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compression during different compressionventilation ratios in manikin-simulated paediatric resuscitation Resuscitation 2000;43(2):115-120 87 Srikantan SK, Berg RA, Cox T, Tice L, Nadkarni VM Effect of onerescuer compression/ventilation ratios on cardiopulmonary resuscitation in infant, pediatric, and adult manikins Pediatr Crit Care Med 2005;6(3):293-297 88 Berg RA, Sanders AB, Kern KB, et al Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest Circulation 2001;104(20):2465-2470 89 Meaney PA, Bobrow BJ, Mancini ME, et al Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association Circulation 2013;128(4):417-435 90 Lautz AJ, Morgan RW, Karlsson M, et al Hemodynamic-directed cardiopulmonary resuscitation improves neurologic outcomes and mitochondrial function in the heart and brain Crit Care Med 2019;47(3):e241-e249 91 Morgan RW, French B, Kilbaugh TJ, et al A quantitative comparison of physiologic indicators of cardiopulmonary resuscitation quality: diastolic blood pressure versus end-tidal carbon dioxide Resuscitation 2016;104:6-11 92 Berg RA, Sutton RM, Reeder RW, et al Association between diastolic blood pressure during pediatric in-hospital cardiopulmonary resuscitation and survival Circulation 2018;137(17):1784-1795 93 Weil MH, Bisera J, Trevino RP, Rackow EC Cardiac output and end-tidal carbon dioxide Crit Care Med 1985;13(11):907-909 94 Sanders AB, Ewy GA, Bragg S, Atlas M, Kern KB Expired PCO2 as a prognostic indicator of successful resuscitation from cardiac arrest Ann Emerg Med 1985;14(10):948-952 95 Sheak KR, Wiebe DJ, Leary M, et al Quantitative relationship between end-tidal carbon dioxide and CPR quality during both inhospital and out-of-hospital cardiac arrest Resuscitation 2015;89:149-154 96 Lui CT, Poon KM, Tsui KL Abrupt rise of end tidal carbon dioxide level was a specific but non-sensitive marker of return of spontaneous circulation in patient with out-of-hospital cardiac arrest Resuscitation 2016;104:53-58 97 Pokorna M, Necas E, Kratochvil J, Skripsky R, Andrlik M, Franek O A sudden increase in partial pressure end-tidal carbon dioxide (P(ET)CO(2)) at the moment of return of spontaneous circulation J Emerg Med 2010;38(5):614-621 98 Hamrick JT, Hamrick JL, Bhalala U, et al End-tidal CO2-guided chest compression delivery improves survival in a neonatal asphyxial cardiac arrest model Pediatr Crit Care Med 2017;18(11): e575-e584 99 Hamrick JL, Hamrick JT, Lee JK, Lee BH, Koehler RC, Shaffner DH Efficacy of chest compressions directed by end-tidal CO2 feedback in a pediatric resuscitation model of basic life support J Am Heart Assoc 2014;3(2):e000450 100 Berg RA, Reeder RW, Meert KL, et al End-tidal carbon dioxide during pediatric in-hospital cardiopulmonary resuscitation Resuscitation 2018;133:173-179 101 Sutton RM, French B, Meaney PA, et al Physiologic monitoring of CPR quality during adult cardiac arrest: A propensity-matched cohort study Resuscitation 2016;106:76-82 102 Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial JAMA 2009;302(20):2222-2229 103 Perkins GD, Ji C, Deakin CD, et al A randomized trial of epinephrine in out-of-hospital cardiac arrest N Engl J Med 2018;379(8): 711-721 104 Andersen LW, Berg KM, Saindon BZ, et al Time to epinephrine and survival after pediatric in-hospital cardiac arrest JAMA 2015;314(8):802-810 105 Raymond TT, Praestgaard A, Berg RA, Nadkarni VM, Parshuram CS, American Heart Association’s Get With The Guidelines-Resuscitation Investigators The Association of Hospital Rate of Delayed Epinephrine Administration with survival to discharge for pediatric nonshockable in-hospital cardiac arrest Pediatr Crit Care Med 2019;20(5):405-416 106 Perondi MB, Reis AG, Paiva EF, Nadkarni VM, Berg RA A comparison of high-dose and standard-dose epinephrine in children with cardiac arrest N Engl J Med 2004;350(17):1722-1730 107 Wenzel V, Krismer AC, Arntz HR, et al A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation N Engl J Med 2004;350(2):105-113 108 Stiell IG, Hebert PC, Wells GA, et al Vasopressin versus epinephrine for inhospital cardiac arrest: a randomised controlled trial Lancet 2001;358(9276):105-109 109 Duncan JM, Meaney P, Simpson P, et al Vasopressin for in-hospital pediatric cardiac arrest: results from the American Heart Association National Registry of Cardiopulmonary Resuscitation Pediatr Crit Care Med 2009;10(2):191-195 110 Morgan RW, Fitzgerald JC, Weiss SL, Nadkarni VM, Sutton RM, Berg RA Sepsis-associated in-hospital cardiac arrest: Epidemiology, pathophysiology, and potential therapies J Crit Care 2017;40: 128-135 111 Valdes SO, Donoghue AJ, Hoyme DB, et al Outcomes associated