IU Indianapolis ScholarWorks :: Browsing by Author "Khemani, Robinder G."

Browsing by Author "Khemani, Robinder G."

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Association of Extubation Failure Rates With High-Flow Nasal Cannula, Continuous Positive Airway Pressure, and Bilevel Positive Airway Pressure vs Conventional Oxygen Therapy in Infants and Young Children: A Systematic Review and Network Meta-Analysis
(American Medical Association, 2023-06-05) Iyer, Narayan Prabhu; Rotta, Alexandre T.; Essouri, Sandrine; Fioretto, Jose Roberto; Craven, Hannah J.; Whipple, Elizabeth C.; Ramnarayan, Padmanabhan; Abu-Sultaneh, Samer; Khemani, Robinder G.
IMPORTANCE: Extubation failure (EF) has been associated with worse outcomes in critically ill children. The relative efficacy of different modes of noninvasive respiratory support (NRS) to prevent EF is unknown. OBJECTIVE: To study the reported relative efficacy of different modes of NRS (high-flow nasal cannula [HFNC], continuous positive airway pressure [CPAP], and bilevel positive airway pressure [BiPAP]) compared to conventional oxygen therapy (COT). DATA SOURCES: MEDLINE, Embase, and CINAHL Complete through May 2022. STUDY SELECTION: Randomized clinical trials that enrolled critically ill children receiving invasive mechanical ventilation for more than 24 hours and compared the efficacy of different modes of postextubation NRS. DATA EXTRACTION AND SYNTHESIS: Random-effects models were fit using a bayesian network meta-analysis framework. Between-group comparisons were estimated using odds ratios (ORs) or mean differences with 95% credible intervals (CrIs). Treatment rankings were assessed by rank probabilities and the surface under the cumulative rank curve (SUCRA). MAIN OUTCOMES AND MEASURES: The primary outcome was EF (reintubation within 48 to 72 hours). Secondary outcomes were treatment failure (TF, reintubation plus NRS escalation or crossover to another NRS mode), pediatric intensive care unit (PICU) mortality, PICU and hospital length of stay, abdominal distension, and nasal injury. RESULTS: A total of 11 615 citations were screened, and 9 randomized clinical trials with a total of 1421 participants were included. Both CPAP and HFNC were found to be more effective than COT in reducing EF and TF (CPAP: OR for EF, 0.43; 95% CrI, 0.17-1.0 and OR for TF 0.27, 95% CrI 0.11-0.57 and HFNC: OR for EF, 0.64; 95% CrI, 0.24-1.0 and OR for TF, 0.34; 95% CrI, 0.16- 0.65). CPAP had the highest likelihood of being the best intervention for both EF (SUCRA, 0.83) and TF (SUCRA, 0.91). Although not statistically significant, BiPAP was likely to be better than COT for preventing both EF and TF. Compared to COT, CPAP and BiPAP were reported as showing a modest increase (approximately 3%) in nasal injury and abdominal distension. CONCLUSIONS AND RELEVANCE: The studies included in this systematic review and network meta-analysis found that compared with COT, EF and TF rates were lower with modest increases in abdominal distension and nasal injury. Of the modes evaluated, CPAP was associated with the lowest rates of EF and TF.
Clinical Challenges in Pediatric Ventilation Liberation: A Meta-Narrative Review
(Wolters Kluwer, 2022) van Dijk, Jefta; Blokpoel, Robert G. T.; Abu-Sultaneh, Samer; Newth, Christopher J. L.; Khemani, Robinder G.; Kneyber, Martin C. J.; Pediatrics, School of Medicine
Objectives: To map the evidence for ventilation liberation practices in pediatric respiratory failure using the Realist And MEta-narrative Evidence Syntheses: Evolving Standards publication standards. Data sources: CINAHL, MEDLINE, COCHRANE, and EMBASE. Trial registers included the following: ClinicalTrials.gov, European Union clinical trials register, International Standardized Randomized Controlled Trial Number register. Study selection: Abstracts were screened followed by review of full text. Articles published in English language incorporating a heterogeneous population of both infants and older children were assessed. Data extraction: None. Data synthesis: Weaning can be considered as the process by which positive pressure is decreased and the patient becomes increasingly responsible for generating the energy necessary for effective gas exchange. With the growing use of noninvasive respiratory support, extubation can lie in the middle of the weaning process if some additional positive pressure is used after extubation, while for some extubation may constitute the end of weaning. Testing for extubation readiness is a key component of the weaning process as it allows the critical care practitioner to assess the capability and endurance of the patient's respiratory system to resume unassisted ventilation. Spontaneous breathing trials (SBTs) are often seen as extubation readiness testing (ERT), but the SBT is used to determine if the patient can maintain adequate spontaneous ventilation with minimal ventilatory support, whereas ERT implies the patient is ready for extubation. Conclusions: Current literature suggests using a structured approach that includes a daily assessment of patient's readiness to extubate may reduce total ventilation time. Increasing evidence indicates that such daily assessments needs to include SBTs without added pressure support. Measures of elevated load as well as measures of impaired respiratory muscle capacity are independently associated with extubation failure in children, indicating that these should also be assessed as part of ERT.
