introduction: Pediatric critical asthma is one of the most common pediatric illnesses in children admitted to the pediatric ward and pediatric intensive care unit (PICU). Adjunct intravenous (IV) bronchodilators are often used when initial management with systemic corticosteroids and inhaled short-acting beta agonists (SABA) fail to provide improvement in a patient's clinical condition. While the recent guidelines gave recommendations for the use of different IV bronchodilators compared to placebo, it did not include ranking on which one should be used as first-line or second-line agent.

AARC and PALISI Clinical Practice Guideline: Pediatric Critical Asthma.

To address the lack of guidance for clinicians in their care of children with critical asthma, a multidisciplinary team of medical providers used Grading of Recommendations, Assessment, Development, and Evaluation methodology to make the following recommendations: 1. We suggest the use of continuous inhaled short-acting β agonist (SABA) over frequent intermittent SABA in children treated for critical asthma. (Conditional recommendation, very low certainty of evidence) 2.

Ventilator Liberation Practices in Pediatric Cardiac Critical Care.

Mechanical ventilation is common in critically ill children with cardiac disease, but literature focused on ventilator liberation practices for this unique pediatric subpopulation is limited. We aimed to describe current ventilator liberation practices in critically ill children with cardiac disease. Through the Pediatric Cardiac Critical Care Consortium, an electronic survey was distributed to pediatric ICU attending physicians caring for patients with cardiac disease evaluating institutional protocols and individual practices around ventilator liberation including criteria for extubation readiness testing (ERT), ERT components, spontaneous breathing trial (SBT) method and duration, timing of extubation, and postextubation respiratory support.

Pharmacological Management of Pediatric Critical Asthma.

Pediatric critical asthma, formerly known as status asthmaticus, is a common pediatric condition encountered in emergency departments, hospital wards, and PICUs. Systemic corticosteroids and inhaled bronchodilators are evidence-based, initial treatments for patients with pediatric critical asthma. If clinical symptoms do not improve, then pediatric practitioners often prescribe adjunctive medications, including inhaled anticholinergics, intravenous ketamine, intravenous magnesium, intravenous short-acting β agonists, and intravenous methylxanthines (eg, aminophylline).

A matched analysis of the use of high flow nasal cannula for pediatric severe acute asthma.

Rationale: The high-flow nasal cannula (HFNC) device is commonly used to treat pediatric severe acute asthma. However, there is little evidence regarding its effectiveness in real-world practice.

Objectives: We sought to compare the physiologic effects and clinical outcomes for children treated for severe acute asthma with HFNC versus matched controls.

Framework for Research Gaps in Pediatric Ventilator Liberation.

Background: The 2023 International Pediatric Ventilator Liberation Clinical Practice Guidelines provided evidence-based recommendations to guide pediatric critical care providers on how to perform daily aspects of ventilator liberation. However, because of the lack of high-quality pediatric studies, most recommendations were conditional based on very low to low certainty of evidence.

Research Question: What are the research gaps related to pediatric ventilator liberation that can be studied to strengthen the evidence for future updates of the guidelines?

Study Design And Methods: We conducted systematic reviews of the literature in eight predefined Population, Intervention, Comparator, Outcome (PICO) areas related to pediatric ventilator liberation to generate recommendations.

Delirium Screening in Critically Ill Children: Secondary Analysis of the Multicenter PICU Up! Pilot Trial Dataset, 2019-2020.

Objectives: To determine the patient-level factors associated with performing daily delirium screening in PICUs with established delirium screening practices.

Design: A secondary analysis of 2019-2020 prospective data from the baseline phase of the PICU Up! pilot stepped-wedge multicenter trial (NCT03860168).

Setting: Six PICUs in the United States.

The Effect of a Collaborative Pediatric Emergency Readiness Improvement Intervention on Patients' Hospital Outcomes.

Objective: We hypothesized that collaborative intervention to improve weighted pediatric readiness score (WPRS) will be associated with decreased pediatric intensive care (PICU) mortality, PICU and hospital length of stay.

Methods: This study analyzes the transfer of acutely ill and injured patients from general emergency departments (GEDs) to our institution. The intervention involved customized assessment reports focusing on team performance and systems improvement for pediatric readiness, sharing best practices and clinical resources, designation of a nurse pediatric emergency care coordinator (PECC) at each GED and ongoing interactions at 2 and 4 months.

Implementing the Pediatric Ventilator Liberation Guidelines Using the Most Current Evidence.

Invasive mechanical ventilation is prevalent and associated with considerable morbidity. Pediatric critical care teams must identify the best timing and approach to liberating (extubating) children from this supportive care modality. Unsurprisingly, practice variation varies widely.

