Background and aims:The COMFORT B score is a validated method for the assessment of the level of sedation in children, but it has its limitations. The bispectral index (BIS) is an electroencephalogram (EEG)-based tool used to assess the level of consciousness. The primary objective was to evaluate agreement between the BIS and the COMFORT B score for sedation in children on mechanical ventilation (MV). Patients and methods:This prospective, noninterventional study was conducted on 138 patients, aged >6 months, receiving MV in the pediatric intensive care unit (PICU). COMFORT B score and BIS were taken 30 minutes after initiation or dosage change of sedatives and then once every 8 hours for a maximum of 96 hours. Results:A total of 1,534 datasets were analyzed. Bispectral index values ranged from 11 to 89, while COMFORT B scores were between 6 and 28. The mean [± standard deviation (SD)] value for the BIS and COMFORT B scores was 54.4 ± 13.8 and 14 ± 4, respectively. Adequate sedation was recorded in 82.5 and 79.9% instances with BIS and COMFORT B scores, respectively. The correlation coefficient (r) of BIS and COMFORT B scores was 0.7. Overall agreement (kappa value) between the BIS and COMFORT B score was 0.642. A BIS score of 43 had 93% sensitivity and 70% specificity in differentiating oversedation from adequate sedation (AUROC 0.81). Similarly, a BIS value of 79 distinguished between adequate and undersedation (sensitivity 90%; specificity 98%; AUROC 0.966). The best AUROC (0.777) was observed in children with central nervous system (CNS) diseases, while the worst (0.54) occurred in patients with neuromuscular diseases. Conclusion:The BIS and COMFORT B scores have a good level of agreement in children, except in children with neuromuscular diseases. How to cite this article:Jhunjhunwala M, Sachdev A, Gupta S, Gupta D, Gupta N. Bispectral Index and COMFORT B Score for Sedation in Mechanically Ventilated Children: A Prospective Observational Study. Indian J Crit Care Med 2026;30(4):305-310.

Despite the high prevalence of tuberculosis (TB) in developing countries, tubercular reactivation or new infections are rarely observed in patients with acute leukemia or after hematopoietic stem cell transplant (HSCT). We describe 9 pediatric oncology or post-HSCT patients with TB. The median age was 9 years (range: 1 to 15 y). All leukemia patients (n=8) developed TB during or immediately after induction chemotherapy. The most common symptoms were fever and cough. Co-infection with other microorganisms was observed in 6 cases. Management included first-line antitubercular therapy (ATT) for 4 cases and second-line ATT for 5 patients, with a switch back to first-line ATT as soon as possible. ATT-induced hepatitis was observed in 3 cases. Tuberculosis led to chemotherapy treatment interruption in all cases, with a median duration of 16 days (range: 7 to 28 d). All children responded well to ATT, with defervescence, resolution of effusion, resolution of cough, and radiologic improvement. The study highlights the clinical mimics, diagnostic difficulties, and treatment-related challenges with modifications needed for both TB and cancer when they occur together.

BACKGROUND:The role of noninvasive ventilation (NIV) and heated humidified high-flow nasal cannula (HFNC) in children with high risk for extubation failure is not established. The objective of our study was to compare the re-intubation rate within 48 h of extubation in high-risk children while receiving HFNC or NIV. METHODS:This open-label, parallel, noninferiority randomized trial was conducted on high-risk cases in a 12-bed quaternary-level pediatric ICU. All patients aged 1 month to 18 years receiving invasive mechanical ventilation through an endotracheal tube for >48 h were screened for eligibility. Criteria for high-risk patients for extubation, spontaneous breathing trial, extubation readiness, and re-intubation were defined a priori. Subjects were randomized immediately prior to extubation to receive NIV or HFNC. FIO2, NIV settings, and flow setting for HFNC were selected according to a predefined algorithm. All subjects were monitored for hemodynamic instability and increased work of breathing, and the target SpO2 was 92%. RESULTS:Intention-to-treat analysis was done with 142 subjects in each group. At baseline, both groups were comparable for severity of disease and organ dysfunction. Re-intubation was required in 15 (10.5%) cases in the NIV and 17 (11.9%) of the HFNC group, with no absolute difference (P = .74). The dosage of dexmedetomidine was significantly lower in the HFNC as compared with the NIV group [(0.85 ± 0.22 versus 1.02 ± 0.13 µg/kg/h; 95% CI 0.12-0.21, P < .001)]. Median (interquartile range) postextubation PICU stay was significantly shorter in HFNC subjects [3 (2-4.75) vs 4 (3-5)] days (P = .02). CONCLUSIONS:HFNC was noninferior to NIV as respiratory support in high-risk children after extubation.

