OBJECTIVE:To evaluate the association between obesity and ICU length of stay (LOS) in children with critical asthma and assess whether socioeconomic factors modify this relationship. DESIGN:A multicenter retrospective cohort study using the Virtual PICU Systems (VPS) database of children 2-19 years old admitted to ICUs with asthma between 2010 and 2020. Patients were classified by body mass index (BMI) percentile. Children with chronic medical conditions and those missing relevant data were excluded. Multivariable Cox and logistic regression models were performed and adjusted for confounders. SETTING:All PICUs in the VPS database. PATIENTS:A total of 16,412 children from 53 centers with available data to assign BMI, race, and insurance type were included. INTERVENTIONS:None. MEASUREMENTS:The primary outcome was hazard of ICU discharge among survivors, with ICU LOS as the time-to-event variable. Secondary outcomes included the use of invasive or noninvasive mechanical ventilation (NIV) within the first hour of ICU admission and after the first hour. MAIN RESULTS:Obesity was associated with a lower hazard of ICU discharge among survivors (hazard ratio [HR] 0.87 [95% CI, 0.83-0.91]), consistent with longer ICU LOS. Obesity was associated with higher odds of MV in the first hour (odds ratio [OR] 1.24 [95% CI, 1.12-1.39]) and after the first hour (OR 1.63 [95% CI, 1.39-1.92]). These associations remained after adjustment for age, sex, race, insurance type, pneumonia diagnosis, transfer status, and overall severity of illness (Pediatric Risk of Mortality III). Among Black children, obesity was not associated with longer ICU LOS (HR 0.95 [95% CI, 0.89-1.03], p = 0.22). Otherwise, race and insurance type did not significantly modify these associations. CONCLUSIONS:Obesity is independently associated with longer ICU stays and increased respiratory support in children with critical asthma. These findings are predominantly consistent across racial and socioeconomic groups.

IMPORTANCE:Viral bronchiolitis is the leading cause of nonelective admission to the PICU. Guidelines recommend management that focuses on supportive care. Evidence suggests that inhaled epinephrine may reduce lower airways resistance and work of breathing in critical bronchiolitis. It has been demonstrated at one institution that it is feasible to administer continuous inhaled epinephrine (CIE) via heated high-flow nasal cannula (HFNC). OBJECTIVES:To describe the demographic and clinical characteristics of patients with bronchiolitis who received CIE and assess their physiologic response to treatment compared with patients who received conventional therapy. DESIGN SETTING AND PARTICIPANTS:We performed a single-center retrospective cohort study of previously healthy children 0-2 years old admitted to the PICU with diagnosis of bronchiolitis from 2017 to 2023. MAIN OUTCOMES AND MEASURES:Physiologic response to treatment was assessed via analysis of vital signs and use of respiratory rate, oxygenation, heart rate (ROX-HR) index. RESULTS:One hundred ninety-three patients were included in the study. Patients who received CIE were younger (median age, 4 vs. 7 mo old; p = 0.01) and smaller (7.0 vs. 8.4 kg; p = 0.06), presented with higher initial peak respiratory rates (70 vs. 50 beats/min; p < 0.0001), and had longer ICU stays (3.4 vs. 1.8 d; p < 0.001). Patients treated with CIE exhibited overall higher respiratory rates and lower ROX-HR indices, indicating more severe illness. Within the first 48 hours of treatment, patients receiving CIE demonstrated a more rapid improvement in both respiratory rate and ROX-HR index compared with those receiving conventional therapy. CONCLUSIONS AND RELEVANCE:In this cohort, CIE was used as novel therapy for younger, smaller patients with more severe bronchiolitis on presentation to the PICU. The physiologic changes suggest potential benefit of this therapy for patients who are not improving with conventional HFNC therapy.