Institutional Variability in Respiratory Support Use for Pediatric Critical Asthma: A Multicenter Retrospective Study.

Over 20,000 children are hospitalized in the United States for asthma every year. Although initial treatment guidelines are well established, there is a lack of high-quality evidence regarding the optimal respiratory support devices for these patients. The objective of this study was to evaluate institutional and temporal variability in the use of respiratory support modalities for pediatric critical asthma.

Development and Implementation of a Quick Response (QR) Code System to Streamline the Process for Fellows' Evaluation in the Pediatric Intensive Care Unit (PICU) and the Neonatal Intensive Care Unit (NICU) at a Large Academic Center.

Background/objective: Useful feedback and evaluation are critical to a medical trainee's development. While most academic physicians understand that giving feedback to learners is essential, many do not consider the components of feedback to be truly useful, and there are barriers to implementation. We sought to use a quick reader (QR) system to solicit feedback for trainees in two pediatric subspecialties (pediatric critical care and neonatal-perinatal medicine) at one institution to increase the quality and quantity of feedback received.

Outcomes of a respiratory therapist driven high flow nasal cannula management protocol for pediatric critical asthma patients.

Introduction: This study aimed to determine if a respiratory therapist (RT)-driven high flow nasal cannula (HFNC) protocol could decrease duration of HFNC use, pediatric intensive care unit (PICU) and hospital length of stay (LOS), and duration of continuous albuterol use in pediatric patients with critical asthma.

Methods: This was a quality improvement project performed at a quaternary academic PICU. Patients admitted to the PICU between 2 and 18 years of age with a diagnosis of asthma requiring continuous albuterol and HFNC were included.

High flow nasal cannula use is associated with increased hospital length of stay for pediatric asthma.

Background: High flow nasal cannula (HFNC) is a respiratory device increasingly used to treat asthma. Recent mechanistic studies have shown that nebulized medications may have reduced delivery with HFNC, which may impair asthma treatment. This study evaluated the association between HFNC use for pediatric asthma and hospital length of stay (LOS).

Factors Associated With Improved Pediatric Resuscitative Care in General Emergency Departments.

Objectives: To describe the quality of pediatric resuscitative care in general emergency departments (GEDs) and to determine hospital-level factors associated with higher quality.

Methods: Prospective observational study of resuscitative care provided to 3 in situ simulated patients (infant seizure, infant sepsis, and child cardiac arrest) by interprofessional GED teams. A composite quality score (CQS) was measured and the association of this score with modifiable and nonmodifiable hospital-level factors was explored.

Association of Extubation Failure Rates With High-Flow Nasal Cannula, Continuous Positive Airway Pressure, and Bilevel Positive Airway Pressure vs Conventional Oxygen Therapy in Infants and Young Children: A Systematic Review and Network Meta-Analysis.

Importance: Extubation failure (EF) has been associated with worse outcomes in critically ill children. The relative efficacy of different modes of noninvasive respiratory support (NRS) to prevent EF is unknown.

Objective: To study the reported relative efficacy of different modes of NRS (high-flow nasal cannula [HFNC], continuous positive airway pressure [CPAP], and bilevel positive airway pressure [BiPAP]) compared to conventional oxygen therapy (COT).

Predicting Duration of Invasive Mechanical Ventilation in the Pediatric ICU.

Background: Timely ventilator liberation can prevent morbidities associated with invasive mechanical ventilation in the pediatric ICU (PICU). There currently exists no standard benchmark for duration of invasive mechanical ventilation in the PICU. This study sought to develop and validate a multi-center prediction model of invasive mechanical ventilation duration to determine a standardized duration of invasive mechanical ventilation ratio.

A Quality Improvement Initiative to Reduce Unnecessary Screening Chest Radiographs in a Pediatric ICU.

Background: The Critical Care Societies Collaborative included not ordering diagnostic tests at regular intervals as one of their Choosing Wisely initiatives. A reduction in unnecessary chest radiographs (CXRs) can help reduce exposure to radiation and eliminate health care waste. We aimed to reduce daily screening CXRs in a pediatric ICU (PICU) by 20% from baseline within 4 months of implementation of CXR criteria.

Improving Outcomes for Bronchiolitis Patients After Implementing a High-Flow Nasal Cannula Holiday and Standardizing Discharge Criteria in a PICU.

Objectives: To decrease length of high-flow nasal cannula (HFNC), PICU, and hospital length of stay (LOS).

Design: Quality improvement project.

Setting: A quaternary academic PICU.

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

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. 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.