with amiodarone and lidocaine in the treatment of in-hospital pediatric cardiac arrest with pulseless ventricular tachycardia or ventricular fibrillation Resuscitation 2014;85(3):381-386 112 Kudenchuk PJ, Leroux BG, Daya M, et al Antiarrhythmic drugs for nonshockable-turned-shockable out-of-hospital cardiac arrest: the ALPS study (Amiodarone, Lidocaine, or Placebo) Circulation 2017;136(22):2119-2131 113 Kudenchuk PJ, Brown SP, Daya M, et al Amiodarone, Lidocaine, or Placebo in out-of-hospital cardiac arrest N Engl J Med 2016;374(18):1711-1722 114 de Mos N, van Litsenburg RR, McCrindle B, Bohn DJ, Parshuram CS Pediatric in-intensive-care-unit cardiac arrest: incidence, survival, and predictive factors Crit Care Med 2006;34(4):1209-1215 115 Meert KL, Donaldson A, Nadkarni V, et al Multicenter cohort study of in-hospital pediatric cardiac arrest Pediatr Crit Care Med 2009;10(5):544-553 116 Srinivasan V, Morris MC, Helfaer MA, Berg RA, Nadkarni VM, American Heart Association National Registry of CPR Investigators Calcium use during in-hospital pediatric cardiopulmonary resuscitation: a report from the National Registry of Cardiopulmonary Resuscitation Pediatrics 2008;121(5):e1144-e1151 117 Raymond TT, Stromberg D, Stigall W, Burton G, Zaritsky A, American Heart Association’s Get With The Guidelines-Resuscitation Investigators Sodium bicarbonate use during in-hospital pediatric pulseless cardiac arrest - a report from the American Heart Association Get With The Guidelines((R))-Resuscitation Resuscitation 2015;89:106-113 118 Conlon TW, Falkensammer CB, Hammond RS, Nadkarni VM, Berg RA, Topjian AA Association of left ventricular systolic function e4 and vasopressor support with survival following pediatric out-ofhospital cardiac arrest Pediatr Crit Care Med 2015;16(2):146-154 119 Adrie C, Adib-Conquy M, Laurent I, et al Successful cardiopulmonary resuscitation after cardiac arrest as a “sepsis-like” syndrome Circulation 2002;106(5):562-568 120 Lin YR, Wu HP, Chen WL, et al Predictors of survival and neurologic outcomes in children with traumatic out-of-hospital cardiac arrest during the early postresuscitative period J Trauma Acute Care Surg 2013;75(3):439-447 121 Lin YR, Li CJ, Wu TK, et al Post-resuscitative clinical features in the first hour after achieving sustained ROSC predict the duration of survival in children with non-traumatic out-of-hospital cardiac arrest Resuscitation 2010;81(4):410-417 122 Ferguson LP, Durward A, Tibby SM Relationship between arterial partial oxygen pressure after resuscitation from cardiac arrest and mortality in children Circulation 2012;126(3):335-342 123 Del Castillo J, Lopez-Herce J, Matamoros M, et al Hyperoxia, hypocapnia and hypercapnia as outcome factors after cardiac arrest in children Resuscitation 2012;83(12):1456-1461 124 Abend NS, Topjian A, Ichord R, et al Electroencephalographic monitoring during hypothermia after pediatric cardiac arrest Neurology 2009;72(22):1931-1940 125 Sutton RM, Niles D, French B, et al First quantitative analysis of cardiopulmonary resuscitation quality during in-hospital cardiac arrests of young children Resuscitation 2014;85(1):70-74 126 Sutton RM, Niles D, Nysaether J, et al Quantitative analysis of CPR quality during in-hospital resuscitation of older children and adolescents Pediatrics 2009;124(2):494-499 127 Niles DE, Duval-Arnould J, Skellett S, et al Characterization of Pediatric In-Hospital Cardiopulmonary Resuscitation Quality Metrics Across an International Resuscitation Collaborative Pediatr Crit Care Med 2018;19(5):421-432 128 Wolfe H, Zebuhr C, Topjian AA, et al Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes Crit Care Med 2014;42(7):1688-1695 129 Cheng A, Duff JP, Kessler D, et al Optimizing CPR performance with CPR coaching for pediatric cardiac arrest: a randomized simulation-based clinical trial Resuscitation 2018;132:33-40 130 Wolfe H, Maltese MR, Niles DE, et al Blood pressure directed booster trainings improve intensive care unit provider retention of excellent cardiopulmonary resuscitation skills Pediatr Emerg Care 2015;31(11):743-747 131 Sutton RM, Niles D, Meaney PA, et al Low-dose, high-frequency CPR training improves skill retention of in-hospital pediatric providers Pediatrics 2011;128(1):e145-e151 132 Sutton RM, Niles D, Meaney PA, et al “Booster” training: evaluation of instructor-led bedside cardiopulmonary resuscitation skill training and automated corrective feedback to improve cardiopulmonary resuscitation compliance of Pediatric Basic Life Support providers during simulated cardiac arrest Pediatr Crit Care Med 2011;12(3):e116-e121 133 Morris MC, Wernovsky G, Nadkarni VM Survival outcomes after extracorporeal