OBJECTIVES:To describe medical management surrounding withdrawal of life-sustaining therapy (WLST) in nine U.S. PICUs. DESIGN:Retrospective, secondary analysis of the "Death One Hour After Terminal Extubation" (DONATE) cohort (2009-2021) assessing usage patterns of: 1) analgesics and sedatives; 2) vasoactive infusions; 3) neuromuscular blockade; and 4) post-extubation respiratory support. SETTING:Nine U.S. PICUs. PATIENTS:Children and adolescents 0-21 years old, who had died after WLST (discontinuation of invasive mechanical ventilation). INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Of 905 patients, 680 (75.1%) died within 1 hour of WLST. Opioids were administered in 721 of 905 patients (79.7%); across sites the range was 68-89% ( p < 0.001). We did not observe a temporal trend. Benzodiazepines were used in 507 of 905 patients (56.0%; site range, 41-66%; p < 0.001), with lower odds of usage per year (odds ratio [OR], 0.95 per year; 95% CI, 0.90-0.99 per year; p = 0.04). Dexmedetomidine was used in 140 of 905 patients (15.5%; sites range, 4-21%; p = 0.002), with greater odds of usage per year (OR, 1.16 per year; 95% CI, 1.05-1.27 per year; p = 0.004). Vasoactive infusions were discontinued in 458 of 520 patients (88.1%) receiving this medication (site range, 59-100%; p < 0.001), with greater odds of discontinuation per year (OR, 1.15 per year; 95% CI, 1.04-1.26 per year; p = 0.007). Neuromuscular blockade was used in 46 of 905 patients (5.1%; sites range, 0-13%; p < 0.001), with greater odds of usage per year (OR, 1.23 per year; 95% CI, 1.08-1.40 per year; p = 0.002). Use of any post-extubation respiratory support occurred in 50 of 905 patients (5.5%), and we did not identify an association with site or year-on-year trend. CONCLUSIONS:The 2009-2021 DONATE dataset shows substantial institutional and temporal variability in WLST practices across our nine collaborating PICUs in the United States. Future studies should focus on understanding the drivers of variability to improve the consistency and quality of end-of-life management.

Objective:To independently validate an empirically optimized algorithm for calculating estimated Oxygenation Index (eOI) using noninvasive parameters from pediatric intensive care populations. Design:Retrospective observational cohort study using an integrated patient data repository spanning over 12 years (August 2012-December 2024). Setting:Single tertiary children's hospital with general pediatric ICU (PICU) and cardiothoracic ICU (CTICU). Key measures:Arterial blood gas measurements were paired with coincident SpO2, heart rate, pulse rate, FiO2, and mean airway pressure measurements. The primary analyses used SpO2 observations between 80%-100%. Using these values eOI was calculated. The primary outcome was the Bias and Limits of Agreement of the difference between measured OI and eOI. Discrimination performance of eOI for severity of hypoxemia was evaluated using receiver operating characteristic curves at OI thresholds of 4, 8, and 16. Results:Analysis included 68,915 observations from 7,109 subjects (44,133 CTICU, 24,782 PICU observations). Bias was minimal in both populations: PICU 0.06 (95% CI; 0.03, 0.10) and CTICU 0.12 (95% CI; 0.09, 0.14). Limits of agreement were -5.2 to 5.4 (PICU) and -4.9 to 5.2 (CTICU). Discrimination performance was excellent, at 3 hypoxemia thresholds (AUROC; 0.91-0.98), and in the CTICU for OI ≥4 when SpO2 >97% (AUROC; 0.83). Conclusions:The new eOI algorithm provides accurate, but not precise, estimation of OI in both general pediatric and cardiothoracic ICU populations. Noninvasive OI monitoring may be shown clinically useful.

