This is a unique state of the art review written by a group of 21 international recognized experts in the field that gathered during a meeting organized by the European Neuromuscular Centre (ENMC) in Naarden, March 2017. It systematically reports the entire evidence base for airway clearance techniques (ACTs) in both adults and children with neuromuscular disorders (NMD). We not only report randomised controlled trials, which in other systematic reviews conclude that there is a lack of evidence base to give an opinion, but also include case series and retrospective reviews of practice. For this review, we have classified ACTs as either proximal (cough augmentation) or peripheral (secretion mobilization). The review presents descriptions; standard definitions; the supporting evidence for and limitations of proximal and peripheral ACTs that are used in patients with NMD; as well as providing recommendations for objective measurements of efficacy, specifically for proximal ACTs. This state of the art review also highlights how ACTs may be adapted or modified for specific contexts (e.g. in people with bulbar insufficiency; children and infants) and recommends when and how each technique should be applied.

Endotracheal suctioning is a procedure used regularly in the pediatric intensive care unit. Despite this, good evidence supporting its practice is limited. Further, controlled clinical studies are needed to develop evidence-based protocols for endotracheal suctioning of infants and children, and to examine the impact of different suctioning techniques on the duration of ventilatory support, incidence of nosocomial infection, and length of pediatric intensive care unit and hospital stay.

ObjectiveMore children are surviving critical illness but are at risk of residual or new health conditions. An evidence-informed and stakeholder-recommended core outcome set is lacking for pediatric critical care outcomes. Our objective was to create a multinational, multi-stakeholder-recommended Pediatric Critical Care Core Outcome Set for inclusion in clinical and research programs. Design A 2-round modified Delphi electronic survey was conducted with 333 invited research, clinical, and family/advocate stakeholders. Stakeholders completing the first round were invited to participate in the second. Outcomes scoring > 69% "critical" and < 15% "not important" advanced to round 2 with write-in outcomes considered. The Steering Committee held a virtual consensus conference to determine the final components. Setting Multinational survey. Patients Stakeholder participants from 6 continents representing clinicians, researchers, and family/advocates. Main Results Overall response rates were 75% and 82% for each round. Participants voted on 7 Global Domains and 45 Specific Outcomes in Round 1, and 6 Global Domains and 30 Specific Outcomes in Round 2. Using Overall (3 stakeholder groups combined) results, consensus was defined as outcomes scoring > 90% "critical" and < 15% "not important" and were included in the final PICU COS: 4 Global domains (Cognitive, Emotional, Physical and Overall Health) and 4 Specific outcomes (Child Health-Related Quality of Life, Pain, Survival, and Communication). Families (n=21) suggested additional critically important outcomes that did not meet consensus, which were included in the PICU COS -Extended. ConclusionsThe PICU Core Outcome Set and PICU COS-Extended are multi-stakeholderrecommended resources for clinical and research programs that seek to improve outcomes for children with critical illness and their families.

PCP is a common cause of hypoxic pneumonia and mortality in HIV-infected South African infants. Underuse of the Prevention of Mother to Child Transmission program and failure to institute trimethoprim-sulfamethoxazole prophylaxis in HIV-exposed children identified through the program are important obstacles to reducing PCP incidence.

Endotracheal suctioning is performed regularly in ventilated infants and children to remove obstructive secretions. The effect of suctioning on respiratory mechanics is not known. This study aimed to determine the immediate effect of endotracheal suctioning on dynamic lung compliance, tidal volume, and airway resistance in mechanically-ventilated paediatric patients by means of a prospective observational clinical study. Lung mechanics were recorded for five minutes before and five minutes after a standardised suctioning procedure in 78 patients intubated with endotracheal tubes < or = 4.0 mm internal diameter. Twenty-four patients with endotracheal tube leaks > or = 20% were excluded from analysis. There was a significant overall decrease in dynamic compliance (p < 0.001) and mechanical expired tidal volume (p = 0.03) following suctioning with no change in the percentage endotracheal tube leak (p = 0.41). The change in dynamic compliance was directly related to both endotracheal tube and catheter sizes. There was no significant change in expiratory or inspiratory airway resistance following suctioning (p > 0.05). Although the majority of patients (68.5%) experienced a drop in dynamic compliance following suctioning, dynamic compliance increased in 31.5% of patients after the procedure. This study demonstrates that endotracheal suctioning frequently causes an immediate drop in dynamic compliance and expired tidal volume in ventilated children with variable lung pathology, intubated with small endotracheal tubes, probably indicating loss of lung volume caused by the suctioning procedure. There is no evidence that suctioning reduces airway resistance.

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.

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Viral respiratory tract infection is common in this pediatric intensive care unit associated with significant morbidity and mortality, which may relate to the high burden of comorbidity and HIV.