OBJECTIVE:To report central sleep apnea (CSA) as an underrecognized cause of respiratory morbidity in pediatric posterior fossa tumors and highlight the benefit of CPAP. METHODS:A 3-year-old child with metastatic medulloblastoma involving the fourth ventricle underwent resection, radiotherapy, and chemotherapy. The course was complicated by recurrent respiratory failure, multiple PICU admissions, and unexplained desaturations initially attributed to seizures. Persistent daytime somnolence and episodic apnea prompted polysomnography. RESULTS:Polysomnography showed severe CSA (respiratory event index 68.3/hour; nadir SpO₂ 75%), unifying the prior hypoxic episodes. CPAP (5 cm H₂O) produced rapid improvement, with restored sleep architecture, fewer respiratory events (index 6.3/hour), stable saturation (~97%), and no further prolonged intensive care admissions. The patient completed oncologic therapy and remained stable on domiciliary CPAP. CONCLUSION:CSA should be considered in children with posterior fossa or brainstem-adjacent lesions presenting with unexplained respiratory events; recognition has important implications for multidisciplinary management and long-term outcomes.

Acute respiratory distress syndrome (ARDS) due to viral or bacterial lower respiratory tract infections is a common indication for mechanical ventilatory support in children.Common viruses involved include Influenza A or B, Parainfluenza, Adenovirus, Coronavirus, and Measles.While the standard respiratory support for pediatric ARDS (pARDS) includes conventional ventilatory support along with non-ventilatory measures, a minority of patients develop refractory hypoxemia and warrant higher forms of ventilation like high-frequency oscillatory ventilation (HFOV) and occasionally extracorporeal membranous oxygenation (ECMO).Extracorporeal life support organization (ELSO) guidelines have recommended the use of ECMO in reversible refractory hypoxemia.Here, we describe a toddler with severe ARDS and air leak, who was managed with venovenous ECMO (VV ECMO) and bronchoscopy toilets.

OBJECTIVES:In this study, we have reviewed the association between esophageal pressure-guided positive end-expiratory pressure (PEEP) setting and oxygenation and lung mechanics with a conventional mechanical ventilation (MV) strategy in patient with moderate to severe pediatric acute respiratory distress syndrome (PARDS). DESIGN:Retrospective cohort, 2018-2021. SETTING:Tertiary PICU. PATIENTS:Moderate to severe PARDS patients who required MV with PEEP of greater than or equal to 8 cm H 2 O. INTERVENTIONS:Esophageal pressure (i.e., transpulmonary pressure [P TP ]) guided MV vs. not. MEASUREMENTS AND MAIN RESULTS:We identified 26 PARDS cases who were divided into those who had been managed with P TP -guided MV (P TP group) and those managed with conventional ventilation strategy (non-P TP ). Oxygenation and lung mechanics were compared between groups at baseline (0 hr) and 24, 48, and 72 hours of MV. There were 13 patients in each group in the first 24 hours. At 48 and 72 hours, there were 11 in P TP group and 12 in non-P TP group. On comparing these groups, first, use of P TP monitoring was associated with higher median (interquartile range) mean airway pressure at 24 hours (18 hr [18-20 hr] vs. 15 hr [13-18 hr]; p = 0.01) and 48 hours (19 hr [17-19 hr] vs. 15 hr [13-17 hr]; p = 0.01). Second, use of P TP was associated with higher PEEP at 24, 48, and 72 hours (all p < 0.05). Third, use of P TP was associated with lower F io2 and greater Pa o2 to F io2 ratio at 72 hours. Last, there were 18 of 26 survivors, and we failed to identify an association between use of P TP monitoring and survival. CONCLUSIONS:In this cohort of moderate to severe PARDS cases undergoing MV with PEEP greater than or equal to 8 cm H 2 O, we have identified some favorable associations of oxygenation status when P TP -guided MV was used vs. not. Larger studies are required.