In the United States and Canada, severe asthma requiring mechanical ventilation has declined over the past decade reflecting a rise in noninvasive therapies. When aggressive noninvasive therapies fail, endotracheal intubation and mechanical ventilation are lifesaving and should be planned for in advance. As speed is important, the most experienced practitioner should intubate and rapid correction of hypercarbia and respiratory acidosis should be avoided. An elevated minute ventilation may cause pulmonary hyperinflation leading to air-leak syndrome and/or hemodynamic instability. Patients with severe air flow obstruction in asthma typically have near-normal respiratory system compliance. Therefore, an increase in plateau pressure (Pplat) usually reflects dynamic hyperinflation. A suggested upper limit for Pplat is 25-30 cm H2O. Intrinsic PEEP (PEEPi) is measured with an expiratory hold and is valuable in that PEEP set on the ventilator can be lower than PEEPi. A reasonable ventilation strategy involving low ventilator rates and PEEP without quick correction of blood gases should be adopted. Alternative modalities to conventional mechanical ventilation are limited and unless very experienced with high-frequency oscillatory ventilation, the risk likely outweighs benefit. Heliox may be beneficial but cannot be delivered by every ventilator and this varies by manufacturer. Inhaled anesthetics are direct bronchodilators and likely beneficial but as no conventional ICU ventilator can deliver them, close cooperation with Anesthesiology is needed. Extracorporeal membrane oxygenation (ECMO) is a rescue therapy that is particularly useful in cases of severe air-leak syndrome. As with mechanical ventilation, ECMO does not reverse the asthma disease process but allows support of the patient until there is improvement with other therapies. Most children who die experience cardiac arrest prior to hospitalization. Otherwise, most mechanically ventilated children survive to hospital discharge but there is a suggestion of additional mortality from asthma in the following decade.

BACKGROUND:Mechanical ventilation strategies that balance lung and diaphragm protection have not been extensively tested in clinical trials. METHODS:We conducted a single-center, phase II randomized controlled trial in children with acute respiratory distress syndrome with two time points of random assignment: the acute and weaning phases of ventilation. Patients in the intervention group were managed with a computerized decision support (CDS) tool, named REDvent, and esophageal manometry to deliver lung and diaphragm protective ventilation. The control group received usual care. A daily standardized spontaneous breathing trial (SBT) was performed in both groups. The primary outcome was the length of weaning. RESULTS:From October 2017 through March 2024, 248 children were randomly assigned to the acute phase. When participants were triggering the ventilator, the adjusted mean difference (REDvent-acute - usual care-acute) for peak inspiratory pressure was -3 cmH2O (95% CI, -5 to -2), positive end-expiratory pressure was -2 cmH2O (95% CI, -2 to -1), and the esophageal pressure swing was -1.8 cmH2O (95% CI, -3.2 to -0.3). For the primary outcome, 55% of REDvent-acute patients passed their SBT or were extubated on the day of the first SBT, compared with 39% in the usual care-acute group. After adjusting for age, immunosuppression, and oxygenation index value, the REDvent-acute intervention resulted in a 1.67 (95% CI, 1.01 to 2.77; P=0.045) odds of a shorter length of weaning than usual care. The median time from intubation to SBT passage was 3.83 days in the intervention group versus 4.75 days in the usual care group. The length of ventilation among survivors was 5.0 days in the intervention group versus 5.6 days in the usual care group. When comparing weaning phase random assignment, clinical outcomes were similar between groups. There were no differences in adverse events between the groups. CONCLUSIONS:A lung and diaphragm protective ventilation strategy using a CDS tool during the acute phase of ventilation resulted in a shorter length of weaning than usual care. Phase III trials in mechanically ventilated patients are warranted. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT03266016.).

