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Evaluation of Respiratory Mechanics and Function in the PICU and NICU

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Evaluation of Respiratory Mechanics and Function in the PICU and NICU AMERICAN THORACIC SOCIETY DOCUMENTS An Official American Thoracic Society/European Respiratory Society Workshop Report: Evaluation of Respiratory Mechanics and Function in the Pediatric and Neonatal Intensive Care Units Stacey Peterson-Carmichael*, Paul C. Seddon*, Ira M. Cheifetz, Inez ´ Frerichs, Graham L. Hall, Jurg ¨ Hammer, Zoltan ´ Hantos, Anton H. van Kaam, Cindy T. McEvoy, Christopher J. L. Newth, J. Jane Pillow, Gerrard F. Rafferty, Margaret Rosenfeld, Janet Stocks, and Sarath C. Ranganathan; on behalf of the ATS/ERS Working Group on Infant and Young Children Pulmonary Function Testing THIS OFFICIAL WORKSHOP REPORT OF THE AMERICAN THORACIC SOCIETY (ATS) AND THE EUROPEAN RESPIRATORY SOCIETY (ERS) WAS APPROVED BY THE ATS BOARD OF DIRECTORS,OCTOBER 2015, AND BY THE ERS SCIENCE COUNCIL AND EXECUTIVE COMMITTEE,SEPTEMBER 2015 Abstract research collaboration. From expert panel discussions and literature reviews, we conclude that many of the techniques can aid in optimizing Ready access to physiologic measures, including respiratory mechanics, respiratory support in the PICU and NICU, quantifying the effect of lung volumes, and ventilation/perfusion inhomogeneity, could optimize therapeutic interventions, and guiding ventilator weaning and the clinical management of the critically ill pediatric or neonatal patient extubation. Most techniques now have commercially available and minimize lung injury. There are many techniques for measuring equipment for the PICU and NICU, and many can generate continuous respiratory function in infants and children but very limited information data points to help with ventilator weaning and other interventions. on the technical ease and applicability of these tests in the pediatric and Technical and validation studies in the PICU and NICU are published neonatal intensive care unit (PICU, NICU) environments. This report for the majority of techniques; some have been used as outcome summarizes the proceedings of a 2011 American Thoracic Society measures in clinical trials, but few have been assessed specifically for their Workshop critically reviewing techniques available for ventilated and ability to improve clinical outcomes. Although they show considerable spontaneously breathing infants and children in the ICU. It outlines for promise, these techniques still require further study in the PICU and each test how readily it is performed at the bedside and how it may NICU together with increased availability of commercial equipment impact patient management as well as indicating future areas of potential before wider incorporation into daily clinical practice. *Joint first authors. This document has an online supplement, which is accessible from this issue’s table of contents at www.atsjournals.org Ann Am Thorac Soc Vol 13, No 2, pp S1–S11, Feb 2016 Copyright © 2016 by the American Thoracic Society DOI: 10.1513/AnnalsATS.201511-730ST Internet address: www.atsjournals.org Contents Chest Wall Measurements funded by the ATS and was held at the 2011 Occlusion Pressures ATS International Conference meeting in Overview Discussion and Future Directions Denver, Colorado, with a follow-on meeting Introduction Proposed Areas of Future Research at the 2012 ATS Conference. The workshop Methods Collaboration was initiated by the joint ATS/European Measurement Techniques Respiratory Society Working Group on Dynamic/Passive Mechanics Infant and Young Children Pulmonary Forced Deflation Overview Function Testing to address the lack of Forced Oscillation Technique information on respiratory function Ventilator Graphics The American Thoracic Society (ATS) techniques available to assist in the Volumetric Capnography workshop on Evaluation of Respiratory management of patients in pediatric Inert Gas Washout Mechanics and Function in the Pediatric and neonatal intensive care units (PICU, Electrical Impedance Tomography and Neonatal Intensive Care Units was NICU). American Thoracic Society Documents S1 AMERICAN THORACIC SOCIETY DOCUMENTS The principal conclusions are as ∘ Once equipment is in situ, each technique stable child in the outpatient or ambulatory follows: can be performed within approximately setting. Discussions within and beyond the d The main clinical issues for which 15 minutes on each patient, and some Working Group in 2010 to 2011 indicated respiratory function measurements can can give continuous real-time data (1) the availability of respiratory provide useful information to guide during supported ventilation. measurement techniques potentially management are: ∘ Additional time needs to be allowed for applicable in pediatric intensive care ∘ assessing the physiologic nature and equipment setup, to