cardiopulmonary resuscitation instituted during active chest compressions following refractory in-hospital pediatric cardiac arrest Pediatr Crit Care Med 2004;5(5):440-446 134 Lasa JJ, Rogers RS, Localio R, et al Extracorporeal Cardiopulmonary Resuscitation (E-CPR) during pediatric in-hospital cardiopulmonary arrest is associated with improved survival to discharge: a report from the American Heart Association’s Get With The Guidelines-Resuscitation (GWTG-R) Registry Circulation 2016; 133(2):165-176 135 Andersen LW, Raymond TT, Berg RA, et al Association between tracheal intubation during pediatric in-hospital cardiac arrest and survival JAMA 2016;316(17):1786-1797 136 Stinson HR, Srinivasan V, Topjian AA, et al Failure of invasive airway placement on the first attempt is associated with progression to cardiac arrest in pediatric acute respiratory compromise Pediatr Crit Care Med 2018;19(1):9-16 137 Hansen ML, Lin A, Eriksson C, et al A comparison of pediatric airway management techniques during out-of-hospital cardiac arrest using the CARES database Resuscitation 2017;120:51-56 138 O’Leary F, Hayen A, Lockie F, Peat J Defining normal ranges and centiles for heart and respiratory rates in infants and children: a cross-sectional study of patients attending an Australian tertiary hospital paediatric emergency department Arch Dis Child 2015;100(8):733-737 139 Sutton RM, Reeder RW, Landis WP, et al Ventilation rates and pediatric in-hospital cardiac arrest survival outcomes Crit Care Med 2019;47(11):1627-1636 140 Lopez J, Fernandez SN, Gonzalez R, Solana MJ, Urbano J, LopezHerce J Different respiratory rates during resuscitation in a pediatric animal model of asphyxial cardiac arrest PLoS One 2016;11(9):e0162185 141 Caffrey SL, Willoughby PJ, Pepe PE, Becker LB Public use of automated external defibrillators N Engl J Med 2002;347(16):12421247 142 Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW, Hardman RG Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos N Engl J Med 2000;343(17):1206-1209 143 Samson RA, Berg RA, Bingham R, et al Use of automated external defibrillators for children: an update: an advisory statement from the pediatric advanced life support task force, International Liaison Committee on Resuscitation Circulation 2003;107(25):32503255 144 Rossano JW, Jones WE, Lerakis S, et al The use of automated external defibrillators in infants: a report from the American Red Cross Scientific Advisory Council Pediatr Emerg Care 2015;31(7): 526-530 145 El-Assaad I, Al-Kindi SG, McNally B, et al Automated external defibrillator application before EMS arrival in pediatric cardiac arrests Pediatrics 2018;142(4):e20171903 e5 Abstract: Pediatric cardiac arrest is not a rare event More than 20,000 children are treated with cardiopulmonary resuscitation (CPR) for a cardiac arrest in the United States annually In the past, survival outcomes were dismal, and many surviving children had severe neurologic sequelae With advances in resuscitation science, survival from pediatric cardiac arrest has improved substantially since the 1990s This chapter focuses on pediatric cardiac arrest, CPR, and therapeutic interventions that impact clinical outcomes Controversies related to pediatric cardiac arrest management are also discussed Key words: cardiopulmonary resuscitation, cardiac arrest, resuscitation, hemodynamics, end-tidal carbon dioxide, coronary perfusion pressure, chest compressions, epinephrine, targeted temperature management SECTION V Pediatric Critical Care: Pulmonary 49 50 51 52 53 54 56 57 55 40 Structure and Development of the Upper Respiratory System, 454 41 Structure and Development of the Lower Respiratory System, 462 42 Physiology of the Respiratory System, 470 43 Noninvasive Respiratory Monitoring and Assessment of Gas Exchange, 483 44 Overview of Breathing Failure, 492 45 Ventilation/Perfusion Inequality, 503 46 Mechanical Dysfunction of the Respiratory System, 509 47 Diseases of the Upper Respiratory Tract, 524 48 Pediatric Acute Respiratory Distress Syndrome and Ventilator-Associated Lung Injury, 536 Acute Viral Bronchiolitis, 546 Asthma, 552 Neonatal Pulmonary Disease, 568 Pneumonitis and Interstitial Disease, 585 Diseases of the Pulmonary Circulation, 608 Mechanical Ventilation and Respiratory Care, 625 Noninvasive Ventilation in the Pediatric Intensive Care Unit, 644 Extracorporeal Life Support, 655 Pediatric Lung Transplantation, 679 453 40 Structure and Development of the Upper Respiratory System ROBERT H CHUN AND JOAN C ARVEDSON The respiratory tract can be divided into the upper or conducting airways and the lower or gaseous exchange airways For the purposes of this chapter, the