Derivation, Validation, and Clinical Relevance of a Pediatric Sepsis Phenotype With Persistent Hypoxemia, Encephalopathy, and Shock
(Wolters Kluwer, 2023) Sanchez-Pinto, L. Nelson; Bennett, Tellen D.; Stroup, Emily K.; Luo, Yuan; Atreya, Mihir; Bubeck Wardenburg, Juliane; Chong, Grace; Geva, Alon; Faustino, E. Vincent S.; Farris, Reid W.; Hall, Mark W.; Rogerson, Colin; Shah, Sareen S.; Weiss, Scott L.; Khemani, Robinder G.; Pediatrics, School of Medicine
Objectives: Untangling the heterogeneity of sepsis in children and identifying clinically relevant phenotypes could lead to the development of targeted therapies. Our aim was to analyze the organ dysfunction trajectories of children with sepsis-associated multiple organ dysfunction syndrome (MODS) to identify reproducible and clinically relevant sepsis phenotypes and determine if they are associated with heterogeneity of treatment effect (HTE) to common therapies. Design: Multicenter observational cohort study. Setting: Thirteen PICUs in the United States. Patients: Patients admitted with suspected infections to the PICU between 2012 and 2018. Interventions: None. Measurements and main results: We used subgraph-augmented nonnegative matrix factorization to identify candidate trajectory-based phenotypes based on the type, severity, and progression of organ dysfunction in the first 72 hours. We analyzed the candidate phenotypes to determine reproducibility as well as prognostic, therapeutic, and biological relevance. Overall, 38,732 children had suspected infection, of which 15,246 (39.4%) had sepsis-associated MODS with an in-hospital mortality of 10.1%. We identified an organ dysfunction trajectory-based phenotype (which we termed persistent hypoxemia, encephalopathy, and shock) that was highly reproducible, had features of systemic inflammation and coagulopathy, and was independently associated with higher mortality. In a propensity score-matched analysis, patients with persistent hypoxemia, encephalopathy, and shock phenotype appeared to have HTE and benefit from adjuvant therapy with hydrocortisone and albumin. When compared with other high-risk clinical syndromes, the persistent hypoxemia, encephalopathy, and shock phenotype only overlapped with 50%-60% of patients with septic shock, moderate-to-severe pediatric acute respiratory distress syndrome, or those in the top tier of organ dysfunction burden, suggesting that it represents a nonsynonymous clinical phenotype of sepsis-associated MODS. Conclusions: We derived and validated the persistent hypoxemia, encephalopathy, and shock phenotype, which is highly reproducible, clinically relevant, and associated with HTE to common adjuvant therapies in children with sepsis.