await patient unit/neonatal intensive care unit progression of respiratory disease stability, and for calculation/ (PICU/NICU), and (2) a desire by ∘ optimizing respiratory support and interpretation of results; this will depend clinicians to know more about these minimizing ventilator-associated lung on the technique, the child’s clinical techniques. These discussions led directly to injury condition, and the experience of the an ATS-funded project: “Evaluation of ∘ assessing the effect of therapeutic operator. respiratory mechanics and function in the interventions (e.g., drugs, physiotherapy) ∘ Risks are minimal, but the following pediatric and neonatal intensive care units.” ∘ assessing readiness to wean from precautions are important: The aim of this Workshop Report respiratory support - infection control issues must be addressed document is to identify and concisely review - awareness of increased dead space during respiratory function tests that show the most d The techniques considered currently some types of measurement promise for the clinical monitoring of useful or promising in providing this - disconnection times must be minimized vulnerable and critically ill young patients, information are: to avoid derecruitment in positive end- requiring care in a PICU, NICU, or similar ∘ measurement of respiratory mechanics expiratory pressure (PEEP)–dependent facility. The objectives were to (1) review the (compliance and resistance of lung or patients safety, feasibility, and published data to date respiratory system) using both dynamic on the relevant techniques; (2) list possible and passive techniques d There is a wealth of published data on applications to guide clinical management ∘ measurement of forced expiratory flows the validity and technical aspects of the in the PICU and NICU; and (3) identify and volumes using the negative pressure various techniques. Most techniques future directions and research needs. Use of forced deflation technique have been used as outcome measures in such techniques in the PICU and NICU ∘ measurement of respiratory resistance studies on therapeutic interventions. may benefit patients through enhancing and reactance using the forced Empirical data on the ability of these optimization of ventilator management and oscillation technique (FOT) measurements to assist in clinical monitoring the response to therapeutic ∘ use of ventilator graphics to provide management of individual patients are interventions. In addition, measurements qualitative visual information (both scarce: available data are restricted can form a baseline to aid with monitoring time-based and XY plots) primarily to respiratory mechanics evolution of respiratory disease both acutely ∘ measurement of carbon dioxide measurements, ventilator graphics, and in the PICU/NICU and at follow up. elimination as a function of exhaled volumetric capnography. Finally, it should be stressed that volume of gas (volumetric capnography) despite the potential clinical benefit many of ∘ measurement of lung volumes and these tests may provide, more research is ventilation distribution using inert gas Introduction warranted for each technique before any washout techniques clinical recommendations on specific ages, ∘ dynamic assessment of regional Respiratory disease dominates admissions disease entities, or outcome measures ventilation using electrical impedance to both pediatric and neonatal intensive associated with testing. We aim to provide tomography care units (PICU, NICU) to a greater the pediatric and neonatal intensivist with a ∘ measurement of tidal volumes, flow extent than equivalent adult units (1). guide for choosing potential respiratory parameters, and thoracoabdominal Nonetheless, the use of respiratory function tests and information regarding asynchrony at the chest wall measurement techniques to guide future research areas of interest, specifically (6simultaneous esophageal manometry) management in children has lagged behind bedside evaluations of lung volumes, ∘ assessment of respiratory drive and adult intensive care practices. Rapid ventilation inhomogeneity, and respiratory respiratory muscle strength using advances in the development of respiratory mechanics in ventilated patients. occlusion pressures function tests applicable to infants and d All of these techniques are feasible and young children have been achieved in have been performed in PICU/NICU recent years. Methods settings. Since its establishment in 1990, the ∘ Suitable commercial equipment is joint American Thoracic Society/European This project originated in a Clinical currently available for all techniques Respiratory Society (ATS/ERS) Working Workshop run at the American Thoracic except FOT, forced deflation, and Group on Infant and Young Children Society Annual Conference in New Orleans occlusion pressures. Pulmonary Function Testing has
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