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Dr Whitaker, in a letter in response to our Archimedes review of whether waveform capnography reliably approximates paCO2 in neonates, highlights two important questions which capnography seeks to address: Firstly, whether or not the endotracheal tube (ETT) is patent and correctly positioned in the trachea and secondly, whether the current ventilation strategy provides optimal CO2 clearance for the patient. The two questions are, of course, interlinked.
To date, in our field of neonatal medicine, the ETCO2 provides a valuable adjunct to clinical examination in determining ETT position and patency both at the point of intubation and during ongoing mechanical ventilation. However, for reasons explained in the paper, the numerical approximations to alveolar pCO2 provided by the currently available techniques of wave form capnography in neonates are not accurate enough to guide ventilatory changes. Thus, to guide ventilator changes, many neonatal intensive care units currently use transcutaneous capnometry.
In addition to the physiological properties, the waveform capnography sensors add extra weight and dead space to an infant’s ventilator circuit. This adds further complexity, like their still not fully assessed effect on volume-guarantee ventilation and potential for auto-triggering of ventilators. As volume guarantee is now considered the gold standard for ventilating preterm infants with respiratory distress syndrome, the value of waveform capnography, in addi...
Dr Whitaker, in a letter in response to our Archimedes review of whether waveform capnography reliably approximates paCO2 in neonates, highlights two important questions which capnography seeks to address: Firstly, whether or not the endotracheal tube (ETT) is patent and correctly positioned in the trachea and secondly, whether the current ventilation strategy provides optimal CO2 clearance for the patient. The two questions are, of course, interlinked.
To date, in our field of neonatal medicine, the ETCO2 provides a valuable adjunct to clinical examination in determining ETT position and patency both at the point of intubation and during ongoing mechanical ventilation. However, for reasons explained in the paper, the numerical approximations to alveolar pCO2 provided by the currently available techniques of wave form capnography in neonates are not accurate enough to guide ventilatory changes. Thus, to guide ventilator changes, many neonatal intensive care units currently use transcutaneous capnometry.
In addition to the physiological properties, the waveform capnography sensors add extra weight and dead space to an infant’s ventilator circuit. This adds further complexity, like their still not fully assessed effect on volume-guarantee ventilation and potential for auto-triggering of ventilators. As volume guarantee is now considered the gold standard for ventilating preterm infants with respiratory distress syndrome, the value of waveform capnography, in addition to standard expiratory tidal volume monitoring on volume-guarantee ventilated infants and transcutaneous capnometry, is a topic worthy of further research and discussion.
Dear Editor
We read with interest Dr Scrivens et al’s commentary [1]. The mother’s question - ‘should capnography be used for breathing tube monitoring?’ – captures the subject addressed in our ‘PICNIC survey’ [2]. Conversely, the authors examine a completely different question - ‘is capnography an optimum respiratory monitor in ventilated neonates?’
A respiratory monitor detects whether the end-tidal CO2 value usefully measures pulmonary ventilation or PaCO2. Although not our focus here, we are surprised the review omitted Kugelman’s study which reported waveform capnography monitoring in neonatal ICU (NICU) improved ventilation accuracy and neurological outcomes [3].
An airway monitor assesses ‘whether lung ventilation is taking place via a tracheal tube that is in the airway and is patent’. High rates of neonatal failed intubation, oesophageal intubation, accidental extubation and reports of associated patient harm all suggest the value of a reliable airway monitor in NICU. Waveform capnography rapidly detects correct intubation with few false positives and immediately detects displacement or disconnection, the evidence for which we have previously set out [4-6].
Some neonatologists argue that continuous waveform capnography cannot be used in neonates. It is used routinely in neonatal anaesthesia. Others use it routinely during transfer of small neonates (eg 400g) (personal communication Dr James Tooley, Consultant, Bristol) sometimes only for it...
Dear Editor
We read with interest Dr Scrivens et al’s commentary [1]. The mother’s question - ‘should capnography be used for breathing tube monitoring?’ – captures the subject addressed in our ‘PICNIC survey’ [2]. Conversely, the authors examine a completely different question - ‘is capnography an optimum respiratory monitor in ventilated neonates?’
A respiratory monitor detects whether the end-tidal CO2 value usefully measures pulmonary ventilation or PaCO2. Although not our focus here, we are surprised the review omitted Kugelman’s study which reported waveform capnography monitoring in neonatal ICU (NICU) improved ventilation accuracy and neurological outcomes [3].
An airway monitor assesses ‘whether lung ventilation is taking place via a tracheal tube that is in the airway and is patent’. High rates of neonatal failed intubation, oesophageal intubation, accidental extubation and reports of associated patient harm all suggest the value of a reliable airway monitor in NICU. Waveform capnography rapidly detects correct intubation with few false positives and immediately detects displacement or disconnection, the evidence for which we have previously set out [4-6].
Some neonatologists argue that continuous waveform capnography cannot be used in neonates. It is used routinely in neonatal anaesthesia. Others use it routinely during transfer of small neonates (eg 400g) (personal communication Dr James Tooley, Consultant, Bristol) sometimes only for it to be removed on arrival at NICU! In veterinary practice it may be used in animals weighing 50g (personal communication, Dr Jonathan Cracknell, Wildlife Anaesthesia Services, Longleat, Wiltshire).