OBJECTIVE:To evaluate age-related differences in respiratory outcomes among critically ill children with Guillain-Barré syndrome (GBS), focusing on mechanical ventilation (MV) requirements and tracheostomy placement. STUDY DESIGN:This retrospective cohort study analyzed data collected prospectively within the Virtual Pediatric Systems registry (2009-2020) for US children <21 years diagnosed with GBS and admitted to an intensive care unit (ICU). The primary outcome evaluated was use of invasive mechanical ventilation (IMV). Secondary outcomes included MV duration and use of tracheostomy. RESULTS:Among 497 children, 185 (37.2%) required IMV, 14 (2.8%) required only noninvasive ventilation, and 45 (9.1%) received a tracheostomy. Most patients (82.7%) requiring either invasive or non-IMV received it within 24 hours of ICU admission. Compared with children ≥12 years, younger children had higher odds of requiring IMV (age <2 years: adjusted odds ratio (aOR) 3.12 [95% CI 1.37, 7.10]; age ≥2-6 years: aOR 1.87 [95% CI 1.07, 3.28]), but experienced shorter duration of ventilation (age ≥2-6 years: adjusted hazard ratio 2.37 [95% CI 1.55, 3.63]; age ≥6-12 years: adjusted hazard ratio 1.74 [95% CI 1.21, 2.50]) and had lower tracheostomy rates (age ≥2-6 years: aOR 0.21 [95% CI 0.07, 0.61]; age ≥6-12 years: aOR 0.35 [95% CI 0.12, 0.99]) when they received IMV. CONCLUSIONS:Most children with GBS admitted to an ICU in the US do not require MV; among those who do, support is typically initiated within 24 hours of ICU admission. There are age-related variations in respiratory outcomes that may help inform clinical management.

OBJECTIVES:In the PICU, predicting death within 1 hour after terminal extubation (TE) is valuable in augmenting family counseling and in identifying suitable candidates for organ donation after circulatory determination of death (DCDD). The objective of this study was to train and validate a machine learning model to predict death within 1 hour after TE. DESIGN:The Death One Hour After Terminal Extubation (DONATE) database was generated using multicenter retrospective data from 2009 to 2021. Data covering demographics, clinical features, vital signs, laboratory values, ventilator settings, medications, and procedures were collected. Machine learning models were trained to predict whether a pediatric patient would die within 1 hour after TE and evaluated on a holdout set. SETTING:Ten U.S. PICUs. PATIENTS:Children and adolescents, 0-21 years old, who died after TE ( n = 957). INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:The final model was a parsimonious extra-trees model with 21 input features. It was trained on the 2009-2018 data from eight sites ( n = 634) and evaluated on a holdout set comprised of the 2019-2021 data of all ten sites ( n = 323), representing temporal and external validation. The area under the receiver operating characteristic curve and 95% CI was 0.84 (95% CI, 0.81-0.87). At a sensitivity of 90%, the positive predictive value (PPV) was 88%, the negative predictive value (NPV) was 70%, and the number needed to alert (NNA) was 1.14. Among potential organ donors, at the same sensitivity level, the PPV was 86%, the NPV was 74%, and the NNA was 1.17. CONCLUSIONS:Our model, trained and validated on multisite data, predicted whether a child will die within 1 hour of TE with high discrimination and a low false alarm rate. This finding has important applications to end-of-life counseling and institutional resource utilization when families wish to attempt DCDD.

AimThis study aims to identify demographic factors, area-based social determinants of health (SDOH), and clinical features associated with medical decision-making after pediatric out-of-hospital cardiac arrest (OHCA).MethodsThis is a retrospective, exploratory, descriptive analysis of patients < 18 years old admitted to the pediatric intensive care unit (ICU) after OHCA from 2011 to 2022 (n=217) at an urban tertiary care, free-standing children’s hospital. Outcomes of interest included: (1) whether a new advance care plan (ACP) (defined as a written advance directive including do not resuscitate and/or do not intubate) was ordered during hospitalization, and (2) whether the patient was discharged with new medical technology (defined as tracheostomy and/or feeding tube). Logistic regression models identified features associated with these outcomes.ResultsOf the 217 patients, 78 patients (36%) had a new ACP placed during their admission. Of the survivors, 26% (27/102) were discharged home with new medical technology. Factors associated with ACP were greater change in Pediatric Cerebral Performance Category (PCPC) score (aOR=1.49, 95% CI [1.28-1.73], p-value <0.001) and palliative care consultation (aOR = 2.39, 95% CI [1.16-4.89], p-value 0.018). Factors associated with new medical technology were lower change in PCPC score (aOR=0.76, 95% C.I. [0.61-0.95], p-value=0.015) and palliative care consultation (aOR = 7.07, 95% CI [3.01-16.60], p-value <0.001). There were no associations between area-based SDOH and outcomes.ConclusionsUnderstanding factors associated with decision-making related to ACP after OHCA is critical to optimize counseling for families. Multi-institutional studies are warranted to identify whether these findings are generalizable.

