In this episode of *Pediatric Critical Care Insights*, Dr. Monica Gray and Dr. Pradip Kamat chat about how capnography, specifically end-tidal CO2 monitoring, is used in the pediatric ICU. They walk through a real-life case of a 9-year-old with respiratory failure from influenza A, showing how ETCO2 monitoring helps confirm endotracheal tube placement, guides ventilation, spots cardiac arrest, and even helps assess the quality of CPR. Along the way, they break down how to interpret capnography waveforms, discuss different types of devices, and explain the key physiological concepts. The episode is packed with practical, bedside tips for intensivists caring for critically ill kids.

Show Highlights:

• Importance of capnography (end-tidal CO2 monitoring) in the pediatric intensive care unit (PICU)
• Clinical case study of a 9-year-old boy with respiratory failure due to influenza A
• Use of capnography for confirming endotracheal tube placement and assessing ventilation status
• Detection of cardiac arrest and guidance for CPR quality through ETCO2 monitoring
• Overview of capnography physics and physiology, including terminology distinctions
• Types of capnography: mainstream vs. sidestream, and their applications in pediatric patients
• Assumptions for accurate ETCO2 approximation of arterial CO2 and conditions affecting this relationship
• Analysis of capnography waveform phases and their clinical significance
• Prognostic value of ETCO2 during cardiac arrest and its correlation with patient outcomes
• Practical applications of ETCO2 monitoring in critical care, focusing on airway, breathing, and circulation management

References:

1. Noninvasive respiratory monitoring and assessment of gas exchange. David F. Butler; Kenneth A. Schenkman. Fuhrman and Zimmerman's Pediatric Critical Care, 43, 483-491.e3
2. Humphreys S, Schibler A, von Ungern-Sternberg BS. Carbon dioxide monitoring in children—A narrative review of physiology, value, and pitfalls in clinical practice. Pediatr Anaesth. 2021;31:839–845. https://doi.org/10.1111/pan.14208
3. Lasa JJ, Dhillon GS, Duff JP, et al. Part 8: Pediatric Advanced Life Support: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2026;157(1):e2025074351
4. O'Flaherty. Capnography: principles and practice. London: BMJ Publishing Group; 1994.
5. Aminiahidashti H, Shafiee S, Zamani Kiasari A, Sazgar M. Applications of End-Tidal Carbon Dioxide (ETCO2) Monitoring in Emergency Department; a Narrative Review. Emerg (Tehran). 2018;6(1):e5. Epub 2018 Jan 15. PMID: 29503830; PMCID: PMC5827051.

In this special episode of *PICU Doc on Call*, hosts Dr. Monica Gray and Dr. Rahul Damania welcome new pediatric critical care fellows across the U.S. with practical advice for day one of fellowship. Joined by third-year PICU fellow Dr. Alexandra Bryant, the episode covers three key areas: navigating PICU logistics, protecting mental health, and managing the overwhelming volume of critical care knowledge. Dr. Bryant shares candid insights from her own training journey, offering actionable strategies for success. The hosts remind listeners that fellowship is a learning process and that new fellows can make a meaningful impact.

Show Highlights

• Introduction to pediatric critical care fellowship for new fellows and learners
• Key insights and advice for first-year fellows in pediatric intensive care
• Importance of understanding logistics in the PICU environment
• Strategies for effective communication and collaboration within the PICU team
• Managing mental health and self-care during fellowship
• Techniques for absorbing and retaining vast knowledge in pediatric critical care
• Recommendations for organizing study materials and resources
• Emphasis on lifelong learning and accessing information effectively
• Practical tips for time management and responsibility organization
• Suggested resources for mindfulness and emotional support in medical training

Resource:

PICU Doc on Call Episode 31

In this episode of *PICU Doc on Call Shorts*, pediatric ICU physicians Dr. Pradip Kamat and Dr. Rahul Damania discuss respiratory time constants and their clinical relevance in pediatric critical care. Using a case of a six-year-old with near-fatal status asthmaticus on mechanical ventilation, they explain how prolonged time constants from high airway resistance cause air trapping, dynamic hyperinflation, and intrinsic PEEP. They emphasize recognizing these issues through ventilator waveforms and highlight that increasing respiratory rate can worsen hypercapnia in obstructive disease. Key management strategies include reducing respiratory rate, extending expiratory time, and accepting permissive hypercapnia to ensure hemodynamic stability.