Proving the value of safety measures by randomised controlled trials (RCTs) is often impractical because of the rarity of the adverse outcomes the intervention is intended to prevent (here hypoxaemic brain injury or death). There are no RCTs that show outcome benefit of oximetry in anaesthesia or critical care, but its use is universal. Proving capnography improves outcomes via RCT may be challenging – though studying the impact on prompt recognition of incorrect intubation, disconnections and accidental extubation is feasible.
In 2011 waveform capnography was available in half of adult ICUs and these often used it infrequently [7]. There was significant resistance to the NAP4 recommendation for universal implementation, including senior intensivists stating its use was impossible and unnecessary - because ventilator parameters would readily identify problems. That some adult ICUs were using it widely and others not at all mirrors current NICU practice: this variation in practice merits urgent investigation and explanation. Four years after NAP4, 98% of adult ICUs had waveform capnography, using it routinely at intubation and for monitoring all ventilated patients [8]. Capnography in ICU is practical and it is now accepted in UK adult ICUs as a standard of care.
Neonates, in common with all humans, exhale carbon dioxide with every breath. Detection of this has the potential to be the most rapid and reliable monitor of airway integrity in neonates reliant on an artificial airway. In determining whether waveform capnography is the right tool in their setting it is important that the neonatal community start to ask the right question.
TM Cook
KE Foy
FE Kelly
References
1. Scrivens A, Zivanovic S, Roehr CC. Is waveform capnography reliable in neonates? Arch Dis Child July 2019 Vol 104 No 7 http://dx.doi.org/10.1136/archdischild-2018-316577
2. Foy K, Mew E, Cook T, et al United Kingdom paediatric and neonatal intensive care airway management: the PICNIC survey, Anaesthesia 2018; 73: 1337-44
3. Kugelman A, Golan A, Riskin A et al. Impact of Continuous Capnography in Ventilated Neonates: A Randomized, Multicenter Study. Journal of Pediatrics 2016; 168: 56-61
4. Cook TM, Foy K, Kelly F. Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey. (Response to Mactier et al.) http://www.respond2articles.com/ANA/forums/thread/2670.aspx
5. Cook TM, Foy K, Kelly F. Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey. (Response to Wyllie et al.) http://www.respond2articles.com/ANA/forums/thread/2677.aspx
6. Cook TM, Foy K, Kelly F. Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey. Anaesthesia 2019; 74; 118-120
7. Cook TM, Woodall N, Harper J, Benger J. Major complications of airway management in the UK: results of the 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2 Intensive Care and Emergency Department. British Journal of Anaesthesia 2011; 106: 632-42
8. Cook TM, Woodall N, Frerk C. A national survey of the impact of NAP4 on airway management practice in United Kingdom hospitals: closing the safety gap in anaesthesia, intensive care and the emergency department. British Journal of Anaesthesia 2016; 117: 182-190
Dear authors,
I read with great interest your article on multiple café-au-lait macules and movement disorder (1). I want to point out that probably an error happened during formatting of table 1. The term RASopathies is used to refer to a group of diseases caused by a mutation in a gene coding for a key component of the RAS-pathway and resulting in hyperactivation of the pathway. This group commonly includes Noonan syndrome, Neurofibromatosis type 1, Legius syndrome, LEOPARD syndrome (now referred to as Noonan syndrome with multiple lentigines), Costello syndrome, CFC syndrome, hereditary gingival fibromatosis, capillary malformation-arteriovenous malformation and Loh syndrome (2). It is confusing to find RASopathies next to Noonan, Legius and LEOPARD syndrome in the same column of table 1. In the same column Legius syndrome is listed as well as NF-like syndrome. Legius syndrome is listed followed by (PTPN11) and NF-like syndrome is followed by the gene (SPRED1). PTPN11 should be listed after Noonan syndrome because it is the most frequent cause of Noonan syndrome and it is not related to Legius syndrome. Legius syndrome is the same as NF1-like syndrome and only one of the two should be listed followed by (SPRED1). In our first publication (3) we named the condition neurofibromatosis 1-like syndrome but later is was renamed Legius syndrome (4).
Congenital mismatch repair deficiency (CMMRD) is another autosomal recessive condition with café-au-lait macules and...
Dear authors,
I read with great interest your article on multiple café-au-lait macules and movement disorder (1). I want to point out that probably an error happened during formatting of table 1. The term RASopathies is used to refer to a group of diseases caused by a mutation in a gene coding for a key component of the RAS-pathway and resulting in hyperactivation of the pathway. This group commonly includes Noonan syndrome, Neurofibromatosis type 1, Legius syndrome, LEOPARD syndrome (now referred to as Noonan syndrome with multiple lentigines), Costello syndrome, CFC syndrome, hereditary gingival fibromatosis, capillary malformation-arteriovenous malformation and Loh syndrome (2). It is confusing to find RASopathies next to Noonan, Legius and LEOPARD syndrome in the same column of table 1. In the same column Legius syndrome is listed as well as NF-like syndrome. Legius syndrome is listed followed by (PTPN11) and NF-like syndrome is followed by the gene (SPRED1). PTPN11 should be listed after Noonan syndrome because it is the most frequent cause of Noonan syndrome and it is not related to Legius syndrome. Legius syndrome is the same as NF1-like syndrome and only one of the two should be listed followed by (SPRED1). In our first publication (3) we named the condition neurofibromatosis 1-like syndrome but later is was renamed Legius syndrome (4).
