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Pediatric (PARDS) and neonatal (NARDS) acute respiratory distress syndrome have different age-specific characteristics and definitions. Trials on surfactant for ARDS in children and neonates have been performed well before the PARDS and NARDS definitions and yielded conflicting results. This is mainly due to heterogeneity in study design reflecting historic lack of pathobiology knowledge. We reviewed the available clinical and preclinical data to create an expert consensus aiming to inform future research steps and advance the knowledge in this area. Eight trials investigated the use of surfactant for ARDS in children and ten in neonates, respectively. There were improvements in oxygenation (7/8 trials in children, 7/10 in neonates) and mortality (3/8 trials in children, 1/10 in neonates) improved. Trials were heterogeneous for patients’ characteristics, surfactant type and administration strategy. Key pathobiological concepts were missed in study design. Consensus with strong agreement was reached on four statements: There are sufficient preclinical and clinical data to support targeted research on surfactant therapies for PARDS and NARDS. Studies should be performed according to the currently available definitions and considering recent pathobiology knowledge. PARDS and NARDS should be considered as syndromes and should be pre-clinically studied according to key characteristics, such as direct or indirect (primary or secondary) nature, clinical severity, infectious or non-infectious origin or patients’ age. Explanatory should be preferred over pragmatic design for future trials on PARDS and NARDS. Different clinical outcomes need to be chosen for PARDS and NARDS, according to the trial phase and design, trigger type, severity class and/or surfactant treatment policy . We advocate for further well-designed preclinical and clinical studies to investigate the use of surfactant for PARDS and NARDS following these principles.

Endotracheal suctioning is a widely used procedure to remove secretions from the airways of ventilated patients. Despite its prevalence, regional effects of this maneuver have seldom been studied. In this study, we explore its effects on regional lung aeration in neonates and young infants using electrical impedance tomography (EIT) as part of the large EU-funded multicenter observational study CRADL. 200 neonates and young infants in intensive care units were monitored with EIT for up to 72 h. EIT parameters were calculated to detect changes in ventilation distribution, ventilation inhomogeneity and ventilation quantity on a breath-by-breath level 5–10 min before and after suctioning. The intratidal change in aeration over time was investigated by means of regional expiratory time constants calculated from all respiratory cycles using an innovative procedure and visualized by 2D maps of the thoracic cross-section. 344 tracheal suctioning events from 51 patients could be analyzed. They showed no or very small changes of EIT parameters, with a dorsal shift of the center of ventilation by 0.5% of the chest diameter and a 7% decrease of tidal impedance variation after suctioning. Regional time constants did not change significantly. Routine suctioning led to EIT-detectable but merely small changes of the ventilation distribution in this study population. While still a measure requiring further study, the time constant maps may help clinicians interpret ventilation mechanics in specific cases.

Although surfactant replacement therapy is an established treatment in infant respiratory distress syndrome, the optimum strategy for ventilatory management before, during, and after surfactant instillation remains to be elucidated. To determine the effects of surfactant and lung volume recruitment on the distribution of regional lung ventilation. Acute lung injury was induced in 16 newborn piglets by endotracheal lavage. Optimum positive end-expiratory pressure was identified after lung recruitment and surfactant was administered either at this pressure in the \"open\" lung or after disconnection of the endotracheal tube in the \"closed\" lung. An additional recruitment maneuver with subsequent optimum end-expiratory pressure finding was executed in eight animals; in the remaining eight animals, end-expiratory pressure was set at the same level as before surfactant without further recruitment. (\"Open\" and \"closed\" lung surfactant administration was evenly distributed in the groups.) Regional ventilation was assessed by electrical impedance tomography. Impedance tomography data, airway pressure, flow, and arterial blood gases were acquired during baseline conditions, after induction of lung injury, after the first lung recruitment, and before as well as 10 and 60 min after surfactant administration. Significant shift in ventilation toward the dependent lung regions and less asymmetry in the right-to-left lung ventilation distribution occurred in the postsurfactant period when an additional recruitment maneuver was performed. Surfactant instillation in an \"open\" versus \"closed\" lung did not influence ventilation distribution in a major way. The spatial distribution of ventilation in the lavaged lung is modified by a recruitment maneuver performed after surfactant administration.