Early Use of Adjunctive Therapies for Pediatric Acute Respiratory Distress Syndrome: A PARDIE Study
(American Thoracic Society, 2020-06) Rowan, Courtney M.; Klein, Margaret J.; Hsing, Deyin Doreen; Dahmer, Mary K.; Spinella, Philip C.; Emeriaud, Guillaume; Hassinger, Amanda B.; Piñeres-Olave, Byron E.; Flori, Heidi R.; Haileselassie, Bereketeab; Lopez-Fernandez, Yolanda M.; Chima, Ranjit S.; Shein, Steven L.; Maddux, Aline B.; Lillie, Jon; Izquierdo, Ledys; Kneyber, Martin C.J.; Smith, Lincoln S.; Khemani, Robinder G.; Thomas, Neal J.; Yehya, Nadir; Pediatrics, School of Medicine
Rationale: Few data exist to guide early adjunctive therapy use in pediatric acute respiratory distress syndrome (PARDS).Objectives: To describe contemporary use of adjunctive therapies for early PARDS as a framework for future investigations.Methods: This was a preplanned substudy of a prospective, international, cross-sectional observational study of children with PARDS from 100 centers over 10 study weeks.Measurements and Main Results: We investigated six adjunctive therapies for PARDS: continuous neuromuscular blockade, corticosteroids, inhaled nitric oxide (iNO), prone positioning, high-frequency oscillatory ventilation (HFOV), and extracorporeal membrane oxygenation. Almost half (45%) of children with PARDS received at least one therapy. Variability was noted in the median starting oxygenation index of each therapy; corticosteroids started at the lowest oxygenation index (13.0; interquartile range, 7.6-22.0) and HFOV at the highest (25.7; interquartile range, 16.7-37.3). Continuous neuromuscular blockade was the most common, used in 31%, followed by iNO (13%), corticosteroids (10%), prone positioning (10%), HFOV (9%), and extracorporeal membrane oxygenation (3%). Steroids, iNO, and HFOV were associated with comorbidities. Prone positioning and HFOV were more common in middle-income countries and less frequently used in North America. The use of multiple ancillary therapies increased over the first 3 days of PARDS, but there was not an easily identifiable pattern of combination or order of use.Conclusions: The contemporary description of prevalence, combinations of therapies, and oxygenation threshold for which the therapies are applied is important for design of future studies. Region of the world, income, and comorbidities influence adjunctive therapy use and are important variables to include in PARDS investigations.
Executive Summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2)
(Wolters Kluwer, 2023) Emeriaud, Guillaume; López-Fernández, Yolanda M.; Iyer, Narayan Prabhu; Bembea, Melania M.; Agulnik, Asya; Barbaro, Ryan P.; Baudin, Florent; Bhalla, Anoopindar; de Carvalho, Werther Brunow; Carroll, Christopher L.; Cheifetz, Ira M.; Chisti, Mohammod J.; Cruces, Pablo; Curley, Martha A. Q.; Dahmer, Mary K.; Dalton, Heidi J.; Erickson, Simon J.; Essouri, Sandrine; Fernández, Analía; Flori, Heidi R.; Grunwell, Jocelyn R.; Jouvet, Philippe; Killien, Elizabeth Y.; Kneyber, Martin C. J.; Kudchadkar, Sapna R.; Korang, Steven Kwasi; Lee, Jan Hau; Macrae, Duncan J.; Maddux, Aline; Alapont, Vicent Modesto I.; Morrow, Brenda M.; Nadkarni, Vinay M.; Napolitano, Natalie; Newth, Christopher J. L.; Pons-Odena, Martí; Quasney, Michael W.; Rajapreyar, Prakadeshwari; Rambaud, Jerome; Randolph, Adrienne G.; Rimensberger, Peter; Rowan, Courtney M.; Sanchez-Pinto, L. Nelson; Sapru, Anil; Sauthier, Michael; Shein, Steve L.; Smith, Lincoln S.; Steffen, Katerine; Takeuchi, Muneyuki; Thomas, Neal J.; Tse, Sze Man; Valentine, Stacey; Ward, Shan; Watson, R. Scott; Yehya, Nadir; Zimmerman, Jerry J.; Khemani, Robinder G.; Pediatrics, School of Medicine
Objectives: We sought to update our 2015 work in the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) guidelines for the diagnosis and management of pediatric acute respiratory distress syndrome (PARDS), considering new evidence and topic areas that were not previously addressed. Design: International consensus conference series involving 52 multidisciplinary international content experts in PARDS and four methodology experts from 15 countries, using consensus conference methodology, and implementation science. Setting: Not applicable. Patients: Patients with or at risk for PARDS. Interventions: None. Measurements and main results: Eleven subgroups conducted systematic or scoping reviews addressing 11 topic areas: 1) definition, incidence, and epidemiology; 2) pathobiology, severity, and risk stratification; 3) ventilatory support; 4) pulmonary-specific ancillary treatment; 5) nonpulmonary treatment; 6) monitoring; 7) noninvasive respiratory support; 8) extracorporeal support; 9) morbidity and long-term outcomes; 10) clinical informatics and data science; and 11) resource-limited settings. The search included MEDLINE, EMBASE, and CINAHL Complete (EBSCOhost) and was updated in March 2022. Grading of Recommendations, Assessment, Development, and Evaluation methodology was used to summarize evidence and develop the recommendations, which were discussed and voted on by all PALICC-2 experts. There were 146 recommendations and statements, including: 34 recommendations for clinical practice; 112 consensus-based statements with 18 on PARDS definition, 55 on good practice, seven on policy, and 32 on research. All recommendations and statements had agreement greater than 80%. Conclusions: PALICC-2 recommendations and consensus-based statements should facilitate the implementation and adherence to the best clinical practice in patients with PARDS. These results will also inform the development of future programs of research that are crucially needed to provide stronger evidence to guide the pediatric critical care teams managing these patients.