Congenital mismatch repair deficiency (CMMRD) is another autosomal recessive condition with café-au-lait macules and similar to ataxia telangiectasia it is important to recognize because it is associated with malignancies (5). I suggest to add CMMRD to table 1.
References
1 Madaan P, Mukherjee S, Reddy C, et al. Multiple café-au-lait macules and movement disorder: think beyond neurofibromatosis. Arch Dis Child 2019;0:1. doi:10.1136/archdischild-2019-317497
2 Aoki Y, Niihori T, Inoue S, Matsubara Y. Recent advances in RASopathies. J Hum Genet 2016 ;61:33-9.
3 Brems H, Chmara M, Sahbatou M,et al. Germline loss-of-function mutations in SPRED1 cause a neurofibromatosis 1-like phenotype. Nat Genet 2007; 39:1120-26.
4 Stevenson D, Viskochil D Pigmentary findings in neurofibromatosis type 1-like syndrome (Legius syndrome): potential diagnostic dilemmas. JAMA 2009;19:2150-1.
5 Suerink M, Ripperger T, Messiaen L et al. Constitutional mismatch repair deficiency as a differential diagnosis of neurofibromatosis type 1: consensus guidelines for testing a child without malignancy. J Med Genet 2019;56:53-62.
I was interested to read the Archimedes article reviewing the structured question ‘in neonates who require ventilation, does waveform capnography give an accurate approximation of PaCO2?’ The findings such as the accuracy of ETCO2 decreases with the severity of lung disease (Grade B) adds to similar knowledge about waveform capnography when it was introduced in adults.
Whenever capnography is discussed however it should always be remembered that the primary reason for its introduction into clinical practice was to reliably ensure patients oxygenation and reduce the incidence of hypoxic brain damage, which it did so dramatically. The presence of a capnography waveform is the gold standard to demonstrate the integrity and correct position of an airway and establish that the patient is being ventilated with the intended oxygen. This eureka moment discovering that waveform capnography is more about oxygenation than accuracy of PaCO2 estimation is crucial for patient safety. The exact value of PaCO2 is secondary.
Unfortunately for over 20 years adult intensive care missed this eureka moment and consequently never started to use waveform capnography in adult ITUs when it was being universally introduced into operating theatres in the late 1980s [1].
Despite waveform capnography continuing to save many patients lives in operating theatres the argument that the accuracy of ETCO2 decreased with the severity of lung disease predominated in intensive care and w...
I was interested to read the Archimedes article reviewing the structured question ‘in neonates who require ventilation, does waveform capnography give an accurate approximation of PaCO2?’ The findings such as the accuracy of ETCO2 decreases with the severity of lung disease (Grade B) adds to similar knowledge about waveform capnography when it was introduced in adults.
Whenever capnography is discussed however it should always be remembered that the primary reason for its introduction into clinical practice was to reliably ensure patients oxygenation and reduce the incidence of hypoxic brain damage, which it did so dramatically. The presence of a capnography waveform is the gold standard to demonstrate the integrity and correct position of an airway and establish that the patient is being ventilated with the intended oxygen. This eureka moment discovering that waveform capnography is more about oxygenation than accuracy of PaCO2 estimation is crucial for patient safety. The exact value of PaCO2 is secondary.
Unfortunately for over 20 years adult intensive care missed this eureka moment and consequently never started to use waveform capnography in adult ITUs when it was being universally introduced into operating theatres in the late 1980s [1].
Despite waveform capnography continuing to save many patients lives in operating theatres the argument that the accuracy of ETCO2 decreased with the severity of lung disease predominated in intensive care and was repeatedly used to justify it never being used there.
Subsequently a minimum of 150 patients probably died from major airway complications because the routine use of continuous waveform capnography in ITUs in the UK was not widely recommended until 2011 when NAP4 was published [2] and changed practice [3].
It would be very sad if this article’s findings were similarly interpreted by others to justify not routinely using lifesaving waveform capnography monitoring when ventilating neonates.
Airway deaths are particularly devastating [4] and I can only hope that for everyone's sake, the babies, their families and any staff 2nd victims history will not continue to repeat itself in neonatal intensive care [5].
David K Whitaker
David K Whitaker FRCA, FFPMRCA, FFICM, Hon FCARCSI
Consultant in Anaesthesia and Intensive care Manchester Royal Infirmary
References
1. Whitaker DK. Time for capnography - everywhere. Anaesthesia. 2011; 66: 544-9.
2. Cook TM, Woodall N, Harper J, Benger J. Major complications of airway management in the UK: results of the 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2 Intensive Care and Emergency Department. British Journal of Anaesthesia 2011; 106: 632-42
3. Cook TM. Airway complications – strategies for prevention. Anaesthesia 2018; 73: 93-111.
4. Baby’s family in call for action over ‘neglect’ finding in inquest https://www.yorkshirepost.co.uk/news/latest-news/baby-s-family-in-call-f... (accessed 07 July 2019)
5. Pathan N. British Broadcasting Corporation. Sick babies at risk from lack of breathing tube monitoring. https://www.bbc.co.uk/news/health-45197375 (accessed 07 July 2019)
Conflict of Interest
DKW is currently Chairman of the Patient Safety Committee of the European Board of Anaesthesiology. He has received lecture fees from Aguettant Ltd and Medtronic, all donated to Lifebox and travel expenses for the Global Capnography Project (GCAP) in Malawi from Medtronic.
