OPTIMAL LEVEL OF NASAL CONTINUOUS POSITIVE AIRWAY PRESSURE IN SEVER VIRAL BRONCHIOLITIS
Essouri S, Durand P, Chevret L, Balu L, Devictor D, Fauroux B, Tissierres P. Intensive Care Medicine. 2011;37:2002-2007.
In this prospective physiological study, the researchers sought to determine the optimal level of nasal continuous positive airway pressure (nCPAP) in infants with severe hypercapnic viral bronchiolitis by assessing the maximal unloading of the respiratory muscles and improvement of breathing pattern and gas exchange. The patients (n = 10) with severe hypercapnic viral bronchiolitis were measured by their breathing pattern, gas exchange, intrinsic end-expiratory pressure, and respiratory muscle effort. The measurements were taken during spontaneous breathing and at 3 increasing levels of nCPAP.
During spontaneous breathing, median intrinsic end-expiratory pressure was 6 cm H2O, and median respiratory rate was 78 breaths/min. In all infants, an nCPAP level of 7 cm H2O was associated with the greatest reduction in respiratory effort. During nCPAP, median respiratory rate decreased to 56 breaths/min. Only 1 infant required intubation related to associated bacterial pneumonia, and all infants were discharged alive from the pediatric intensive care unit with a median stay of 5.5 days (range, 3-27 days).
The researchers concluded that, in infants with hypercapnic respiratory failure due to acute viral bronchiolitis, an nCPAP level of 7 cm H2O was associated with the greatest unloading of respiratory muscles with concomitant significant improvement in respiratory distress and clinical outcome.
OUTCOMES OF PNEUMOCYSTIS JIROVECI PNEUMONIA INFECTIONS IN PEDIATRIC HEART TRANSPLANT RECIPIENTS
Ng B, Dipchand A, Naftel D, Rusconie P, Zaoutis T, Edens E. Pediatric Transplant. 2011;12:844-848.
Pneumocystis jiroveci pneumonia (PJP) can cause significant morbidity and mortality in immunosuppressed individuals, but there is limited information on the prevalence and outcomes of PJP in pediatric solid organ transplant recipients. The authors sought to establish prevalence and outcome of PJP in pediatric heart transplant patients.
This prospective cohort study from January 1, 1993, to December 31, 2004, which included 24 contributing institutions (representing 60% of the heart transplants in the United States during the study period), found a total 2038 infections in 1220 patients. Of these patients there were 139 fungal infections in 123 individual patients, and 18 of these were because of PJP.
The authors state this resulted in a rate of PJP infection of 1% during the study period and an incidence of 2.6 infections for every 1000 patient-years. The authors also found that of the 18 patients with PJP, only 2 were documented to be taking trimethoprim/sulfamethoxazole prophylaxis. The authors also found that children who receive their heart transplant at less than 1 year of age have a significantly increased risk for PJP during the first 2 years after transplantation as compared with those children who are transplanted at 1 year or older.
The authors concluded that the incidence of PJP in pediatric heart transplant patients is very low, and the mortality related to PJP continues to be less than other fungal infections. The patients are the highest risk of PJP from ages 2 months to 2 years after transplantation and that patients who receive a transplant at younger than 1 year have a higher risk of acquiring PJP for the first 2 years after transplantation. The authors also recommend that transplanted patients younger than 1 year will benefit the most from PJP prophylaxis during the first 2 years after transplantation.