BACKGROUND:Current knowledge of the impact of socioeconomic factors on the risk of admission to the pediatric intensive care unit (PICU) for asthma is limited. Using composite measures of social vulnerability-Social Vulnerability Index (SVI) and Child Opportunity Index (COI) 2.0-we compared patients admitted for status asthmaticus to the PICU and pediatric ward at Children's Hospital Los Angeles (CHLA). We hypothesized patients with a high SVI and low COI are at higher risk for PICU admission. METHODS:Patients were identified using ICD-10 codes for asthma. Primary outcome was admission to PICU versus ward for status asthmaticus. Patient-registered residential street addresses were geocoded and spatially joined to SVI and COI 2.0 data at the census tract level. Univariate and regression analyses using the patient's SVI, COI 2.0, and admission location were conducted. RESULTS:From January 2017 to March 2022, there were 2458 admissions matched to addresses from 1983 distinct patients. The overall median SVI for all patients was 0.86 (IQR 0.6, 0.9). Overall median COI was 25.0 (IQR 10, 50). There was no difference in SVI or COI for admission to the PICU versus the ward. However, children requiring multiple hospital admissions for asthma were associated with higher SVI and lower COI. CONCLUSIONS:Children admitted to CHLA for asthma had an elevated SVI and low COI. There was no difference between admission locations based on SVI or COI scores. This indicates we care for children at increased socioeconomic risk, but this did not increase PICU use for asthma.

ObjectiveOur aim was to confirm whether extreme hyperoxemic events had been associated with excess mortality in our diverse critical care population.MethodsRetrospective analysis of 9 years of data collected in the pediatric and cardiothoracic ICUs in Children's Hospital Los Angeles was performed. The analysis was limited to those mechanically ventilated for at least 24 h, with at least 1 arterial blood gas measurement. An extreme hyperoxemic event was defined as a PaO2 of ≥300 torr. Multivariable logistic regression was used to assess the association of extreme hyperoxemia events and mortality, adjusting for confounding variables. Selected a-priori, these were Pediatric Risk of Mortality III predicted mortality, general or cardiothoracic ICU, number of blood gas measurements, as well as an abnormal blood gas measurements (pH < 7.25, pH > 7.45, and PaO2 < 50 torr).ResultsThere were 4,003 admissions included with a predicted mortality of 7.1% and an actual mortality of 9.7%. Their care was associated with 75,129 blood gas measurements, in which abnormal measurements were common. With adjustments for these covariates, any hyperoxemic event was associated with excess mortality (p < 0.001). Excess mortality increased with multiple hyperoxemic events (p < 0.046). Additionally, treatment resulting in SpO2 > 98% markedly increased the risk of a hyperoxemic event.ConclusionRetrospective analysis of critical care admissions showed that extreme hyperoxemic events were associated with higher mortality. Supplemental oxygen levels resulting in SpO2 > 98% should be avoided.