We welcome the comments made by Professor Andrew Williams, who has been a great supporter of our UK-wide study of children with progressive intellectual and neurological deterioration (PIND). The PIND Study uses the mechanism provided by the British Paediatric Surveillance Unit (BPSU), which is based in the Royal College of Paediatrics and Child Health. Since 1986 the BPSU has provided paediatricians in the United Kingdom with the means of investigating rare disorders of childhood. As Professor Williams points out there is a need to make research central to good paediatric practice and the BPSU continues to facilitate that.
The PIND Study is funded by the National Institute for Health Research (NIHR) Policy Research Programme to look for cases of variant Creutzfeldt-Jakob disease (vCJD) among the many neurodegenerative diseases of childhood. Since the PIND Study started in 1997 we have identified children with more than 190 of these rare disorders - that number constantly increases as new diseases and new genetic variants of known diseases are discovered. Thus our study not only provides the sole means of systematically searching for vCJD in children but also gives a unique oversight of the changing pattern of childhood neurodegenerative disease in the UK. We work closely with the National Creutzfeldt-Jakob Disease Research and Surveillance Unit which carries out surveillance for vCJD in adults.
Professor Williams highlights the fact that our work could not be...
We welcome the comments made by Professor Andrew Williams, who has been a great supporter of our UK-wide study of children with progressive intellectual and neurological deterioration (PIND). The PIND Study uses the mechanism provided by the British Paediatric Surveillance Unit (BPSU), which is based in the Royal College of Paediatrics and Child Health. Since 1986 the BPSU has provided paediatricians in the United Kingdom with the means of investigating rare disorders of childhood. As Professor Williams points out there is a need to make research central to good paediatric practice and the BPSU continues to facilitate that.
The PIND Study is funded by the National Institute for Health Research (NIHR) Policy Research Programme to look for cases of variant Creutzfeldt-Jakob disease (vCJD) among the many neurodegenerative diseases of childhood. Since the PIND Study started in 1997 we have identified children with more than 190 of these rare disorders - that number constantly increases as new diseases and new genetic variants of known diseases are discovered. Thus our study not only provides the sole means of systematically searching for vCJD in children but also gives a unique oversight of the changing pattern of childhood neurodegenerative disease in the UK. We work closely with the National Creutzfeldt-Jakob Disease Research and Surveillance Unit which carries out surveillance for vCJD in adults.
Professor Williams highlights the fact that our work could not be carried out without the active support and involvement of the paediatricians who report cases to our study (and all the other studies that are carried out via the BPSU system). By giving their time in this way individual paediatricians become an active part of a highly successful national epidemiological surveillance system and their contribution should be acknowledged – many thanks to them all.
We thank Luamar Dolfini and Gabriella Williamson for noting the sepsis screening tool that we developed in Leeds. Our tool was based on the NICE guidance, but used local early warning scores (PAWS) to simplify the assessment risk for sepsis. At Leeds Children's Hospital our tool is used on all acute paediatric admissions and in any child that deteriorates on the paediatric wards. Since our initial letter was published in 2018, our team have further amended our screening tool in response to human factors work, and have introduced the acronym LEEDS (Look for sepsis is all acute admissions or children who deteriorate: Evaluate the risk of sepsis by completing the sepsis screening tool; Escalate to a senior decision maker to consider the risk of sepsis; Decide whether there is a high/medium/low risk of sepsis using clinical assessment and investigations such as lactate; Start antibiotics in under 60 minutes if sepsis is a possibility). Our team have found the paper by Roland and Snelson ("So why didn't you think this baby was ill?" Decision-making in acute paediatrics, Arch Dis Educ Pract Ed 2019; 104:43-48) invaluable in educating our team about making decisions and assessing risk and this e-letter highlights that all parts of the puzzle (e.g. a full and comprehensive set of observations) are essential in being able to appropriately risk stratify patients, including for sepsis.
This most welcome paper by Verity et al relates the important longstanding work that the PIND Study produces and which all paediatricians should most strongly continue to support.[1]
However, it is important for readers to understand that the PIND Study itself cannot in many cases be expected to be the full story when a child is referred to them.
Indeed the relationship between the referring paediatrician and the PIND Study group can very helpfully continue long after the patient's death when new investigative technologies can finally provide a definitive diagnosis, so long as the appropriate samples have been appropriately taken. In this area, I have found guidance from the PIND Study can be very helpful.
We in Northampton have always referred where appropriate to the PIND Study not only because we highly esteem its work, but also because it remains the only practical means of systemic surveillance of vCJD and other neurodegenerative conditions in the UK. Where inspite of every endeavour a diagnosis has not been found while the patient was alive, we in Northampton have continued to keep the PIND Study in the loop while working internationally with other groups to find an answer.
For one such example, we have had children 2 brothers both referred to the PIND study in the early 2000's with a then undiagnosed condition. Both boys, having had post mortems and DNA storage and working with Professor Baas in the Netherlands were found to hav...
This most welcome paper by Verity et al relates the important longstanding work that the PIND Study produces and which all paediatricians should most strongly continue to support.[1]
However, it is important for readers to understand that the PIND Study itself cannot in many cases be expected to be the full story when a child is referred to them.