Executive Summary: International Clinical Practice Guidelines for Pediatric Ventilator Liberation, A PALISI Network Document
(American Thoracic Society Journals, 2022-08-15) Abu-Sultaneh, Samer; Iyer, Narayan Prabhu; Fernández, Analía; Gaies, Michael; González-Dambrauskas, Sebastián; Hotz, Justin Christian; Kneyber, Martin C.J.; López-Fernández, Yolanda M.; Rotta, Alexandre T.; Werho, David K.; Baranwal, Arun Kumar; Blackwood, Bronagh; Craven, Hannah J.; Curley, Martha A.Q.; Essouri, Sandrine; Fioretto, Jose Roberto; Hartmann, Silvia M.M.; Jouvet, Philippe; Korang, Steven Kwasi; Rafferty, Gerrard F.; Ramnarayan, Padmanabhan; Rose, Louise; Tume, Lyvonne N.; Whipple, Elizabeth C.; Wong, Judith Ju Ming; Emeriaud, Guillaume; Mastropietro, Christopher W; Napolitano, Natalie; Newth, Christopher J.L.; Khemani, Robinder G.
RATIONALE: Pediatric specific ventilator liberation guidelines are lacking despite the many studies exploring elements of extubation readiness testing. The lack of clinical practice guidelines has led to significant and unnecessary variation in methods used to assess pediatric patients' readiness for extubation. METHODS: Twenty-six international experts comprised a multi-professional panel to establish pediatric specific ventilator liberation clinical practice guidelines, focusing on acutely hospitalized children receiving invasive mechanical ventilation for more than 24 hours. Eleven key questions were identified and first prioritized using the Modified Convergence of Opinion on Recommendations and Evidence. Systematic review was conducted for questions which did not meet an a-priori threshold of ≥80% agreement, with Grading of Recommendations, Assessment, Development, and Evaluation methodologies applied to develop the guidelines. The panel evaluated the evidence, drafted, and voted on the recommendations. MEASUREMENTS AND MAIN RESULTS: Three questions related to systematic screening, using an extubation readiness testing bundle and use of a spontaneous breathing trial as part of the bundle met Modified Convergence of Opinion on Recommendations criteria of ≥80% agreement. For the remaining 8 questions, 5 systematic reviews yielded 12 recommendations related to the methods and duration of spontaneous breathing trials; measures of respiratory muscle strength; assessment of risk of post-extubation upper airway obstruction and its prevention; use of post-extubation non-invasive respiratory support; and sedation. Most recommendations were conditional and based on low to very low certainty of evidence. CONCLUSION: This clinical practice guideline provides a conceptual framework with evidence-based recommendations for best practices related to pediatric ventilator liberation.