Nigri, Daniel1; Huang, Ruiqi2; Newth, Christopher2; Ross, Patrick2; Castro, Cristina2; Laksana, Eugene3; Flynn, Alysia2; Aczon, Melissa3; Winter, Meredith4 Author Information

Introduction Accurate formulae to predict the optimal insertion length of endotracheal tubes (ETT) are necessary for safe care and have been based on height, weight, age, and ETT size. We believe height best reflects the somatic growth of the trachea. Our goal is to compare a formula generated using height for optimal initial insertion length of ETT to previously published formulae based on height, weight, age, and ETT size. Methods We retrospectively reviewed chest radiographs over a two-year period where the head was assured in midline and midposition. We excluded children with conditions altering tracheal dimensions or stature, and scoliosis. We chose 2 cm above the carina to be the optimal insertion length of the ETT which was then correlated to height. We created linear regression equations and Bland-Altman plots. Results Two hundred three orotracheally intubated children were included. The optimal ETT insertion length using the formula Height (cm)/8 + 3.4 had a high association with linear regression and Bland-Altman plots had the narrowest 95% limits of agreement as compared to previously published formulae. Conclusions We found optimal insertion length = Height (cm)/8 + 3.4 is more accurate as compared to commonly used formulae that are based on weight, age, or ETT size. This formula places the ETT 2 cm above the carina which should be safe until a chest radiograph is obtained. We find that the use of formulae that divide the height by 10 overestimates the depth of insertion in younger, smaller children and underestimates the depth of insertion in older children.

Purpose of Review To find the best anesthesia practices for patients with aerodigestive disorders undergoing triple endoscopy. Recent Findings While there is abundant literature on the utility of aerodigestive programs as well as the triple endoscopy performed in aerodigestive patients, there is a lack of studies investigating the optimal anesthetic technique for this patient population. Summary Triple endoscopy has been shown to expedite diagnosis and treatment while exposing patients to less anesthesia and decreasing the frequency of unnecessary evaluations. Due to the high-risk nature of airway procedures and the frequent underlying comorbidities in this special patient population, perioperative respiratory complications are common. Collaborative, multidisciplinary care among anesthesiologists, otolaryngologists, pulmonologists, and gastroenterologists is essential to meet the specific needs of each aerodigestive patient and safely perform the triple endoscopy. This article outlines our anesthetic approach and the perioperative considerations taken for each stage of the process.

Introduction: Racial and socioeconomic disparities in pediatric asthma prevalence, severity, and use of primary and emergency care have been well studied. However, understanding of the impact of these disparities on risk of hospitalization in the pediatric intensive care unit (PICU) is limited. We used composite measures of socioeconomic risk factors through the Centers for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI), and the Child Opportunity Index (COI) 2.0 to compare patients admitted for status asthmaticus to the PICU or pediatric ward at Children’s Hospital Los Angeles (CHLA). We hypothesized patients with a high SVI and low COI are at higher risk for PICU level care. Methods: Following IRB approval, patients were identified using ICD-10 codes for asthma. The outcome of interest was need for PICU versus ward care. Patients were included as requiring PICU level of care if admitted to the PICU during their stay. Patient registered street address was geocoded and linked to US Census-American Community Survey 2019 Data (5-Year) at the census tract level. Bivariate analysis with the patient’s SVI, COI, hospital length of stay (LOS), and PICU admission were conducted. Statistical analysis used SAS, STATA, and ArcGIS Pro. Results: From [October 2015 – May 2022], there were 4,766 admissions matched to addresses from 3,617 distinct patients of which 626 (13.1%) required PICU admission. Overall median SVI for all patients was 0.86 with no difference between groups for SVI: median (1,3 IQR) PICU 0.86 (0.67, 0.93) Ward 0.86 (0.69, 0.93) p=0.56; or for COI: PICU 27 (9, 50) Ward 24 (10, 50) p=0.82. Hospital LOS was significantly longer for those requiring PICU admission: PICU 3 (3, 5) Ward 2 (2, 3) (days) p< 0.001. Conclusions: We found that children admitted to CHLA for asthma had an elevated SVI overall reflecting a patient population among the lowest socioeconomic status in the United States. The median 0.86 SVI score indicates a population that is more socially vulnerable than all but 14% of the US population. Similarly, the COI score demonstrated a population at risk. Yet, there was no difference between groups for the SVI or COI scores indicating we care for children at increased socioeconomic risk, but this did not increase PICU use for asthma admissions.