Indeed the relationship between the referring paediatrician and the PIND Study group can very helpfully continue long after the patient's death when new investigative technologies can finally provide a definitive diagnosis, so long as the appropriate samples have been appropriately taken. In this area, I have found guidance from the PIND Study can be very helpful.
We in Northampton have always referred where appropriate to the PIND Study not only because we highly esteem its work, but also because it remains the only practical means of systemic surveillance of vCJD and other neurodegenerative conditions in the UK. Where inspite of every endeavour a diagnosis has not been found while the patient was alive, we in Northampton have continued to keep the PIND Study in the loop while working internationally with other groups to find an answer.
For one such example, we have had children 2 brothers both referred to the PIND study in the early 2000's with a then undiagnosed condition. Both boys, having had post mortems and DNA storage and working with Professor Baas in the Netherlands were found to have EXOSC3 mutation in 2012 (8 and 2 years after their deaths respectively). [1]
Being part of a team which maybe many years after that child's death that uncovers the cause, giving that family a reason and specifically a diagnostic test, can give great comfort and closure for all involved in that child's care. Readers of this article will be well aware that medically managing such children can present severe challenges, which even under the best possible care can lead to terrible physical and emotional suffering.
It is for paediatricians and child health professionals to continue to work with the PIND Study.It cannot be expected to shoulder the entire weight for this process. Coincidentally, the very same issue of the Archives has another article emphasising making research central to good paediatric practice.[3] I could not agree more.
References
1] Verity C, Winstone AM, Will R, et al. Surveillance for variant CJD: should more children with neurodegenerative diseases have autopsies?. Archives of Disease in Childhood 2019;104:360-365.
2] Eggens V.R.C., Barth P.G., Niermeijer J. F., Berg J.N., Darin N., Dixit A., Flus J., Foulds N., Hortobágyi T., Jacques T., King M.D., Makrythanasis P., Máté A., O'Rourke D., Price S., Williams A.N., Wilson L.,Suri M., Sztriha L., Dijns-de Wissel M.B., van Meegen M.T., van Ruissen F., Aronica E., Troost D., Majoie C.B.L.M., Marquering H.A.,Poll-Thé B-T, Baas F. EXOSC3 mutations in pontocerebellar hypoplasia type 1: novel mutations and genotype-phenotype correlations Orphanet Journal of Rare Diseases 2014 9:23. doi:10.1186/1750-1172-9-23.
3] Davies HT, Phillips B, Preston J, et al. Making research central to good paediatric practice. Archives of Disease in Childhood 2019;104:385-388.
Powell and Jeavons undertook a hospital-based audit(1) comparing the new guidelines for identifying paediatric sepsis(2) to previous cases that had attended the emergency department. By contrast, our recent sepsis audit investigating the assessment of under 5s with fever ≥37.5°C (before possible referral to hospital) was done in primary care.
The National Institute for Health and Care Excellence (NICE) guidelines for sepsis assessment outlines four signs that should be recorded: temperature, pulse, respiratory rate and capillary refill time. An initial audit looking at compliance to these guidelines was conducted looking at data in computerised records from May 2014 – May 2018 at an inner-city general practice. Results showed that in only 15% of 111 consecutive consultations with feverish children aged <5 were all four signs recorded. More specifically, pulse was recorded in 81%, respiratory rate in 49%, and capillary refill time in only 32% of consultations.
Following presentation of these findings to the general practitioners and practice nurses, a re-audit was undertaken assessing 48 consecutive consultations from June 2018 – June 2019. Results showed a slight improvement from 15% to 25% of consultations recording all four signs, with 94% of consultations recording pulse, 42% recording respiratory rate, and 50% recording capillary refill time.
Powell and Jeavons have now created a simple ED paediatric sepsis pathway to minimise unnecessary inv...
Powell and Jeavons undertook a hospital-based audit(1) comparing the new guidelines for identifying paediatric sepsis(2) to previous cases that had attended the emergency department. By contrast, our recent sepsis audit investigating the assessment of under 5s with fever ≥37.5°C (before possible referral to hospital) was done in primary care.
The National Institute for Health and Care Excellence (NICE) guidelines for sepsis assessment outlines four signs that should be recorded: temperature, pulse, respiratory rate and capillary refill time. An initial audit looking at compliance to these guidelines was conducted looking at data in computerised records from May 2014 – May 2018 at an inner-city general practice. Results showed that in only 15% of 111 consecutive consultations with feverish children aged <5 were all four signs recorded. More specifically, pulse was recorded in 81%, respiratory rate in 49%, and capillary refill time in only 32% of consultations.
Following presentation of these findings to the general practitioners and practice nurses, a re-audit was undertaken assessing 48 consecutive consultations from June 2018 – June 2019. Results showed a slight improvement from 15% to 25% of consultations recording all four signs, with 94% of consultations recording pulse, 42% recording respiratory rate, and 50% recording capillary refill time.
Powell and Jeavons have now created a simple ED paediatric sepsis pathway to minimise unnecessary investigations and identify children who need emergency interventions(1). Perhaps something similar is needed in primary care.
References
1. Powell R, Jeavons K. Identifying paediatric sepsis: the difficulties in following recommended practice and the creation of our own pathway. Archives of Disease in Childhood 2018;103:114.