Show Highlights

• Respiratory time constants and their clinical significance in pediatric patients
• Case study of a six-year-old boy with near-fatal status asthmaticus
• Management of severe obstructive respiratory failure in pediatric patients
• Understanding airway resistance and lung compliance in relation to time constants
• Impact of ventilator settings on patient outcomes, including air trapping and intrinsic PEEP
• Importance of adequate expiratory time to prevent dynamic hyperinflation
• Recognizing signs of inadequate expiratory time in mechanically ventilated patients
• Strategies for managing hypercapnia and optimizing ventilator settings
• Differences in time constants related to various pediatric respiratory conditions
• Key takeaways for pediatric critical care practice and ventilator management

1. Depta F, Kallet RH, Gentile MA, Kassis EN. Expiratory time constants in mechanically ventilated patients: rethinking the old concept — a narrative review. Intensive Care Medicine Experimental. 2025;13:40. The review summarizes the definition of expiratory time constant, the relationship to resistance and compliance, the 63/86/95/98/99% rule, and clinical applications in obstructive and acute lung injury states.
2. Depta F, et al. Six methods to determine expiratory time constants in mechanically ventilated patients: a prospective observational physiology study. Intensive Care Medicine Experimental. 2024. This study describes expiratory time constant as a parameter that can guide respiratory rate and I:E adjustment to support complete exhalation.
3. Alibrahim O, Rehder KJ, Miller AG, Rotta AT. Mechanical Ventilation and Respiratory Support in the Pediatric Intensive Care Unit. Pediatric Clinics of North America. 2022;69(3):587–605. This pediatric review specifically discusses passive exhalation, the expiratory time constant, and why asthma and bronchiolitis require longer expiratory times to avoid gas trapping.
4. Arnal JM. Monitoring respiratory mechanics in mechanically ventilated patients. Hamilton Medical Knowledge Base. This source provides a practical bedside description of time constants, waveform-based respiratory mechanics, and typical RCexp ranges, while emphasizing dependence on resistance and compliance.
5. Emeriaud G, López-Fernández YM, Iyer NP, et al.; PALICC-2 Group; PALISI Network. Executive summary of the second international guidelines for the diagnosis and management of pediatric ARDS. Pediatric Critical Care Medicine. 2023;24(2):143–168. The PALICC-2 guideline framework supports lung-protective ventilation in PARDS, including attention to tidal volume, PEEP, plateau pressure, and driving pressure.

In this episode of *PICU Doc on Call*, Dr. Monica Gray and Dr. Pradip Kamat are joined by fellow Dr. Hope Vancleve to discuss a complex case of a 12-year-old with MRSA septic shock requiring VA ECMO. The conversation covers sepsis-induced myocardial dysfunction, including its pathophysiology, diagnosis, and management. The hosts also explore differential hypoxia, or Harlequin syndrome, a serious VA ECMO complication causing upper body deoxygenation, and discuss monitoring strategies and circuit reconfiguration to prevent cerebral and myocardial ischemia.

Show Highlights:

• Clinical case discussion of a 12-year-old male patient with MRSA septic shock.
• Complications of sepsis, including sepsis-induced myocardial dysfunction and refractory shock.
• Management strategies for septic shock, including antibiotic therapy and fluid resuscitation.
• Use of venoarterial ECMO support in pediatric patients with severe cardiac dysfunction.
• Pathophysiology of sepsis-induced myocardial dysfunction and its impact on cardiac function.
• Differential hypoxia (North-South syndrome) in patients on femoral VA ECMO.
• Diagnostic approaches for sepsis-induced myocardial dysfunction, including echocardiography and biomarkers.
• Importance of monitoring and managing end-organ function in septic patients.
• Strategies for addressing differential hypoxia in ECMO patients, including circuit reconfiguration.
• Discussion of the risks and benefits of various ECMO configurations and management techniques.

