Resp Care
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The current trend for supporting neonates with respiratory distress syndrome is nasal continuous positive airway pressure (CPAP). Nearly half of all neonates who are supported with CPAP will still develop respiratory failure that requires potentially injurious endotracheal intubation and invasive ventilation. ⋯ With the inception of nasal airway interfaces, clinicians have ushered in many different forms of NIV in neonates, often with very little experimental data to guide management. This review will explore in detail all of the different forms of neonatal NIV that are currently focused within an area of intense clinical investigation.
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As the basis for this paper, it must be acknowledged that children are not simply small adults. But this acknowledgment must go further: infants are not simply small adolescents. ⋯ Hopefully, with the collaboration of multicenter investigator networks, additional and definitive pediatric data may be on the horizon. In the meantime, sharing data between adult and pediatric populations seems to be an essential approach to the management of critically ill patients.
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The mixture of oxygen and nitrogen is usually sufficient to achieve the therapeutic objective of supporting adequate gas exchange. Pediatric and neonatal patients have an assortment of physiologic conditions that may require adjunctive inhaled gases to treat the wide variety of diseases seen in this heterogeneous population. Inhaled nitric oxide, helium oxygen mixtures, inhaled anesthetics, hypercarbic mixtures, hypoxic mixtures, inhaled carbon monoxide, and hydrogen sulfide have been used to alter physiology in an attempt to improve patient outcomes. Balancing the therapeutic potential, possible adverse effects, and the complexity of the technical aspects of gas delivery, it is essential that clinicians thoroughly understand the application of medical gas therapy beyond the traditional nitrogen/oxygen mixture.
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Review
Pediatric airway maintenance and clearance in the acute care setting: how to stay out of trouble.
Traditional airway maintenance and clearance therapy and principles of application are similar for neonates, children, and adults. Yet there are distinct differences in physiology and pathology between children and adults that limit the routine application of adult-derived airway-clearance techniques in children. This paper focuses on airway-clearance techniques and airway maintenance in the pediatric patient with acute respiratory disease, specifically, those used in the hospital environment, prevailing lung characteristics that may arise during exacerbations, and the differences in physiologic processes unique to infants and children. ⋯ Airway-clearance techniques consume a substantial amount of time and equipment. Available disease-specific evidence of airway-clearance techniques and airway maintenance will be discussed whenever possible. Unfortunately, more questions than answers remain.
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Pediatric clinicians strive to base their management decisions on best available evidence. In the quantitative research paradigm, the highest level of evidence is derived from a conclusive randomized controlled clinical trial (RCT). ⋯ We are all obligated to ensure the relevance of our research, to mentor junior investigators, and to support knowledge development in our field. This paper reviews the hurdles faced by clinical investigators in the field of pediatric critical care and offers suggestions for future clinical studies.