2. National Institute for Health and Clinical Excellence. Fever in under 5s: assessment and initial management. 2018. Available from: https://www.nice.org.uk/guidance/cg160
We thank Dr Woodruff for the opportunity to ensure that the correct figure is being used for the burden of childhood blindness.
As indicated in a correction(1) published alongside our original article,(2) the correct figure for the estimate of the global burden of childhood blindness is 1.4 million children.
1. Solebo AL, Teoh L, Rahi J. Correction: Epidemiology of blindness in children Archives of Disease in Childhood 2017;102:995
2. Solebo AL, Teoh L, Rahi J. Epidemiology of blindness in children Archives of Disease in Childhood 2017;102:853-857
We thank Professor Connett for his ornithological expertise, the extent of which we had not previously realised. There is indeed a wealth of literature about psychological stress to mothers affecting foetal outcomes [1], and stress being associated with asthma attacks [2] and worsening the effects of allergen challenge [3], and the importance of addressing this is emphasised by ourselves and many others [4]. Acknowledging this in no way contradicts the need also to address refractory airway pathology by the reductionist approach we advocate [5]. A holistic approach to severe asthma deploying the skills of a multidisciplinary team is essential. Render unto Caesar the things that are Caeser’s.
Andrew Bush
Ian Pavord
References
1. Wright RJ, Visness CM, Calatroni A, Grayson MH, Gold DR, Sandel MT, et al. Prenatal maternal stress and cord blood innate and adaptive cytokine responses in an inner-city cohort. Am J Respir Crit Care Med. 2010; 182: 25-33.
2. Sandberg S, Paton JY, Ahola S, McCann DC, McGuinness D, Hillary CR, Oja H. The role of acute and chronic stress in asthma attacks in children. Lancet. 2000; 356: 982-7.
3. Liu LY, Coe CL, Swenson CA, Kelly EA, Kita H, Busse WW. School examinations enhance airway inflammation to antigen challenge. Am J Respir Crit Care Med. 2002; 165: 1062-7.
4. Cook J, Beresford F, Fainardi V, Hall P, Housley G, Jamalzadeh A, Nightingale M, Winch D, Bush A, Fleming L, Saglani S. Managing the paediatr...
We thank Professor Connett for his ornithological expertise, the extent of which we had not previously realised. There is indeed a wealth of literature about psychological stress to mothers affecting foetal outcomes [1], and stress being associated with asthma attacks [2] and worsening the effects of allergen challenge [3], and the importance of addressing this is emphasised by ourselves and many others [4]. Acknowledging this in no way contradicts the need also to address refractory airway pathology by the reductionist approach we advocate [5]. A holistic approach to severe asthma deploying the skills of a multidisciplinary team is essential. Render unto Caesar the things that are Caeser’s.
Andrew Bush
Ian Pavord
References
1. Wright RJ, Visness CM, Calatroni A, Grayson MH, Gold DR, Sandel MT, et al. Prenatal maternal stress and cord blood innate and adaptive cytokine responses in an inner-city cohort. Am J Respir Crit Care Med. 2010; 182: 25-33.
2. Sandberg S, Paton JY, Ahola S, McCann DC, McGuinness D, Hillary CR, Oja H. The role of acute and chronic stress in asthma attacks in children. Lancet. 2000; 356: 982-7.
3. Liu LY, Coe CL, Swenson CA, Kelly EA, Kita H, Busse WW. School examinations enhance airway inflammation to antigen challenge. Am J Respir Crit Care Med. 2002; 165: 1062-7.
4. Cook J, Beresford F, Fainardi V, Hall P, Housley G, Jamalzadeh A, Nightingale M, Winch D, Bush A, Fleming L, Saglani S. Managing the paediatric patient with refractory asthma: a multidisciplinary approach. Journal of Asthma and Allergy 2017; 10: 123-30
5. Pavord ID, Beasley R, Agusti A, Anderson GP, Bel E, Brusselle G, et al. After asthma – redefining airways diseases. A Lancet commission. Lancet 2018; 391: 350-400
Dr Whitaker, in a letter in response to our Archimedes review of whether waveform capnography reliably approximates paCO2 in neonates, highlights two important questions which capnography seeks to address: Firstly, whether or not the endotracheal tube (ETT) is patent and correctly positioned in the trachea and secondly, whether the current ventilation strategy provides optimal CO2 clearance for the patient. The two questions are, of course, interlinked.
Show MoreTo date, in our field of neonatal medicine, the ETCO2 provides a valuable adjunct to clinical examination in determining ETT position and patency both at the point of intubation and during ongoing mechanical ventilation. However, for reasons explained in the paper, the numerical approximations to alveolar pCO2 provided by the currently available techniques of wave form capnography in neonates are not accurate enough to guide ventilatory changes. Thus, to guide ventilator changes, many neonatal intensive care units currently use transcutaneous capnometry.
In addition to the physiological properties, the waveform capnography sensors add extra weight and dead space to an infant’s ventilator circuit. This adds further complexity, like their still not fully assessed effect on volume-guarantee ventilation and potential for auto-triggering of ventilators. As volume guarantee is now considered the gold standard for ventilating preterm infants with respiratory distress syndrome, the value of waveform capnography, in addi...
