The mechanics of breathing in children with acute severe croup

Argent, Andrew C.; Newth, Christopher J. L.; Klein, Max

doi:10.1007/s00134-007-0910-x

Cited by 40 publications

(34 citation statements)

References 35 publications

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“…Inspiratory flow limitation is characterized by disproportionately high inspiratory effort (negative esophageal pressure) relative to the increase in flow (16,22,23). The pressure $ rate product (PRP) is a measure of breathing effort and is the product of the respiratory rate and the change in esophageal pressure during the respiratory cycle.…”

Section: Original Article Uao Determination and Classificationmentioning

confidence: 99%

Evaluating Risk Factors for Pediatric Post-extubation Upper Airway Obstruction Using a Physiology-based Tool

Khemani

Hotz

Morzov

et al. 2016

Am J Respir Crit Care Med

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127

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Rationale: Subglottic edema is the most common cause of pediatric extubation failure, but few studies have confirmed risk factors or prevention strategies. This may be due to subjective assessment of stridor or inability to differentiate supraglottic from subglottic disease.Objectives: Objective 1 was to assess the utility of calibrated respiratory inductance plethysmography (RIP) and esophageal manometry to identify clinically significant post-extubation upper airway obstruction (UAO) and differentiate subglottic from supraglottic UAO. Objective 2 was to identify risk factors for subglottic UAO, stratified by cuffed versus uncuffed endotracheal tubes (ETTs).Methods: We conducted a single-center prospective study of children receiving mechanical ventilation. UAO was defined by inspiratory flow limitation (measured by RIP and esophageal manometry) and classified as subglottic or supraglottic based on airway maneuver response. Clinicians performed simultaneous blinded clinical UAO assessment at the bedside. Measurements and Main Results:A total of 409 children were included, 98 of whom had post-extubation UAO and 49 (12%) of whom were subglottic. The reintubation rate was 34 (8.3%) of 409, with 14 (41%) of these 34 attributable to subglottic UAO. Five minutes after extubation, RIP and esophageal manometry better identified patients who subsequently received UAO treatment than clinical UAO assessment (P , 0.006). Risk factors independently associated with subglottic UAO included low cuff leak volume or high preextubation leak pressure, poor sedation, and preexisting UAO (P , 0.04) for cuffed ETTs; and age (range, 1 mo to 5 yr) for uncuffed ETTs (P , 0.04). For uncuffed ETTs, the presence or absence of preextubation leak was not associated with subglottic UAO.Conclusions: RIP and esophageal manometry can objectively identify subglottic UAO after extubation. Using this technique, preextubation leak pressures or cuff leak volumes predict subglottic UAO in children, but only if the ETT is cuffed.

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Section: Original Article Uao Determination and Classificationmentioning

confidence: 99%

Evaluating Risk Factors for Pediatric Post-extubation Upper Airway Obstruction Using a Physiology-based Tool

Khemani

Hotz

Morzov

et al. 2016

Am J Respir Crit Care Med

Self Cite

127

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“…An editorial that accompanied the meta-analysis28 suggests that during weaning, the f/V T index can be thought of as a screening test with high sensitivity and low specificity, and therefore should be used early in the course of MV to identify patients who can breathe on their own. Specificity is obtained by applying a confirmatory test such as esophageal pressure trend measurements29 which are easy to apply in a PICU setting30.…”

Section: Concepts Of Weaning Spontaneous Breathing and Extubation Rementioning

confidence: 99%

“…This is sometimes ignored in clinically relevant papers81. Peak and mid-inspiratory flows in humans are approximately 0.5 L/kg/min30. When related to a 60 kg adult, this gives flows of about 30 L/min with a resistance of 10 cmH 2 O/L/sec in even a 6.5 mmID ETT (Figure 4).…”

Section: Misperceptions About the Impact Of Endotracheal Tubes On Weamentioning

confidence: 99%

Weaning and extubation readiness in pediatric patients*

Newth

Venkataraman

Willson

et al. 2009

Pediatric Critical Care Medicine

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283

204

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Objective-A systematic review of weaning and extubation for pediatric patients on mechanical ventilation. Data Selection-Pediatric and Adult Literature, English languageStudy Selection-Invited review Data Sources-Literature review using National Library of Medicine PubMed from January 1972 until April 2008, earlier cross-referenced article citations, the Cochrane Database of Systematic Reviews and the Internet.Conclusions-Despite the importance of minimizing time on mechanical ventilation, only limited guidance on weaning and extubation is available from the pediatric literature. A significant proportion of patients being evaluated for weaning are actually ready for extubation, suggesting that weaning is often not considered early enough in the course of ventilation. Indications for extubation are even less clear, although a trial of spontaneous breathing would seem a prerequisite. Several indices have been developed in an attempt to predict weaning and extubation success but the available literature would suggest they offer no improvement over clinical judgment. Extubation failure rates range from 2-20% and bear little relationship to the duration of mechanical ventilation. Upper airway obstruction is the single most common cause of extubation failure. A reliable method of assessing readiness for weaning and predicting extubation success is not evident from the pediatric literature.

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“…PRP is a surrogate for effort of breathing [22][23][24][25], and unlike work of breathing (calculated from the pressure-volume curve)…”

Section: Study Protocolmentioning

confidence: 99%

Pediatric extubation readiness tests should not use pressure support

et al. 2016

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Key Points: By performing direct measures of patient effort of breathing before and after extubation on over 400 mechanically ventilated children, we have found that patient effort of breathing on CPAP of 5cmH20 alone provides a good estimate of post-extubation effort. Regardless of the endotracheal tube size, pressure support should not be added to CPAP for extubation readiness testing because it results in significant under-estimation of postextubation effort of breathing.Social Network: Regardless of endotracheal tube size, PS during ERTs significantly underestimates post-extubation effort of breathing. ManuscriptClick here to download Manuscript BreathingThroughStraw_ICM_NoFigs.doc Click here to view linked References 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64

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The mechanics of breathing in children with acute severe croup

Cited by 40 publications

References 35 publications

Evaluating Risk Factors for Pediatric Post-extubation Upper Airway Obstruction Using a Physiology-based Tool

Evaluating Risk Factors for Pediatric Post-extubation Upper Airway Obstruction Using a Physiology-based Tool

Weaning and extubation readiness in pediatric patients*

Pediatric extubation readiness tests should not use pressure support

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