Executive Summary: International Clinical Practice Guidelines for Pediatric Ventilator Liberation, A Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network Document
(American Thoracic Society, 2023) Abu-Sultaneh, Samer; Iyer, Narayan Prabhu; Fernández, Analía; Gaies, Michael; González-Dambrauskas, Sebastián; Hotz, Justin Christian; Kneyber, Martin C. J.; López-Fernández, Yolanda M.; Rotta, Alexandre T.; Werho, David K.; Baranwal, Arun Kumar; Blackwood, Bronagh; Craven, Hannah J.; Curley, Martha A. Q.; Essouri, Sandrine; Fioretto, Jose Roberto; Hartmann, Silvia M. M.; Jouvet, Philippe; Korang, Steven Kwasi; Rafferty, Gerrard F.; Ramnarayan, Padmanabhan; Rose, Louise; Tume, Lyvonne N.; Whipple, Elizabeth C.; Wong, Judith J. M.; Emeriaud, Guillaume; Mastropietro, Christopher W.; Napolitano, Natalie; Newth, Christopher J. L.; Khemani, Robinder G.; Pediatrics, School of Medicine
Rationale: Pediatric-specific ventilator liberation guidelines are lacking despite the many studies exploring elements of extubation readiness testing. The lack of clinical practice guidelines has led to significant and unnecessary variation in methods used to assess pediatric patients’ readiness for extubation. Methods: Twenty-six international experts comprised a multiprofessional panel to establish pediatrics-specific ventilator liberation clinical practice guidelines, focusing on acutely hospitalized children receiving invasive mechanical ventilation for more than 24 hours. Eleven key questions were identified and first prioritized using the Modified Convergence of Opinion on Recommendations and Evidence. A systematic review was conducted for questions that did not meet an a priori threshold of ⩾80% agreement, with Grading of Recommendations, Assessment, Development, and Evaluation methodologies applied to develop the guidelines. The panel evaluated the evidence and drafted and voted on the recommendations. Measurements and Main Results: Three questions related to systematic screening using an extubation readiness testing bundle and a spontaneous breathing trial as part of the bundle met Modified Convergence of Opinion on Recommendations criteria of ⩾80% agreement. For the remaining eight questions, five systematic reviews yielded 12 recommendations related to the methods and duration of spontaneous breathing trials, measures of respiratory muscle strength, assessment of risk of postextubation upper airway obstruction and its prevention, use of postextubation noninvasive respiratory support, and sedation. Most recommendations were conditional and based on low to very low certainty of evidence. Conclusions: This clinical practice guideline provides a conceptual framework with evidence-based recommendations for best practices related to pediatric ventilator liberation.
Existing Data Analysis in Pediatric Critical Care Research
(Frontiers Media, 2014-07-29) Bennett, Tellen D.; Spaeder, Michael C.; Matos, Renée I.; Watson, R. Scott; Typpo, Katri V.; Khemani, Robinder G.; Crow, Sheri; Benneyworth, Brian D.; Thiagarajan, Ravi R.; Dean, J. Michael; Markovitz, Barry P.; Pediatric Acute Lung Injury and Sepsis Investigators (PALISI); Pediatrics, School of Medicine
Our objectives were to review and categorize the existing data sources that are important to pediatric critical care medicine (PCCM) investigators and the types of questions that have been or could be studied with each data source. We conducted a narrative review of the medical literature, categorized the data sources available to PCCM investigators, and created an online data source registry. We found that many data sources are available for research in PCCM. To date, PCCM investigators have most often relied on pediatric critical care registries and treatment- or disease-specific registries. The available data sources vary widely in the level of clinical detail and the types of questions they can reliably answer. Linkage of data sources can expand the types of questions that a data source can be used to study. Careful matching of the scientific question to the best available data source or linked data sources is necessary. In addition, rigorous application of the best available analysis techniques and reporting consistent with observational research standards will maximize the quality of research using existing data in PCCM.
A Network Meta-analysis of Dexamethasone for Preventing Post-Extubation Upper Airway Obstruction in Children
(American Thoracic Society Journals, 2022-08-17) Iyer, Narayan Prabhu; López-Fernández, Yolanda M.; González-Dambrauskas, Sebastián; Baranwal, Arun K.; Hotz, Justin C.; Zhu, Meng; Zhang, Yuan; Craven, Hannah J.; Whipple, Elizabeth C.; Abu-Sultaneh, Samer; Khemani, Robinder G.