Introduction:Children on extracorporeal membrane oxygenation (ECMO) support need adequate sedation and analgesia for optimal care.Often, they need neuromuscular blocking agents (NMBAs).These drugs are associated with adverse consequences.The current survey was done to identify the sedation practices in children on ECMO support.Materials and methods: An online survey was conducted via Google form in December 2023.The Google form was circulated among the members of the ECMO Society of India and personal contacts.ECMO specialists and pediatric intensivists performing pediatric ECMO were requested to respond.The survey had 29 questions in five domains: demographics, drug details, protocols, sedation withdrawal, and outcomes.Results: There were 19 responses in the survey from across eight states, and were predominantly from non-government organizations.All except one used a combination of sedatives and analgesics for optimal sedation; midazolam and fentanyl were the most common combination (44%).About 37% of the respondents used dexmedetomidine as the first-line sedative agent.Two thirds of the respondents reported that children on ECMO have greater difficulty in achieving adequate sedation and 42% used sedative and analgesic doses higher than the usual doses.About 37% of all children received NMBAs.Two-thirds of the respondents never practice awake ECMO.Ramsay sedation scale (RSS) (36.8%) and richmond agitation sedation scale (RASS) (31.6%) were commonly used for sedation assessment and withdrawal assessment tool (WAT-1) (63.2%) was the most commonly used withdrawal scale.Nearly 80% of the respondents reported that sedation-related adverse events (SRAEs) affect the overall outcomes including the duration of ventilation or duration of pediatric intensive care unit (PICU) stay or duration of hospital stay in children on ECMO. Conclusion:In this survey, we observed that a combination of benzodiazepines and opioids was the preferred agent with increasing use of dexmedetomidine as a first-line agent in children on ECMO.A greater proportion of children on ECMO have difficulty in achieving optimal sedation and need for higher doses or NMBAs.Future studies should focus on reporting sedation practices, effects on outcomes, and methods to improve outcomes related to sedation in children on ECMO.Clinical significance: Sedation in children on ECMO poses a challenge and optimal sedation strategies to be employed for best results minimizing adverse consequences.

Background: There is paucity of reliable epidemiological data regarding the burden of food allergy in most developing countries, including India. Objective: To provide current estimates of the prevalence and distribution of food allergy among urban and rural school children aged 6-14 years in Delhi and the National Capital Region (NCR) of Khekra in India. Methods: A cross-sectional study was conducted from January 2022 to February 2023 to enroll school children, 6-14 years, from select urban and rural schools in Delhi and NCR. A questionnaire consisting of questions focused on household environment, early life factors, and pediatric food allergy characteristics was administered by a trained medical researcher to collect parent -proxy data. Univariate statistics were used to describe frequencies, percentages, and 95% confidence intervals for survey items. Results: The estimated prevalence of parent -reported food allergy was 0.8% (95% CI: 0.4-1.5; urban: 0.4%, 95% CI: 0.1-1.1; rural: 1.7%, 95% CI: 0.7-3.5). Fruits such as mango (0.3%, 95% CI: 0.1-0.9), strawberry (0.1%, 95% CI: 0.0-0.7), orange (0.1%, 95% CI: 0.0-0.7), and custard apple (0.1%, 95% CI: 0.0-0.7) were reported only by urban children, while rural children reported yogurt (0.6%, 95% CI: 0.1-1.8) and wheat (0.3%, 95% CI: 0.0-1.3). Both groups reported brinjal (also known as eggplant) and banana, 0.1% (95% CI: 0.0-0.7) of urban and 0.3% (95% CI: 0.0-1.3) of rural, respectively. Overall, commonly reported clinical symptoms were diarrhea and/or vomiting (100%, 95% CI: 76.2-100), abdominal pain (88.9%, 95% CI: 58.6-98.8), and rash/itchy skin (66.7%, 95% CI: 34.8-89.6). Among children with parent reported food allergy, 66.7% (95% CI: 34.8-89.6) of food allergies were physician diagnosed, of which 33.3% were diagnosed via history alone (95% CI:7.7-71.4) while 66.7% (95% CI: 28.6-92.3) were confirmed via skin prick test and/or blood test. Conclusion: The overall prevalence of food allergy is very low in Delhi and Khekra, India. Future work should focus on elucidating the complex interplay of early -life, environmental, genetic, and lifestyle factors to understand the reasons for India's low food allergy burden and improve epidemiological clues to prevention for the nations with higher disease burden.

Hypersensitivity pneumonitis (HP) in children is a common cause of interstitial lung disease. HP has been seen in the patient due to the inhalation of different bacteria, fungi, and other particles, such as feathers of various types of birds. In our study, we observed that children who were forced to feed themselves with lentil-based weaning food had respiratory symptoms and radiology similar to HP. Here, we are reporting nine patients admitted over 13 months with symptoms of persistent cough, breathing difficulty, not responding to antibiotics, and persistent radiological changes in chest radiographs and computerized tomography. The median age of the cases was 12 months, with male predominance. Flexible bronchoscopy was done to rule out any structural anomalies in the airways and to obtain broncho-alveolar lavage, which yielded no results for pyogenic and tubercular infections. The immunoglobulin G (IgG) specific for lentils ranges from 17.6 to > 200 mgA/L. All children received oral steroids for up to 8 weeks and showed remarkable improvement in clinical and radiological status. In conclusion, lentil-induced HP in infants during weaning should be considered in cases with persistent cough and non-resolving pneumonia.