References:

• Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter
• Reference 1: Torre DE, Pirri C. Harlequin Syndrome in Venoarterial ECMO and ECPELLA: When ECMO and Native or Impella Circulations Collide - A Comprehensive Review. Rev Cardiovasc Med. 2025 Aug 26;26(8):39992. doi: 10.31083/RCM39992. PMID: 40927093; PMCID: PMC12415751.
• Reference 2 : Cove ME. Disrupting differential hypoxia in peripheral veno-arterial extracorporeal membrane oxygenation. Crit Care. 2015 Jul 22;19(1):280. doi: 10.1186/s13054-015-0997-3. PMID: 27391473; PMCID: PMC4511033.

In this episode of PICU Doc on Call, hosts Dr. Monica Gray and Dr. Pradip Kamat discuss a 15-year-old girl who attempted suicide by ingesting rat poison, acetaminophen, ibuprofen, and amlodipine. The episode focuses on long-acting anticoagulant rodenticides (LAARs), such as brodifacoum, which inhibit vitamin K epoxide reductase, causing delayed coagulopathy. Key topics include clinical presentation, diagnostic evaluation, and management, emphasizing vitamin K1 as the primary antidote and prothrombin complex concentrate or fresh-frozen plasma for major bleeding. The patient stabilized with aggressive supportive care, including vasoactive agents and NAC therapy, alongside psychiatric intervention. Listen to learn more!

Show Highlights

• Clinical case of a 15-year-old girl who attempted suicide through polypharmacy ingestion
• Ingestion of multiple substances, including chewable rat poison, acetaminophen, ibuprofen, and amlodipine
• Discussion of toxicology related to long-acting anticoagulant rodenticides (LAARs) like brodifacoum
• Symptoms and clinical presentation following acute ingestion, including metabolic acidosis and elevated lactate
• Diagnostic evaluation and laboratory findings, including coagulation studies and liver function tests
• Management strategies for LAAR poisoning, including the use of vitamin K and supportive care
• Importance of monitoring for delayed coagulopathy and serial INR testing
• Consideration of calcium channel blocker toxicity in the context of the patient's clinical instability
• Overview of the mechanisms of action of LAARs and their impact on vitamin K-dependent clotting factors
• Key take-home points regarding the recognition and management of rodenticide ingestion in pediatric patients

References

Reference: King N, Tran MH. Long-Acting Anticoagulant Rodenticide (Superwarfarin) Poisoning: A Review of Its Historical Development, Epidemiology, and Clinical Management. Transfus Med Rev. 2015 Oct;29(4):250-8.

Reference 2: Feinstein DL, Akpa BS, Ayee MA, et al. The emerging threat of superwarfarins: history, detection, mechanisms, and countermeasures. Ann N Y Acad Sci. 2016 Jun;1374(1):111-22.

In this episode of PICU Doc on Call, Dr. Monica Gray and Dr. Pradip Kamat chat about flexible fiberoptic bronchoscopy (FFB) in the pediatric ICU. They walk through a case involving an eight-year-old who’s dealing with respiratory failure after a stem cell transplant. Along the way, they talk about when and why you might use bronchoscopy both for diagnosis and treatment—plus how to approach sedation and what effects the procedure can have on the heart and lungs. They also dive into important topics like managing hypoxia, handling increased airway and pulmonary vascular resistance, and what to keep in mind if your patient has a traumatic brain injury. The episode wraps up with tips for managing fever after the procedure and a quick look at how rigid bronchoscopy compares.

Show Highlights:

• Use of flexible fiberoptic bronchoscopy (FFB) in the pediatric ICU (PICU)
• Indications for performing bronchoscopy (diagnostic and therapeutic)
• Management of sedation and analgesia during bronchoscopy
• Cardiovascular effects associated with bronchoscopy procedures
• Respiratory effects and complications during bronchoscopy
• Special considerations for bronchoscopy in patients with traumatic brain injury (TBI)
• Post-procedure complications, including fever and its management
• Overview of rigid bronchoscopy and its indications
• Importance of understanding physiological changes during bronchoscopy
• Educational focus on acute pediatric care for current and aspiring PICU interns

References:

Reference 1: Sachdev A, Chhawchharia R. Flexible Fiberoptic Bronchoscopy in Pediatric Practice. Indian Pediatr. 2019 Jul 15;56(7):587-593. PMID: 31333214.