Dear Editor
Show MoreWe read with interest Dr Scrivens et al’s commentary [1]. The mother’s question - ‘should capnography be used for breathing tube monitoring?’ – captures the subject addressed in our ‘PICNIC survey’ [2]. Conversely, the authors examine a completely different question - ‘is capnography an optimum respiratory monitor in ventilated neonates?’
A respiratory monitor detects whether the end-tidal CO2 value usefully measures pulmonary ventilation or PaCO2. Although not our focus here, we are surprised the review omitted Kugelman’s study which reported waveform capnography monitoring in neonatal ICU (NICU) improved ventilation accuracy and neurological outcomes [3].
An airway monitor assesses ‘whether lung ventilation is taking place via a tracheal tube that is in the airway and is patent’. High rates of neonatal failed intubation, oesophageal intubation, accidental extubation and reports of associated patient harm all suggest the value of a reliable airway monitor in NICU. Waveform capnography rapidly detects correct intubation with few false positives and immediately detects displacement or disconnection, the evidence for which we have previously set out [4-6].
Some neonatologists argue that continuous waveform capnography cannot be used in neonates. It is used routinely in neonatal anaesthesia. Others use it routinely during transfer of small neonates (eg 400g) (personal communication Dr James Tooley, Consultant, Bristol) sometimes only for it...
Dear authors,
Show MoreI read with great interest your article on multiple café-au-lait macules and movement disorder (1). I want to point out that probably an error happened during formatting of table 1. The term RASopathies is used to refer to a group of diseases caused by a mutation in a gene coding for a key component of the RAS-pathway and resulting in hyperactivation of the pathway. This group commonly includes Noonan syndrome, Neurofibromatosis type 1, Legius syndrome, LEOPARD syndrome (now referred to as Noonan syndrome with multiple lentigines), Costello syndrome, CFC syndrome, hereditary gingival fibromatosis, capillary malformation-arteriovenous malformation and Loh syndrome (2). It is confusing to find RASopathies next to Noonan, Legius and LEOPARD syndrome in the same column of table 1. In the same column Legius syndrome is listed as well as NF-like syndrome. Legius syndrome is listed followed by (PTPN11) and NF-like syndrome is followed by the gene (SPRED1). PTPN11 should be listed after Noonan syndrome because it is the most frequent cause of Noonan syndrome and it is not related to Legius syndrome. Legius syndrome is the same as NF1-like syndrome and only one of the two should be listed followed by (SPRED1). In our first publication (3) we named the condition neurofibromatosis 1-like syndrome but later is was renamed Legius syndrome (4).
Congenital mismatch repair deficiency (CMMRD) is another autosomal recessive condition with café-au-lait macules and...
I was interested to read the Archimedes article reviewing the structured question ‘in neonates who require ventilation, does waveform capnography give an accurate approximation of PaCO2?’ The findings such as the accuracy of ETCO2 decreases with the severity of lung disease (Grade B) adds to similar knowledge about waveform capnography when it was introduced in adults.
Whenever capnography is discussed however it should always be remembered that the primary reason for its introduction into clinical practice was to reliably ensure patients oxygenation and reduce the incidence of hypoxic brain damage, which it did so dramatically. The presence of a capnography waveform is the gold standard to demonstrate the integrity and correct position of an airway and establish that the patient is being ventilated with the intended oxygen. This eureka moment discovering that waveform capnography is more about oxygenation than accuracy of PaCO2 estimation is crucial for patient safety. The exact value of PaCO2 is secondary.
Unfortunately for over 20 years adult intensive care missed this eureka moment and consequently never started to use waveform capnography in adult ITUs when it was being universally introduced into operating theatres in the late 1980s [1].
Despite waveform capnography continuing to save many patients lives in operating theatres the argument that the accuracy of ETCO2 decreased with the severity of lung disease predominated in intensive care and w...
Show MoreWe welcome the comments made by Professor Andrew Williams, who has been a great supporter of our UK-wide study of children with progressive intellectual and neurological deterioration (PIND). The PIND Study uses the mechanism provided by the British Paediatric Surveillance Unit (BPSU), which is based in the Royal College of Paediatrics and Child Health. Since 1986 the BPSU has provided paediatricians in the United Kingdom with the means of investigating rare disorders of childhood. As Professor Williams points out there is a need to make research central to good paediatric practice and the BPSU continues to facilitate that.
Show MoreThe PIND Study is funded by the National Institute for Health Research (NIHR) Policy Research Programme to look for cases of variant Creutzfeldt-Jakob disease (vCJD) among the many neurodegenerative diseases of childhood. Since the PIND Study started in 1997 we have identified children with more than 190 of these rare disorders - that number constantly increases as new diseases and new genetic variants of known diseases are discovered. Thus our study not only provides the sole means of systematically searching for vCJD in children but also gives a unique oversight of the changing pattern of childhood neurodegenerative disease in the UK. We work closely with the National Creutzfeldt-Jakob Disease Research and Surveillance Unit which carries out surveillance for vCJD in adults.
Professor Williams highlights the fact that our work could not be...
