We describe a 9-year-old boy with acute liver failure of unknown etiology, unresponsive to standard medical therapy, with increasing hyperammonemia blood level, lactate elevation, a pediatric end liver stage of 20, a hepatic encephalopathy (HE) score of 2, and scheduled for emergent liver transplantation on the waiting list. We admitted him in the pediatric intensive care unit and managed him in the early stages with continuous renal replacement therapy and therapeutic plasma exchange as soon as neurologic impairment started to worsen. He recovered from his HE after 3 days of blood purification and was removed from the transplantation waiting list due to progressive liver function improvement.This case report comply with the guidelines for human studies and the research was conducted ethically in accordance with the World Medical Association Declaration of Helsinki. In the manuscript, parents or guardians have given their written informed consent to publish their case (including publication of images). The study protocol was approved by the institute's committee on human research.

Objectives: To evaluate the effects of two different levels of positive end-expiratory pressure (PEEP) during helmet continuous positive airway pressure (HCPAP) support on the intubation rate in infants with bronchiolitis admitted to pediatric intensive care units (PICUs). Design: Multicentric prospective, randomized, open clinical trial. Setting: Four tertiary PICUs in Italy. Participants: Infants admitted to PICUs due to severe bronchiolitis and requiring respiratory support. Interventions: The enrolled patients were randomly assigned one of two PEEP levels for HCPAP support: high (P10 group: 10 cmH O) or low (P5 group: 5 cmH O). Measurements and Main Results: In total, 64 patients were randomly assigned to the P10 group, and 60 to the P5 group. The intubation rate was 9/60 (15%) and 9/64 (14%) in P5 and P10 groups (OR 0.94, 95% CI 0.36-2.46, p=0.99). Of the patients in the P5 group, 47 (78%) were escalated to a PEEP level of 10 cmH O. PEEP level was not associated to intubation rate (OR 0.69, 95% CI 0.19 to 2.40, p=0.57), after adjustment for age, gestational age, high flow nasal cannula application, bronchiolitis severity score and pediatric index of mortality 3. No cases of pneumothorax were observed in this study. Conclusions: In this trial on infants with severe bronchiolitis, a PEEP level of 10 cm H O during HCPAP in comparison to an initial level of 5 cm H O did not show to prevent intubation. These results are not conclusive due to the premature stopping.