Flexible bronchoscopy (FB) is a very rewarding procedure in the evaluation and management of appropriately selected children with respiratory issues in pediatric intensive care unit (PICU). An understanding of the alterations in respiratory physiology (airway resistance, compliance, and air exchange) during FB is absolutely essential for the safety of the child. To reduce discomfort and other side effects of FB it is necessary to optimize the condition of the child including sedation, analgesia, paralysis, ventilator settings, and cardiovascular status. With advancements in technology and instrumentation many interventional procedures can be performed safely and effectively using access to the airway through the endotracheal tube, tracheostomy tube, or Laryngeal Mask Airway (LMA). Close monitoring during and after FB minimizes complications.

Bronchiolitis and status asthmaticus are common diagnoses encountered in the pediatric intensive care unit setting with overlapping clinical manifestations that can create perplexity in treatment following hospital admission. While there are clear first-line therapies for each of these medical conditions, the use of adjunct therapies has been inconsistent and more dependent on provider preference at times. In this review, a brief introduction to the epidemiology, clinical presentation, and diagnosis allows for a review of proposed therapies to highlight the distinctions between these two entities.

In pediatric patients with acute respiratory illnesses, the widespread availability of heated humidified high-flow nasal cannula (HHHFNC) devices, ease of use, and increased compliance have increased their use in conditions such as pneumonia, acute respiratory failure, asthma, and acute respiratory distress syndrome. Due to the patient comfort and ease of use of HHHFNC, there are widely used. Similarly, the use of NIV is increasing due to the availability of better interfaces and non-invasive ventilators (NIV) for use in infants The conundrum has been regarding the generation of positive end-expiratory pressure in these open circuits of the HHHFNC devices versus the pressures delivered by the closed circuits in the NIV devices. This article reviewed the latest literature based on the clinical conditions and the rationale for selecting respiratory support in common acute respiratory illnesses.

Mechanical ventilation is one of the common lifesaving interventions used in the care of critically ill children admitted to the pediatric intensive care unit. However, it may induce lung inflammation that can cause or aggravates lung injury. Ventilator-induced lung injury (VILI) is defined as acute lung injury inflicted or aggravated by mechanical ventilation. In the presence of preexisting lung disease (pneumonia and acute respiratory distress syndrome), the immune system hyper-reactivity may lead to cascading lung injury due to mechanical ventilation. The possible mechanisms postulated are too high tidal volume (volutrauma), excessive pressure (barotrauma), repetitive opening and closure of alveoli (atelectotrauma), inflammation (biotrauma), oxygen toxicity, adverse heart–lung interactions, deflation-related injuries, effort-related injuries, and genetic variation in expression of inflammatory mediators. Prevention is the most important strategy for VILI by using lung-protective mechanical ventilation strategies to prevent volutrauma, barotrauma, and atelectotrauma. Low tidal volume ventilation, optimal positive end-expiratory pressure and FiO₂, limiting plateau pressure, neuromuscular blockers, and prone positioning are some of the important strategies to prevent and treat VILI. VILI has the potential to cause significant morbidity, mortality, and long-term pulmonary sequelae. The clinical relevance of VILI is poorly understood in critically ill children due to lack of pediatric literature, and most of the information are derived from the adult literature. In this review, we will elucidate the epidemiology, etiopathogenesis, clinical evaluation, management, and measures to attenuate or prevent VILI.

Rickettsia is a common zoonotic disease causing fever, malaise, rash, and eruption changing to eschar with lymphadenopathy. Very few cases of Rickettsia disease with Kawasaki syndrome (KS) have been reported. We report a case of a 4-year-old girl with rickettsial disease presented with acute renal failure, shock, and features of KS. She was treated successfully with doxycycline, ceftriaxone, and intravenous immunoglobulins along with supportive management.

Massive gastrointestinal (GI) bleed frequently presents as a pediatric emergency, which needs to be aggressively managed and thoroughly investigated. We report the case of a 9-month-old infant who presented with a massive GI bleed due to foreign body ingestion. The chest X-ray showed a hairpin lodgment in the stomach. The patient had recurrent GI bleeds leading to shock. Once stabilized, a hairpin was retrieved from his gastric rugae folds by upper GI endoscopy. Our case highlights the need of looking beyond the routine causes in cases of intractable GI bleed, especially in the pediatric age group.

Acute necrotizing encephalopathy of childhood (ANEC) is a clinico-radiological diagnosis characterized by acute onset, and progressive febrile encephalopathy preceded by viral-associated febrile illness and carries a very poor prognosis. We present a case of 9-year-old child with dengue virus-induced necrotizing encephalopathy who was managed with pulse methylprednisolone therapy followed by oral prednisolone. The rarity of ANEC in association with dengue and good neurological recovery with supportive treatment made us to report this case.