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| EDITORIAL |
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| Year : 2023 | Volume
: 10
| Issue : 3 | Page : 83-84 |
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Updates on pediatric respiratory critical care: Part I
Farhan Shaikh
Department of Pediatric Critical Care, Rainbow Children's Hospital, Hyderabad, Telangana, India
| Date of Submission | 26-Apr-2023 |
| Date of Acceptance | 04-May-2023 |
| Date of Web Publication | 19-May-2023 |
Correspondence Address:
Dr. Farhan Shaikh
Department of Pediatric Critical Care, Rainbow Children's Hospital, Banjara Hills, Hyderabad, Telangana
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jpcc.jpcc_36_23
How to cite this article:
Shaikh F. Updates on pediatric respiratory critical care: Part I. J Pediatr Crit Care 2023;10:83-4 |
Journal of Pediatric Intensive Care shall issue two symposiums devoted to pediatric acute respiratory care. The primary objective of this effort is to promote the spread of knowledge and skills in acute respiratory care in children. The present supplement is the first part of the two supplements. It contains articles discussing essential topics relevant to practicing pediatric intensivists working in basic to advanced pediatric intensive care setups.
The first article is about the role of pediatric bronchoscopy in the pediatric intensive care unit by Chugh et al. The authors have described the practical aspects of the procedure, including clinical indications, possible adverse events, and appropriate preventive measures.
The article ends with some handy illustrations on the usefulness of flexible bronchscopy (FB) in pediatric critical care. This article can be a very useful guide to anyone who wishes to start the practice of flexible bronchoscopy in his/her pediatric intensive care unit.
The second article by Dr. Alicia Williams delineates the differences and similarities between bronchiolitis and asthma. Although, pathophysiologically, two different clinical conditions, bronchiolitis and asthma, present clinically with expiratory wheezing and tachypnea, leading to a diagnostic dilemma. It is essential to differentiate between the two conditions as the line of treatment is considerably different for each of them.[1]
High-flow nasal cannula (HFNC), a recent device, is increasingly used as the primary support for infants and children with respiratory distress mainly because it is well tolerated, especially in infants with bronchiolitis.[2],[3],[4],[5],[6] In children with status asthmaticus, external positive end-expiratory pressure (PEEP) may decrease the work of breathing[6] based on the “waterfalls” principle described by Tobin and Lodato.[7] HFNC, on the other hand, has been shown to reduce the metabolic demand by supplying warmed and humidified gas, mainly in infants with severe bronchiolitis, significantly reducing the work of breathing and respiratory rate.[8] Dr. Karthik and Dr. Manu Sundaram have tried to address this question of when and where to use noninvasive ventilation or HFNC in children with respiratory distress using a case-based approach. They have provided valuable illustrations and scientific references to simple decision-making.
The last article by Dr. Suresh et al. discussed the essential aspects of ventilator-induced lung injury (VILI) by reviewing the latest available literature. They have reviewed the evidence around various factors causing VILI and covered many recent concepts such as driving pressure, stress, strain, and mechanical power. It is, however, interesting to note that despite so much research work in this area, no clinical study has convincingly demonstrated that VILI is the direct causal link between ventilation strategy and risk of mortality. We still do not know how much mechanical ventilation is directly responsible for mortality risk.[9]
We also need to understand that PEEP and plateau pressure (Pplat) are measured using the “static inflation” method. Driving pressure, which is tidal volume normalized to respiratory compliance, is calculated as the difference between Pplat and PEEP.[10] These parameters, therefore, do not consider real-time factors like respiratory rate and the rate at which there is a change in airway pressure (which in turn depends on available inspiratory time and flow amplitude).[11],[12],[13] Thus, there is still much work left to be done in this area to fully understand the concept of VILI.
The authors of all four articles have made their concepts easy to understand and clinically relevant. We hope the readers will find them helpful in their day-to-day clinical practice.
| References | |  |
| 1. | Jartti T, Mäkelä MJ, Vanto T, Ruuskanen O. The link between bronchiolitis and asthma. Infect Dis Clin North Am 2005;19:667-89.  |
| 2. | Baudin F, Gagnon S, Crulli B, Proulx F, Jouvet P, Emeriaud G. Modalities and complications associated with the use of high-flow nasal cannula: Experience in a Pediatric ICU. Respir Care 2016;61:1305-10. |
| 3. | Ward JJ. High-flow oxygen administration by nasal cannula for adult and perinatal patients. Respir Care 2013;58:98-122. |
| 4. | McKiernan C, Chua LC, Visintainer PF, Allen H. High flow nasal cannulae therapy in infants with bronchiolitis. J Pediatr 2010;156:634-8. |
| 5. | Milési C, Essouri S, Pouyau R, Liet JM, Afanetti M, Portefaix A, et al. High flow nasal cannula (HFNC) versus nasal continuous positive airway pressure (nCPAP) for the initial respiratory management of acute viral bronchiolitis in young infants: A multicenter randomized controlled trial (TRAMONTANE study). Intensive Care Med 2017;43:209-16. |
| 6. | Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, et al. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation. Crit Care Med 2005;33:1519-28. |
| 7. | Tobin MJ, Lodato RF. PEEP, auto-PEEP, and waterfalls. Chest 1989;96:449-51. |
| 8. | Milési C, Baleine J, Matecki S, Durand S, Combes C, Novais AR, et al. Is treatment with a high flow nasal cannula effective in acute viral bronchiolitis? A physiologic study. Intensive Care Med 2013;39:1088-94. |
| 9. | Marini JJ, Rocco PR, Gattinoni L. Static and dynamic contributors to ventilator-induced lung injury in clinical practice. Pressure, energy, and power. Am J Respir Crit Care Med 2020;201:767-74. |
| 10. | Amato MB, Meade MO, Slutsky AS, Brochard L, Costa EL, Schoenfeld DA, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med 2015;372:747-55. |
| 11. | Maeda Y, Fujino Y, Uchiyama A, Matsuura N, Mashimo T, Nishimura M. Effects of peak inspiratory flow on development of ventilator-induced lung injury in rabbits. Anesthesiology 2004;101:722-8. |
| 12. | Garcia CS, Abreu SC, Soares RM, Prota LF, Figueira RC, Morales MM, et al. Pulmonary morphofunctional effects of mechanical ventilation with high inspiratory air flow. Crit Care Med 2008;36:232-9. |
| 13. | Spieth PM, Silva PL, Garcia CS, Ornellas DS, Samary CS, Moraes L, et al. Modulation of stress versus time product during mechanical ventilation influences inflammation as well as alveolar epithelial and endothelial response in rats. Anesthesiology 2015;122:106-16. |
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