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Item ATS Core Curriculum 2016: Part II. Adult Critical Care Medicine(American Thoracic Society, 2016-05) McSparron, Jakob I.; Hayes, Margaret M.; Poston, Jason T.; Thomson, Carey C.; Fessler, Henry E.; Stapleton, Renee D.; Carlos, W. Graham; Hinkle, Laura; Liu, Kathleen; Shieh, Stephanie; Ali, Alyan; Rogers, Angela; Shah, Nirav G.; Slack, Donald; Patel, Bhakti; Wolfe, Krysta; Schweickert, William D.; Bakhru, Rita N.; Shin, Stephanie; Sell, Rebecca E.; Luks, Andrew M.; Medicine, School of MedicineThe American Thoracic Society (ATS) Core Curriculum updates clinicians annually in adult and pediatric pulmonary disease, medical critical care, and sleep medicine, in a 3-year recurring cycle of topics. The 2016 course was presented in May during the annual International Conference. The four parts of the course are published in consecutive issues of AnnalsATS. Part II covers topics in adult critical care medicine. An American Board of Internal Medicine Maintenance of Certification module and a Continuing Medical Education exercise covering the contents of the CORE Curriculum can be accessed online at www.thoracic.org until July 2019.Item Implementation of a High Flow Nasal Cannula Management Protocol in the Pediatric ICU(American Association for Respiratory Care, 2021-04-01) Peterson, Rachel J.; Hassumani, Daniel O.; Hole, Acrista J.; Slaven, James E.; Tori, Alvaro J.; Abu-Sultaneh, SamerItem Noninvasive Ventilation Exposure Prior to Intubation in Pediatric Hematopoietic Cell Transplant Recipients(Daedalus Enterprises, 2022) Cater, Daniel T.; Fitzgerald, Julie C.; Gertz, Shira J.; McArthur, Jennifer A.; Daniel, Megan C.; Mahadeo, Kris M.; Hsing, Deyin D.; Smith, Lincoln S.; Pike, Francis; Rowan, Courtney M.; Pediatrics, School of MedicineBackground: Noninvasive ventilation (NIV) has become more studied in immunocompromised patients. However, it has not been studied in hematopoietic cell transplantation (HCT) recipients, who have higher mortality and higher pulmonary complication rates than other immunocompromised patients. This population may be prone to negative effects from this treatment modality. The aim of this study was to determine whether NIV use is associated with worse outcomes in this vulnerable patient population. Methods: A secondary analysis of a retrospective multi-center database was performed. Twelve pediatric ICUs across the United States enrolled HCT subjects from 2009-2014 that were admitted to the pediatric ICU (PICU) with the diagnosis of acute respiratory failure. Subjects exposed to NIV prior to intubation were compared against those not exposed to NIV. Our primary outcome was all-cause mortality at 90 d; secondary outcomes included ventilator-free days (VFD) at 28 d and development of pediatric ARDS. Multivariable logistic and linear regression models were constructed using variables significant on univariable analysis. Results: Two-hundred eleven subjects were included. Of these, 82 (39%) received NIV prior to intubation. Those that received NIV prior to intubation were older (13 vs 6 y, P < .001) and more commonly diagnosed with respiratory distress (90% vs 74%, P = .004). On multivariable analysis, NIV use prior to intubation was associated with a higher PICU mortality (hazard ratio 1.51 [95% CI 1.18-2.28], P = .02) and fewer VFD at 28 d (β -3.50 [95% CI -6.09 to 0.91], P = .008). Those with NIV exposure prior to intubation also had higher rates of development of pediatric ARDS (95% vs 78%, P = .001). Conclusions: In this cohort of children post-HCT, NIV use prior to intubation was associated with worse outcomes. The benefits and risks of NIV in this patient population should be carefully evaluated prior to its use, and careful patient selection is crucial for its optimal utilization.Item Pediatric asthma severity score is associated with critical care interventions(Baishideng Publishing Group, 2017-02-08) Maue, Danielle K.; Krupp, Nadia; Rowan, Courtney M.; Department of Pediatrics, IU School of MedicineAIM: To determine if a standardized asthma severity scoring system (PASS) was associated with the time spent on continuous albuterol and length of stay in the pediatric intensive care unit (PICU). METHODS: This is a single center, retrospective chart review study at a major children's hospital in an urban location. To qualify for this study, participants must have been admitted to the PICU with a diagnosis of status asthmaticus. There were a total of 188 participants between the ages of two and nineteen, excluding patients receiving antibiotics for pneumonia. PASS was calculated upon PICU admission. Subjects were put into one of three categories based on PASS: ≤ 7 (mild), 8-11 (moderate), and ≥ 12 (severe). The groups were compared based on different variables, including length of continuous albuterol and PICU stay. RESULTS: The age distribution across all groups was similar. The median length of continuous albuterol was longest in the severe group with a duration of 21.5 h (11.5-27.5), compared to 15 (7.75-23.75) and 10 (5-15) in the moderate and mild groups, respectively (P = 0.001). The length of stay was longest in the severe group, with a stay of 35.6 h (22-49) compared to 26.5 (17-30) and 17.6 (12-29) in the moderate and mild groups, respectively (P = 0.001). CONCLUSION: A higher PASS is associated with a longer time on continuous albuterol, an increased likelihood to require noninvasive ventilation, and a longer stay in the ICU. This may help safely distribute asthmatics to lower and higher levels of care in the future.Item The Use and Duration of Preintubation Respiratory Support Is Associated With Increased Mortality in Immunocompromised Children With Acute Respiratory Failure(Wolters Kluwer, 2022) Lindell, Robert B.; Fitzgerald, Julie C.; Rowan, Courtney M.; Flori, Heidi R.; Di Nardo, Matteo; Napolitano, Natalie; Traynor, Danielle M.; Lenz, Kyle B.; Emeriaud, Guillaume; Jeyapalan, Asumthia; Nishisaki, Akira; National Emergency Airway Registry for Children (NEAR4KIDS); Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network; Pediatrics, School of MedicineObjectives: To determine the association between preintubation respiratory support and outcomes in patients with acute respiratory failure and to determine the impact of immunocompromised (IC) diagnoses on outcomes after adjustment for illness severity. Design: Retrospective multicenter cohort study. Setting: Eighty-two centers in the Virtual Pediatric Systems database. Patients: Children 1 month to 17 years old intubated in the PICU who received invasive mechanical ventilation (IMV) for greater than or equal to 24 hours. Interventions: None. Measurements and main results: High-flow nasal cannula (HFNC) or noninvasive positive-pressure ventilation (NIPPV) or both were used prior to intubation in 1,825 (34%) of 5,348 PICU intubations across 82 centers. When stratified by IC status, 50% of patients had no IC diagnosis, whereas 41% were IC without prior hematopoietic cell transplant (HCT) and 9% had prior HCT. Compared with patients intubated without prior support, preintubation exposure to HFNC (adjusted odds ratio [aOR], 1.33; 95% CI, 1.10-1.62) or NIPPV (aOR, 1.44; 95% CI, 1.20-1.74) was associated with increased odds of PICU mortality. Within subgroups of IC status, preintubation respiratory support was associated with increased odds of PICU mortality in IC patients (HFNC: aOR, 1.50; 95% CI, 1.11-2.03; NIPPV: aOR, 1.76; 95% CI, 1.31-2.35) and HCT patients (HFNC: aOR, 1.75; 95% CI, 1.07-2.86; NIPPV: aOR, 1.85; 95% CI, 1.12-3.02) compared with IC/HCT patients intubated without prior respiratory support. Preintubation exposure to HFNC/NIPPV was not associated with mortality in patients without an IC diagnosis. Duration of HFNC/NIPPV greater than 6 hours was associated with increased mortality in IC HCT patients (HFNC: aOR, 2.41; 95% CI, 1.05-5.55; NIPPV: aOR, 2.53; 95% CI, 1.04-6.15) and patients compared HCT patients with less than 6-hour HFNC/NIPPV exposure. After adjustment for patient and center characteristics, both preintubation HFNC/NIPPV use (median, 15%; range, 0-63%) and PICU mortality varied by center. Conclusions: In IC pediatric patients, preintubation exposure to HFNC and/or NIPPV is associated with increased odds of PICU mortality, independent of illness severity. Longer duration of exposure to HFNC/NIPPV prior to IMV is associated with increased mortality in HCT patients.