Purpose: Music therapy intervention (MT) could be used as an adjunctive therapy in PICU for anxiety and pain management. The aim of the study was to examine the perception of MT by children’s parents in a PICU of a tertiary care teaching hospital. Methods: This is a retrospective cohort study summarizing the results of an institutional quality improvement initiative. Questionnaires were distributed to parents whose children were exposed to MT. Results: From April 2019 to July 2021, 263 patients received a total of 603 h of MT. Twenty-five questionnaires were distributed to parents over a 4-month period (February–June 2021). A total of 19 (76%) parents completed the questionnaire. The majority of parents thought that MT helped their child to communicate (89%), feel less isolated (100%) and cope with stress during hospitalization (100%). The majority of parents also thought that MT contributed to physical recovery (90%) and alleviated feelings of anxiety (90%). Parents also believed that MT should be offered as an out-patient service. Conclusions: Our study agrees with other studies on the positive potentials of MT in PICU. Music therapy intervention could be used to promote children’s and parents’ psychological well-being. Further studies are warranted to evaluate the impact of MT on long-term post-ICU outcomes.

Pneumothorax is a potentially life‐threatening complication of neonatal respiratory distress syndrome (RDS). We describe a case of a tension pneumothorax that occurred during neurally adjusted ventilatory assist (NAVA) in a preterm infant suffering from RDS. The infant was included in a multicenter study examining the role of electrical impedance tomography (EIT) in intensive care and therefore continuously monitored with this imaging method. The attending physicians were blinded for EIT findings but offline analysis revealed the potential of EIT to clarify the underlying cause of this complication, which in this case was heterogeneous lung disease resulting in uneven ventilation distribution. Instantaneous increase in end‐expiratory lung impedance on the affected side was observed at time of the air leak. Real‐time bedside availability of EIT data could have modified the treatment decisions made. Real‐time bedside availability of EIT for continuous monitoring of aeration and ventilation distribution in neonatal RDS might help to recognize patients at risk of complications, allow timely treatment decisions and early detection of undesired events.

Purpose Much of the common practice in paediatric mechanical ventilation is based on personal experiences and what paediatric critical care practitioners have adopted from adult and neonatal experience. This presents a barrier to planning and interpretation of clinical trials on the use of specific and targeted interventions. We aim to establish a European consensus guideline on mechanical ventilation of critically children. Methods The European Society for Paediatric and Neonatal Intensive Care initiated a consensus conference of international European experts in paediatric mechanical ventilation to provide recommendations using the Research and Development/University of California, Los Angeles, appropriateness method. An electronic literature search in PubMed and EMBASE was performed using a combination of medical subject heading terms and text words related to mechanical ventilation and disease-specific terms. Results The Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) consisted of a panel of 15 experts who developed and voted on 152 recommendations related to the following topics: (1) general recommendations, (2) monitoring, (3) targets of oxygenation and ventilation, (4) supportive measures, (5) weaning and extubation readiness, (6) normal lungs, (7) obstructive diseases, (8) restrictive diseases, (9) mixed diseases, (10) chronically ventilated patients, (11) cardiac patients and (12) lung hypoplasia syndromes. There were 142 (93.4%) recommendations with “strong agreement”. The final iteration of the recommendations had none with equipoise or disagreement. Conclusions These recommendations should help to harmonise the approach to paediatric mechanical ventilation and can be proposed as a standard-of-care applicable in daily clinical practice and clinical research.

Background The provision of guidance in ventilator therapy by continuous monitoring of regional lung ventilation, aeration and respiratory system mechanics is the main clinical benefit of electrical impedance tomography (EIT). A new application was recently described in critically ill patients undergoing diagnostic bronchoalveolar lavage (BAL) with the intention of using EIT to identify the region where sampling was performed. Increased electrical bioimpedance was reported after fluid instillation. To verify the accuracy of these findings, contradicting the current EIT knowledge, we have systematically analysed chest EIT data acquired under controlled experimental conditions in animals undergoing a large number of BAL procedures. Methods One hundred thirteen BAL procedures were performed in 13 newborn piglets positioned both supine and prone. EIT data was obtained at 13 images before, during and after each BAL. The data was analysed at three time points: (1) after disconnection from the ventilator before the fluid instillation and by the ends of fluid (2) instillation and (3) recovery by suction and compared with the baseline measurements before the procedure. Functional EIT images were generated, and changes in pixel electrical bioimpedance were calculated relative to baseline. The data was examined in the whole image and in three (ventral, middle, dorsal) regions-of-interest per lung. Results Compared with the baseline phase, chest electrical bioimpedance fell after the disconnection from the ventilator in all animals in both postures during all procedures. The fluid instillation further decreased electrical bioimpedance. During fluid recovery, electrical bioimpedance increased, but not to baseline values. All effects were highly significant ( p  < 0.001). The fractional changes in individual regions-of-interest were posture-dependent. The regional fall in electrical bioimpedance was smaller in the ventral and larger in the dorsal regions after the fluid instillation than after the initial disconnection to ambient pressure in supine animals ( p  < 0.001) whereas these changes were of comparable amplitude in prone position. Conclusions The results of this study show a regionally dissimilar initial fall in electrical bioimpedance caused by non-uniform aeration loss at the beginning of the BAL procedure. They also confirm a further pronounced fall in bioimpedance during fluid instillation, incomplete recovery after suction and a posture-dependent distribution pattern of these effects.