RATIONALE: Peri-extubation corticosteroids are commonly used in children to prevent upper airway obstruction (UAO). However, the best timing and dose combination of corticosteroids is unknown. OBJECTIVES: To compare effectiveness of different corticosteroid regimens in preventing UAO and reintubation. METHODS: MEDLINE, CINAHL and Embase search identified randomized trials in children using corticosteroids to prevent UAO. All studies used dexamethasone. The studies were categorized based on timing of initiation of dexamethasone (early use: >12 hours prior to extubation) and the dose (high dose: (>/= 0.5mg/kg/dose). We performed Bayesian network meta-analysis (NMA) with studies grouped into four regimens- High dose, Early use (HE); Low dose, Early use (LE); High dose, Late use (HL) and Low dose, Late use (LL). RESULTS: 8 trials (n=903) were included in the analysis. For preventing UAO, (odds ratio, 95% credible interval), HE (0.13; 0.04, 0.36), HL (0.39; 0.19, 0.74) and LE (0.15; 0.04, 0.58) regimens appear to be more effective compared to no dexamethasone (low certainty). HE and LE had the highest probability of being the top ranked regimens for preventing UAO [surface under the cumulative ranking (SUCRA) 0.901 and 0.808 respectively]. For preventing reintubation, the effect estimate was imprecise for all four dexamethasone regimens compared to no dexamethasone (very low certainty). HE and LE were the top ranked regimens (SUCRA 0.803 and 0.720 respectively) for preventing reintubation. Sensitivity analysis showed that regimens which started >12 hours prior to extubation were likely more effective than regimens started >6 hours prior to extubation. CONCLUSIONS: Peri-extubation dexamethasone can prevent post-extubation UAO in children but effectiveness is highly dependent on timing and dosing regimen. Early initiation (ideally >12 hours prior to extubation) appears to be more important than the dose of dexamethasone. Ultimately the specific steroid strategy should be personalized considering the potential for adverse events associated with dexamethasone and the individual risk of UAO and reintubation.
Noninvasive Ventilation for Pediatric Acute Respiratory Distress Syndrome: Experience From the 2016/2017 Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Prospective Cohort Study
(Wolters Kluwer, 2023) Emeriaud, Guillaume; Pons-Òdena, Marti; Bhalla, Anoopindar K.; Shein, Steven L.; Killien, Elizabeth Y.; Modesto i Alapont, Vicent; Rowan, Courtney; Baudin, Florent; Lin, John C.; Grégoire, Gabrielle; Napolitano, Natalie; Mayordomo-Colunga, Juan; Diaz, Franco; Cruces, Pablo; Medina, Alberto; Smith, Lincoln; Khemani, Robinder G.; Pediatric Acute Respiratory Distress syndrome Incidence and Epidemiology (PARDIE) Investigators; Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network; Pediatrics, School of Medicine
Objectives: The worldwide practice and impact of noninvasive ventilation (NIV) in pediatric acute respiratory distress syndrome (PARDS) is unknown. We sought to describe NIV use and associated clinical outcomes in PARDS. Design: Planned ancillary study to the 2016/2017 prospective Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology study. Setting: One hundred five international PICUs. Patients: Patients with newly diagnosed PARDS admitted during 10 study weeks. Interventions: None. Measurements and main results: Children were categorized by their respiratory support at PARDS diagnosis into NIV or invasive mechanical ventilation (IMV) groups. Of 708 subjects with PARDS, 160 patients (23%) received NIV at PARDS diagnosis (NIV group). NIV failure rate (defined as tracheal intubation or death) was 84 of 160 patients (53%). Higher nonrespiratory pediatric logistic organ dysfunction (PELOD-2) score, Pa o2 /F io2 was less than 100 at PARDS diagnosis, immunosuppression, and male sex were independently associated with NIV failure. NIV failure was 100% among patients with nonrespiratory PELOD-2 score greater than 2, Pa o2 /F io2 less than 100, and immunosuppression all present. Among patients with Pa o2 /F io2 greater than 100, children in the NIV group had shorter total duration of NIV and IMV, than the IMV at initial diagnosis group. We failed to identify associations between NIV use and PICU survival in a multivariable Cox regression analysis (hazard ratio 1.04 [95% CI, 0.61-1.80]) or mortality in a propensity score matched analysis ( p = 0.369). Conclusions: Use of NIV at PARDS diagnosis was associated with shorter exposure to IMV in children with mild to moderate hypoxemia. Even though risk of NIV failure was high in some children, we failed to identify greater hazard of mortality in these patients.

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