We thank Luamar Dolfini and Gabriella Williamson for noting the sepsis screening tool that we developed in Leeds. Our tool was based on the NICE guidance, but used local early warning scores (PAWS) to simplify the assessment risk for sepsis. At Leeds Children's Hospital our tool is used on all acute paediatric admissions and in any child that deteriorates on the paediatric wards. Since our initial letter was published in 2018, our team have further amended our screening tool in response to human factors work, and have introduced the acronym LEEDS (Look for sepsis is all acute admissions or children who deteriorate: Evaluate the risk of sepsis by completing the sepsis screening tool; Escalate to a senior decision maker to consider the risk of sepsis; Decide whether there is a high/medium/low risk of sepsis using clinical assessment and investigations such as lactate; Start antibiotics in under 60 minutes if sepsis is a possibility). Our team have found the paper by Roland and Snelson ("So why didn't you think this baby was ill?" Decision-making in acute paediatrics, Arch Dis Educ Pract Ed 2019; 104:43-48) invaluable in educating our team about making decisions and assessing risk and this e-letter highlights that all parts of the puzzle (e.g. a full and comprehensive set of observations) are essential in being able to appropriately risk stratify patients, including for sepsis.
This most welcome paper by Verity et al relates the important longstanding work that the PIND Study produces and which all paediatricians should most strongly continue to support.[1]
However, it is important for readers to understand that the PIND Study itself cannot in many cases be expected to be the full story when a child is referred to them.
Indeed the relationship between the referring paediatrician and the PIND Study group can very helpfully continue long after the patient's death when new investigative technologies can finally provide a definitive diagnosis, so long as the appropriate samples have been appropriately taken. In this area, I have found guidance from the PIND Study can be very helpful.
We in Northampton have always referred where appropriate to the PIND Study not only because we highly esteem its work, but also because it remains the only practical means of systemic surveillance of vCJD and other neurodegenerative conditions in the UK. Where inspite of every endeavour a diagnosis has not been found while the patient was alive, we in Northampton have continued to keep the PIND Study in the loop while working internationally with other groups to find an answer.
For one such example, we have had children 2 brothers both referred to the PIND study in the early 2000's with a then undiagnosed condition. Both boys, having had post mortems and DNA storage and working with Professor Baas in the Netherlands were found to hav...
Show MorePowell and Jeavons undertook a hospital-based audit(1) comparing the new guidelines for identifying paediatric sepsis(2) to previous cases that had attended the emergency department. By contrast, our recent sepsis audit investigating the assessment of under 5s with fever ≥37.5°C (before possible referral to hospital) was done in primary care.
The National Institute for Health and Care Excellence (NICE) guidelines for sepsis assessment outlines four signs that should be recorded: temperature, pulse, respiratory rate and capillary refill time. An initial audit looking at compliance to these guidelines was conducted looking at data in computerised records from May 2014 – May 2018 at an inner-city general practice. Results showed that in only 15% of 111 consecutive consultations with feverish children aged <5 were all four signs recorded. More specifically, pulse was recorded in 81%, respiratory rate in 49%, and capillary refill time in only 32% of consultations.
Following presentation of these findings to the general practitioners and practice nurses, a re-audit was undertaken assessing 48 consecutive consultations from June 2018 – June 2019. Results showed a slight improvement from 15% to 25% of consultations recording all four signs, with 94% of consultations recording pulse, 42% recording respiratory rate, and 50% recording capillary refill time.
Powell and Jeavons have now created a simple ED paediatric sepsis pathway to minimise unnecessary inv...
Show MoreWe thank Dr Woodruff for the opportunity to ensure that the correct figure is being used for the burden of childhood blindness.
As indicated in a correction(1) published alongside our original article,(2) the correct figure for the estimate of the global burden of childhood blindness is 1.4 million children.
1. Solebo AL, Teoh L, Rahi J. Correction: Epidemiology of blindness in children Archives of Disease in Childhood 2017;102:995
2. Solebo AL, Teoh L, Rahi J. Epidemiology of blindness in children Archives of Disease in Childhood 2017;102:853-857
We thank Professor Connett for his ornithological expertise, the extent of which we had not previously realised. There is indeed a wealth of literature about psychological stress to mothers affecting foetal outcomes [1], and stress being associated with asthma attacks [2] and worsening the effects of allergen challenge [3], and the importance of addressing this is emphasised by ourselves and many others [4]. Acknowledging this in no way contradicts the need also to address refractory airway pathology by the reductionist approach we advocate [5]. A holistic approach to severe asthma deploying the skills of a multidisciplinary team is essential. Render unto Caesar the things that are Caeser’s.
Andrew Bush
Ian Pavord
References
Show More1. Wright RJ, Visness CM, Calatroni A, Grayson MH, Gold DR, Sandel MT, et al. Prenatal maternal stress and cord blood innate and adaptive cytokine responses in an inner-city cohort. Am J Respir Crit Care Med. 2010; 182: 25-33.
2. Sandberg S, Paton JY, Ahola S, McCann DC, McGuinness D, Hillary CR, Oja H. The role of acute and chronic stress in asthma attacks in children. Lancet. 2000; 356: 982-7.
3. Liu LY, Coe CL, Swenson CA, Kelly EA, Kita H, Busse WW. School examinations enhance airway inflammation to antigen challenge. Am J Respir Crit Care Med. 2002; 165: 1062-7.
4. Cook J, Beresford F, Fainardi V, Hall P, Housley G, Jamalzadeh A, Nightingale M, Winch D, Bush A, Fleming L, Saglani S. Managing the paediatr...
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