Reference 2: Li SX, Tao XF, Wu HJ, Jin F, Zhu GH, Wang YS, Tang LF, Chen ZM, Wu L. Advances in pediatric flexible bronchoscopy. World J Pediatr. 2025 Oct;21(10):945-956. doi: 10.1007/s12519-025-00967-7. Epub 2025 Oct 4. PMID: 41045338; PMCID: PMC12578761.

Reference 3: Truitt BA, Kasi AS, Kamat PP, Fundora MP, Simon DM, Guglani L. Cryoextraction via flexible bronchoscopy in children with tracheobronchial obstruction. Pediatr Pulmonol. 2023 Sep;58(9):2527-2534. doi: 10.1002/ppul.26540. Epub 2023 Jun 23. PMID: 37350368.

In this episode of "PICU Doc on Call," Drs. Monica Gray and Pradip Kamat from Children's Healthcare of Atlanta dive into the use of inhaled anesthetics, especially isoflurane, in the pediatric ICU. We’re focusing on those tough cases: refractory status asthmaticus and status epilepticus.

We’ll chat about why isoflurane is our go-to over other agents like sevoflurane, desflurane, or nitrous oxide, and break down its bronchodilatory and anticonvulsant properties. We’ll also touch on important pharmacology concepts, such as MAC and the blood-gas partition coefficient, and discuss how we approach dosing and ventilator management when using isoflurane.

Of course, we’ll also discuss the potential adverse effects that can come with prolonged use, and why it’s important to stop other sedatives and beta-agonists once you start isoflurane. Join us as we walk through the practical aspects and pearls for using inhaled anesthetics in the PICU!

Show Highlights:

• Use of inhaled anesthetics in pediatric intensive care units (PICU)
• Focus on isoflurane for managing refractory status asthmaticus and status epilepticus
• Comparison of inhaled anesthetic agents: isoflurane, sevoflurane, nitrous oxide, and desflurane
• Importance of minimum alveolar concentration (MAC) and blood-gas partition coefficient in anesthetic pharmacodynamics
• Mechanism of action of isoflurane in airway management and bronchodilation
• Clinical administration techniques for isoflurane in critically ill children
• Ventilator management principles for intubated children with status asthmaticus
• Role of isoflurane in refractory and super-refractory status epilepticus
• Potential adverse effects and considerations for prolonged isoflurane use
• Summary of pharmacologic concepts essential for safe isoflurane therapy in pediatric patients

References:

• Rogers Text Book of Pediatric Intensive Care: Chapter 47: Acute Severe Asthma. Stewart C, Brilli RJ. pages 763-775
• Reference 1: Stetefeld HR, Schaal A, Scheibe F, Nichtweiß J, Lehmann F, Müller M, Gerner ST, Huttner HB, Luger S, Fuhrer H, Bösel J, Schönenberger S, Dimitriadis K, Neumann B, Fuchs K, Fink GR, Malter MP; IGNITE Study Group, with support from the German Neurocritical Care Society (DGNI). Isoflurane in (Super-) Refractory Status Epilepticus: A Multicenter Evaluation. Neurocrit Care. 2021 Dec;35(3):631-639. doi: 10.1007/s12028-021-01250-z. Epub 2021 Jul 20. PMID: 34286464; PMCID: PMC8692280.
• Reference 2: Zeiler FA, Zeiler KJ, Teitelbaum J, Gillman LM, West M. Modern inhalational anesthetics for refractory status epilepticus. Can J Neurol Sci. 2015 Mar;42(2):106-15. doi: 10.1017/cjn. 2014.121. Epub 2015 Jan 9. PMID: 25572922.
• Reference 3: Werner HA. Status asthmaticus in children: a review. Chest. 2001 Jun;119(6):1913-29. doi: 10.1378/chest. 119.6.1913. PMID: 11399724.
• Reference 4: Gill B, Bartock JL, Damuth E, Puri N, Green A. Case report: Isoflurane therapy in a case of status asthmaticus requiring extracorporeal membrane oxygenation. Front Med (Lausanne). 2022 Nov 8;9:1051468. doi: 10.3389fmed. .2022.1051468. PMID: 36425104; PMCID: PMC9679515.