High-frequency oscillatory ventilation (HFOV) is an established mode of respiratory support in the neonatal intensive care unit. Large clinical trial data is based on first intention use in preterm infants with acute respiratory distress syndrome. Clinical practice has evolved from this narrow population. HFOV is most often reserved for term and preterm infants with severe, and often complex, respiratory failure not responding to conventional modalities of respiratory support. Thus, optimal, and safe, application of HFOV requires the clinician to adapt mean airway pressure, frequency, inspiratory:expiratory ratio and tidal volume to individual patient needs based on pathophysiology, lung volume state and infant size. This narrative review summarises the status of HFOV in neonatal intensive care units today, the lessons that can be learnt from the past, how to apply HFOV in different neonatal populations and conditions and highlights potential new advances. Specifically, we provide guidance on how to apply an open lung approach to mean airway pressure, selecting the correct frequency and use of volume-targeted HFOV.

Severe bronchiolitis patients are often supported with non-invasive ventilation (NIV). In case of NIV failure, we recently started to use non-invasive neurally adjusted ventilatory assist ventilation (NIV-NAVA) with a total face mask interface (TFM) and report now our experience with this modality of respiratory support. Retrospective study was made from October 2022 to May 2023 at the Geneva University Hospital Paediatric Intensive Care Unit. Inclusion criteria were children, aged from 0 to 6 months, with severe bronchiolitis with initial NIV failure and switch to NIV-NAVA-TFM. From 49 children with respiratory syncytial virus (RSV)-induced bronchiolitis requiring any form of respiratory support, 10 (median age 61 days (IQR 44–73) failing CPAP or NIV underwent rescue treatment with NIV-NAVA using a TFM. Patients were switched to TFM-NIV-NAVA 8 h (IQR 3–22) after admission for 24.5 h (IQR 13–60). After initiation of TFM-NIV-NAVA, oxygenation improved significantly as early as 1 h after initiation, whereas transcutaneous CO 2 values remained stable. None of the patients needed to be intubated and there was no episode of TFM discontinuation due to interface discomfort or other unwanted side effects. Sedation was used in all patients with high proportion of intravenous dexmedetomidine. Median ventilatory assistance duration was 2.5 days (IQR 2–4) and median PICU stay was 4.5 (IQR 3–6).   Conclusion : In infants with severe RSV-induced bronchiolitis, respiratory support with TFM-NIV-NAVA seems to be feasible as a rescue therapy and might be considered in selected patients. What is Known: • Bronchiolitic patients with NIV support failure may require invasive mechanical ventilation. • Interface related complications, especially facial sores, can be a cause of NIV failure. What is New: • Total face mask with non-invasive neurally adjusted ventilatory assist (TFM-NIV-NAVA) seems feasible as a rescue therapy in deteriorating patients with CPAP or NIV failure. • TFM-NIV-NAVA can improve oxygenation rapidly in patients with aggravating hypoxemia and seems to be well tolerated.

Invasive mechanical ventilation (MV) is one of the most practiced interventions in the intensive care unit (ICU) and is unmistakably lifesaving for children with acute respiratory failure (ARF). However, if delivered inappropriately (i.e. ignoring the respiratory system mechanics and not targeted to the need of the individual patient at a specific time point in the disease trajectory), the side effects will outweigh the benefits. Decades of experimental and clinical investigations have resulted in a better understanding of three important detrimental effects of MV. These are ventilation-induced lung injury (VILI), patient self-inflicted lung injury (P-SILI), and ventilation-induced diaphragmatic injury (VIDD). VILI, P-SILI, and VIDD have in common that they occur when there is either too much or too little ventilatory assistance. Conclusion : The purpose of this review is to give the paediatrician an overview of the challenges to prevent these detrimental effects and titrate MV to the individual patient needs.