Sidharth Mahapatra, MD, PhD, Leads Published Collaborative Study

A team of investigators led by Sidharth Mahapatra, MD, PhD, celebrates the publication of their manuscript,Sid Mahapatra “A Retrospective Analysis of Feeding Practices and Complications in Patients with Critical Bronchiolitis on Non-Invasive Respiratory Support,” in the journal Children* last month. Dr. Mahapatra takes us briefly through the story of this project in the following Q&A.
 
Your study addresses questions about the safety and value of giving enteral feeding to young viral bronchiolitis patients while they receive non-invasive respiratory support (NRS) in the pediatric intensive care unit (PICU). What are some of the factors that weigh on intensivists when making this decision?
 
Historically, intensivists worried about feeding patients with impending respiratory failure managed on non-invasive respiratory support (NRS) for the following reasons: (a) the potential for the patient’s status to worsen, requiring mechanical ventilation which should, ideally, be done on an empty stomach to reduce the risk of aspiration during intubation; (b) nasogastric tubes interfering with optimal NRS mask seal by worsening a leak around the nasogastric tube; (c) exacerbating respiratory failure from breaks to allow oral feeds and (d) concerns surrounding aspiration of gastric contents during feeds due to the high-flow and/or positive pressure delivered by NRS that can lead to gastric distension and subsequent emesis. Notably, pediatric patients often require sedation to tolerate NRS, which further raises the concern for aspiration from relaxation of airway protective reflexes.
 
Who worked with you on this project, and what approach did you take?
 
As Director for Research in the Division of Pediatric Critical Care Medicine, I have dedicated my efforts to proactively supporting the academic interests of members of our division. Our advanced practice provider team has always expressed their deep want to engage in a longitudinal research project. This project was started for that reason with the investment of Ariann Lenihan, Vannessa Ramos and Nichole Nemec. I engaged them in all aspects of the academic discovery process from IRB submission, to hypothesis generation, to data collection, curation and analysis, to presentations at national conferences and finally to manuscript development and submission. During the process, we were joined by an undergraduate student, Joe Lukowski, and my partner, Meghan Kendall, DO, whose primary interest is in facilitating early enteral nutrition in the critical care setting. The entire team worked cohesively and well together.
 
What conclusions were you able to draw from this study?
 
First, we learned that during the time frame of our study, one third of our team was opting to keep patients NPO (nil per os, meaning “nothing by mouth”) during their critical illness while on NRS. In the other 2/3, a majority of patients (>90%) were not only fed early (within 48 hours) but also reached full feeds within a week. Given that the leading critical care nutrition groups, such as ASPEN and ESPNIC, recommend the same, our team’s practice was reassuring. We further learned that feeding was safe on NRS for patients with acute respiratory failure. Our complication rate was 8% with an aspiration rate of 1%. But, none of these patients suffered a worsening of their respiratory status necessitating escalation of NRS or mechanical ventilation. We also showed that after initiating feeds, patients experienced a significant reduction in their heart rate and respiratory rates, approximating age-based norms. Taken together, our study highlights the observation that it is safe to feed pediatric critically ill patients managed on NRS.
 
How does this contribute to the wider discussion in the pediatric critical care field? – do you envision more studies?
 
Currently, the practice of feeding pediatric patients on NRS is not universal. A slew of retrospective studies support the practice, but prospective studies are lacking. Thus, I do envision that prospective studies are on the horizon. As a follow-up to our study, Dr. Kendall is working on developing a nursing-led nutrition algorithm to be adopted in the PICU. This derives from her work as a fellow at the University of Washington, St. Louis, Missouri. Having done the retrospective work, we can now prospectively test the hypothesis that feeding patients with acute respiratory failure on NRS is safe and well-tolerated, randomizing patients to the NPO versus EN (enteral nutrition) arms and studying outcomes.
 
*Citation: Lenihan A, Ramos V, Nemec N, et al. A Retrospective Analysis of Feeding Practices and Complications in Patients with Critical Bronchiolitis on Non-Invasive Respiratory Support. Children (Basel). 2021;8(5):410. Published 2021 May 18. doi:10.3390/children8050410