This is a unique state of the art review written by a group of 21 international recognized experts in the field that gathered during a meeting organized by the European Neuromuscular Centre (ENMC) in Naarden, March 2017. It systematically reports the entire evidence base for airway clearance techniques (ACTs) in both adults and children with neuromuscular disorders (NMD). We not only report randomised controlled trials, which in other systematic reviews conclude that there is a lack of evidence base to give an opinion, but also include case series and retrospective reviews of practice. For this review, we have classified ACTs as either proximal (cough augmentation) or peripheral (secretion mobilization). The review presents descriptions; standard definitions; the supporting evidence for and limitations of proximal and peripheral ACTs that are used in patients with NMD; as well as providing recommendations for objective measurements of efficacy, specifically for proximal ACTs. This state of the art review also highlights how ACTs may be adapted or modified for specific contexts (e.g. in people with bulbar insufficiency; children and infants) and recommends when and how each technique should be applied.

Endotracheal suctioning is a procedure used regularly in the pediatric intensive care unit. Despite this, good evidence supporting its practice is limited. Further, controlled clinical studies are needed to develop evidence-based protocols for endotracheal suctioning of infants and children, and to examine the impact of different suctioning techniques on the duration of ventilatory support, incidence of nosocomial infection, and length of pediatric intensive care unit and hospital stay.

ObjectiveMore children are surviving critical illness but are at risk of residual or new health conditions. An evidence-informed and stakeholder-recommended core outcome set is lacking for pediatric critical care outcomes. Our objective was to create a multinational, multi-stakeholder-recommended Pediatric Critical Care Core Outcome Set for inclusion in clinical and research programs. Design A 2-round modified Delphi electronic survey was conducted with 333 invited research, clinical, and family/advocate stakeholders. Stakeholders completing the first round were invited to participate in the second. Outcomes scoring > 69% "critical" and < 15% "not important" advanced to round 2 with write-in outcomes considered. The Steering Committee held a virtual consensus conference to determine the final components. Setting Multinational survey. Patients Stakeholder participants from 6 continents representing clinicians, researchers, and family/advocates. Main Results Overall response rates were 75% and 82% for each round. Participants voted on 7 Global Domains and 45 Specific Outcomes in Round 1, and 6 Global Domains and 30 Specific Outcomes in Round 2. Using Overall (3 stakeholder groups combined) results, consensus was defined as outcomes scoring > 90% "critical" and < 15% "not important" and were included in the final PICU COS: 4 Global domains (Cognitive, Emotional, Physical and Overall Health) and 4 Specific outcomes (Child Health-Related Quality of Life, Pain, Survival, and Communication). Families (n=21) suggested additional critically important outcomes that did not meet consensus, which were included in the PICU COS -Extended. ConclusionsThe PICU Core Outcome Set and PICU COS-Extended are multi-stakeholderrecommended resources for clinical and research programs that seek to improve outcomes for children with critical illness and their families.