Our study suggests that a high-flow nasal cannula "holiday" protocol is a safe and effective way to successfully wean PICU patients off high-flow nasal cannula. Additional investigation including validation of the scoring system used is warranted.

Introduction Children with severe bronchospasm requiring mechanical ventilation may become refractory to conventional therapy. In these critically ill patients, isoflurane is an inhaled anesthetic agent available in some centers to treat bronchospasm. We hypothesized that isoflurane is safe and would lead to improved gas exchange in children with life-threatening bronchospasm refractory to conventional therapy. Methods A retrospective review was conducted and included mechanically ventilated children treated with isoflurane in a quaternary pediatric intensive care unit for life-threatening bronchospasm from 1993–2007. Demographic, blood gas, ventilator and outcome data were collected. Results Thirty-one patients with a mean age of 9.5 years (range; 0.4 – 23 years) were treated with isoflurane from 1993–2007. Mean time to initiation of isoflurane after intubation was 13 hours (0–120 hours) and the mean maximum isoflurane dose was 1.1 % (0.3 – 2.5%). Mean duration of isoflurane administration was 54.5 hours (1 – 181), with a total mean duration of mechanical ventilation of 252 hours (33.3 – 1454.5). Isoflurane led to significant improvement in pH and pCO2 within four hours of initiation (p ≤ 0.001). Complications during isoflurane administration included hypotension requiring vasoactive infusions in 24 (77%), arrhythmia in 3 (10%), neurologic side effects in 3 (10%), and pneumothorax in 1 (3%) patient. Conclusions Isoflurane led to improvement in pH and pCO2 within four hours in this series of mechanically ventilated patients with life-threatening bronchospasm. The majority of patients in this series developed hypotension, but there was a low incidence of other side effects related to isoflurane administration. Isoflurane appears to be an effective therapy in patients with life-threatening bronchospasm refractory to conventional therapy. However, further investigation is warranted given the uncertain overall impact of isoflurane in this context.

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