Objectives: The coronavirus disease 2019 pandemic has reinforced the use of personal protective equipments in healthcare settings. Although filtering face piece 2 respirators provide adequate protection from the aerosolised viral spread, their prolonged use is often associated with subjective discomfort. The study aimed to identify whether an intervening mask-free period is less harmful in terms of discomfort and desaturation when compared against continuous use for 6-h. Material and Methods: This was a prospective and interventional study. A cohort of 87 previously healthy nurses from a multidisciplinary tertiary care hospital were recruited. Study participants were subjected to continuous and intermittent (with 15 min break) mask use, each for a 2-month duration, during their 6-h clinical shifts. Baseline and post-shift oxygen saturation (SpO2) were compared in real time using cumulative sum (CUSUM) statistics. Comfort level was also assessed on a scale of 0–10 in the two groups with 10 subjective parameters. Results: Nurses have experienced a significant drop in SpO2 in both phases with 525 and 984 recordings in continuous and intermittent mask group, respectively. The mean % (2SD) saturation drop in the two groups was 4.688 (39.35) and 1.169 (2.62). The overall discomfort level was more in the continuous phase (8.89 ± 1.610) than in intermittent (7.28 ± 3.216) mask use. CUSUM statistics helped in the real-time monitoring of subjects in the intermittent mask group. Conclusions: Significant adverse health effects in healthcare workers are highlighted using objective and subjective parameters such as desaturation and discomfort levels while using protective face masks. A mask-free period of 15 min, in between their duty shifts, might help reduce the unfavourable effects without compromising efficacy.

INTRODUCTION: Asthma and allergic rhinitis (AR) are among the most prevalent diseases worldwide and they frequently persist throughout the life. These have significant effect on physical, financial, and mental wellbeing of patients and caregivers. There have been few attempts previously, assessing the quality of life (QOL) in affected families suffering from these diseases. However, the data from developing countries are scarce. QOL assessment in children and caregivers of patients suffering can help in symptomatic management and provide inputs for the better utilization of resources to achieve optimal treatment. MATERIALS AND METHODS: Patient and caregiver QOLs were ascertained using Mini Pediatric Asthma QOL Questionnaire and Pediatric Asthma Caregiver's QOL Questionnaire, respectively, in the study and correlated with disease severity and chronicity using the parametric and nonparametric statistical tools. RESULTS: There were 246 pairs of children diagnosed with asthma and/or AR and their caregivers attending the pediatric allergy and asthma clinic. Symptom score, emotional domain, and activity limitation in children did not validate a statistically significant difference in QOL in the various grades of AR/asthma/AR with asthma (P = 0.632) (P = 0.772) (P = 0.496) (P = 0.918) (P = 0.384) and (P = 0.561), respectively. In addition, there was no significant correlation between the severity of asthma and caregiver emotional disturbance (P = 0.594) or caregiver activity limitation (P = 0.446). CONCLUSIONS: QOL in children and caregivers where children are suffering from either AR or asthma, or both has not shown any significant difference as per the disease severity or chronicity in various domains. There was no significant difference in QOL noted as per the change in age group, gender of patients, or education status of caregivers.

Mechanical ventilation is a lifesaving support for patients suffering with acute respiratory distress syndrome. This modality is likely to cause ventilator-induced lung injury if not used judiciously and appropriately. Lung protective ventilation strategy is routinely practiced in adult and pediatric intensive care units. Positive end-expiratory pressure (PEEP) and recruitment maneuvers (RMs) are used in “Open Lung Ventilation” strategy and to keep the lung open. PEEP is applied to recruit collapsed alveoli to improve oxygenation, compliance, reduce tidal stress, and strain on the lungs and to promote homogenous lung ventilation. There is no agreement on methods to set “Best PEEP” for a particular patient. There are many approaches described in published literature to optimize PEEP. PEEP titration may be done with PEEP/FiO2 grid, targeted compliance, driving pressure, by using pressure-volume curve and stress index. Esophageal manometry and measurement of end-expiratory lung volume may be used if special equipment, machines, and expertise are available. No single method of PEEP titration has been shown to improve outcome. RM is characterised by sudden transient increase in transpulmonary pressure. Different RMs including high-frequency oscillator ventilation and prone position ventilation have been studied in adults and pediatric patients with very conflicting results and inconsistent survival benefits. Serious complications, hemodynamic instability, air leak syndrome, transient, or no improvements in oxygenation are reported. In this narrative review, we have discussed different methods of PEEP titration and RMs and available evidence for each especially in children.