trachea down to the carina is included as part of the upper or conducting airways The upper airway shares its development with that of the upper digestive tract; the lower airway shares its development with the cardiovascular system Developmental Anatomy of the Upper Airway The embryologic development of the nasal cavity, mouth, nasopharynx, and hypopharynx occurs in a separate environment from that of the larynx, trachea, bronchi, and lung parenchyma Because the upper airway and lower respiratory tract develop separately, there are few coincident congenital anomalies between these two contiguous, but developmentally distinct, areas The branchial arches derived from the neural crest cells begin to appear during the fourth week of embryogenesis The branchial arches give rise to the formation of the face, neck, nasal cavities, mouth, larynx, pharynx, and striated muscles in the head and neck that are involved in breathing and swallowing The development of these structures is usually complete by week 14 The respiratory system—including parts of the larynx, trachea, and lungs—also begins to appear during week 4, when the laryngotracheal groove develops into a diverticulum that subsequently separates from the pharynx In the fourth and fifth weeks, the longitudinal tracheoesophageal folds fuse, forming the tracheoesophageal septum and dividing the foregut into ventral and dorsal portions The ventral portion becomes the larynx, trachea, bronchi, and lungs; the dorsal portion becomes the esophagus 454 • The structures of the upper airway undergo extensive changes from infancy through young adulthood An understanding of the numerous variations, congenital anomalies, and resulting special vulnerabilities of the developing airway and underlying illness should result in improved health outcomes and a lower morbidity rate in children with airway disease • • PEARLS The upper and lower respiratory tracts develop separately Thus, there are few coincident congenital anomalies between these two contiguous areas An understanding of possible congenital anomalies of the airway will improve diagnosis and treatments Abnormalities in the development of the esophagus and trachea can lead to tracheoesophageal fistula A rare but significant tracheoesophageal fistula is the H type that could present with recurrent lower airway disease (Fig 40.1) The embryogenesis of the larynx is complex The cartilages and muscles are derived from the fourth and sixth branchial arches The epithelium is derived from the endoderm of the laryngotracheal tube As this epithelium proliferates rapidly, the larynx is temporarily occluded until the 10th week, when recanalization occurs Failure to recanalize can result in laryngeal webs, stenosis, or, rarely, atresia (Fig 40.2) The epiglottis forms by mesenchymal proliferation of the third and fourth branchial arches (Fig 40.3) Another developmental abnormality is a laryngeal cleft that presents as a defect in the posterior arytenoid muscles and, sometimes, tracheal cartilage, leading to aspiration The cleft can vary from mild to severe, depending on the extent of the defect that may extend from the top of the cricoid cartilage into the thoracic trachea (Fig 40.4) Findings on videofluoroscopic swallow studies are suspicious for laryngeal cleft when liquid is seen to move into the trachea posteriorly and lower than typically seen with simple delayed airway closure Those findings typically lead to further workup to include operative endoscopy with palpation of the larynx, which is the definitive diagnostic procedure The tracheobronchial tree also has several embryonic origins Its epithelium is derived from the laryngotracheal tube The connective tissue, cartilages, and muscles are derived from the surrounding splanchnic mesenchyme All cartilages of the trachea are C-shaped with a membranous posterior tracheal wall, giving the airway flexibility to expand, except for the cricoid cartilage immediately below the true vocal folds The cricoid cartilage is considered to be anatomically part of the larynx It is the only ... resuscitation science, survival from pediatric cardiac arrest has improved substantially since the 1990s This chapter focuses on pediatric cardiac arrest, CPR, and therapeutic interventions that impact... 470 43 Noninvasive Respiratory Monitoring and Assessment of Gas Exchange, 483 44 Overview of Breathing Failure, 492 45 Ventilation/Perfusion Inequality, 503 46 Mechanical Dysfunction of the Respiratory... into the upper or conducting airways and the lower or gaseous exchange airways For the purposes of this chapter, the trachea down to the carina is included as part of the upper or conducting airways