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Objective The aim of the study was to identify early predictors of mortality in children with severe dengue fever admitted to pediatric intensive care unit (PICU). Materials and methods All consecutive children with laboratory-confirmed severe dengue fever were enrolled in this prospective observational study. Besides demographic data, disease severity and organ dysfunction scores, laboratory investigations and interventions are done in PICU were recorded and analyzed. Results During the study period of 42 months, 172 patients with dengue fever were admitted to PICU. A total of 78 (45.3%) patients with severe dengue fever were included and analyzed. There were 20 (25.6%) deaths. There were significant differences in disease severity and organ dysfunction scores, transaminases, blood lactate level and serum creatinine between survivors and nonsurvivors. A significantly higher number of nonsurvivors required interventions in first 24 hours of admission. Platelet counts (P value 0.22) and hematocrit (P value 0.47) were not statistically different in 2 groups. There was a significantly high vasopressor-inotrope score (VIS) ( 10% (0.002) in nonsurvivors. Multivariate stepwise logistic regression analysis identified serum glutamic pyruvic transaminases (≥ 284 IU/L; odds ratio [OR] 1.002, 95% confidence interval [CI]: 1.001-1.003), blood lactate level (≥2.73 mmol/L; OR 2.08, 95% CI: 1.354-3.202), Pediatric Risk of Mortality score at 12 hours (≥14.5; OR 1.35, 95% CI: 1.077-1.693), VIS (≥22.5, OR 1.129, 95% CI: 1.059-1.204) and positive fluid balance >10% (OR 22.937, 95% CI: 2.393-219.84) at 24 hours of admission as independent predictors of mortality. Conclusion Disease severity, hyperlactatemia at admission, need for multiple vasoactive drugs and positive fluid balance are predictors of mortality in severe dengue infection in children admitted to PICU.

The prevalence of asthma is increasing rapidly, worldwide, due to changing gene-environment interactions. The rate of rise is more in resource poor nations due to lack of knowledge and non-availability of expertise. Monitoring of lung functions is mandatory for diagnosis and further management of asthmatic patients. Spirometry, the widely available investigation, is the gold standard test used for mapping pulmonary dynamicity. It has got its own limitations in the form of operational difficulties in children, the elderly, and in those with neuromuscular or behavioral issues. In the current era of COVID-19 pandemic, the utility of spirometry has been further restricted to selected cohort only, due to potential risk of viral transmission during the procedure. Oscillometry technique has been used previously, to monitor lung functions, with promising results. Ultrasonic waves of various frequencies accompany the tidal breath of patients and respiratory impedance is calculated by measured pressure and flow signals from exhaled breath. The results are interpreted in the form of resistance, reactance, resonant frequency, and reactance area. Various manufacturers have developed different mechanical models with slight variation in impulse pattern till date. There are certain distinct advantages of oscillometry over spirometry. Being tidal breath-based maneuver, it is more child friendly. People with neuromuscular weakness, cognitive limitations, and the elderly can easily perform it with only minor understanding and effort. Oscillometry is more sensitive than spirometry in detecting peripheral airway diseases. Post-bronchodilator reversibility can be evaluated by comparing with the baseline respiratory characteristics. Their utility in restrictive diseases and vocal cord dysfunction has also been explored. Less aerosol generation during the normal tidal breath is another advantage of oscillometry, over spirometry needing forceful efforts, which makes it more suitable for use in viral pandemic situations for monitoring patients with both asthma and pneumonia. More research is needed, in various geographic locations and heterogeneous populations, to devise the normative data of oscillometric parameters. Simultaneously, there is an urgent need for standardization of available machines at global platform.

Background Multisystem inflammatory syndrome in children (MIS-C) associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a new entity affecting a small percentage of children during the COVID-19 pandemic. Materials and methods Demography, clinical, and laboratory variables of children admitted from April to September 2020 with MIS-C were studied retrospectively at eight hospitals in Delhi, India. Results We identified 120 patients [median age: 7 years (interquartile range (IQR): 4–10)] with male-to-female ratio of 2.3:1. Overall, 73 out of 120 children (60.8%) presented with shock, 63 (52.5%) required inopressor support, and 51 (43%) required respiratory support. We categorized the cohort into three observed clinical phenotypes: MIS-C with shock (n = 63), MIS-C with Kawasaki disease (KD) (n = 23), and MIS-C without shock and KD (n = 34). Atypical presentations were hypothermia, orchitis, meningoencephalitis, demyelination, polyneuropathy, pancreatitis, and appendicitis. Ninety-four percent had laboratory evidence of SARS-CoV-2 (78.3%, seropositive and 15.8%, RT-PCR positive). The median C-reactive protein (CRP) was 136 mg/L (IQR, 63.5–212.5) and ferritin was 543 ng/mL (IQR, 225–1,127). More than 90% received immunomodulatory therapy (intravenous immunoglobulins and/or steroids) with an excellent outcome (96% survived). CRP and absolute neutrophil count (ANC) were correlated statistically with severity. Conclusion MIS-C data from Delhi are presented. Rising CRP and ANC predict the severe MIS-C. How to cite this article Mehra B, Pandey M, Gupta D, Oberoi T, Jerath N, Sharma R, et al. COVID-19-associated Multisystem Inflammatory Syndrome in Children: A Multicentric Retrospective Cohort Study. Indian J Crit Care Med 2021;25(10):1176–1182.

Aim and objective To study the profile, indications, related complications, and predictors of decannulation and mortality in patients who underwent tracheostomy in the pediatric intensive care unit (PICU). Materials and methods Retrospective analysis of prospectively collected data of tracheostomies was done on patients admitted at PICU. Demographics, primary diagnosis, indication of tracheostomy, and durations of endotracheal intubation, mechanical ventilation, and tracheostomy cannulation were recorded. The indication was recorded in one of the four categories—upper airway obstruction (UAO), central neurological impairment (CNI), prolonged mechanical ventilation, and peripheral neuromuscular disorders). Results Two hundred ninety cases were analyzed. UAO (42%) and CNI (48.2%) were main indications in the halves of the study period, respectively. Decannulation was successful in 188 (64.8%) patients. Seventy-seven percentage UAO patients were decannulated successfully [OR (odds ratio); 95% CI (confidence interval), 2.647; 1.182–5.924, p = 0.018]. Age

Background Consensus Guidelines for Pediatric Intensive Care Units (PICUs) were published in Indian Pediatrics in 2002. Objective The current document represents a recent update in the Indian context, regarding unit design, equipment, organization, staffing as well as admission and discharge criteria for different levels of Pediatric Intensive Care and teaching units with PICU training programs, as well as nonteaching units. Process The Pediatric Intensive Care College Council (PICC), an academic wing of the Indian Academy of Pediatrics (IAP) Intensive Care Chapter took the initiative to update the guidelines with members of the PICU guidelines Committee writing group. After a great deal of discussion at conferences and through mailing and feedback with listed members, as well as with the guidance and feedback of senior PICU guidelines advisory committee members, The consensus is now updated. These guidelines are intended to serve as a reference for health Care institutions wishing to establish a new PICU or to modify an existing PICU. As a resource, experience of those members who have worked extensively in western PICUs was also taken into consideration, in addition to published guidelines in the medical literature. PICUs with teaching programs run by the IAP Intensive Care Chapter must follow these criteria for unit accreditation and teaching curricula as applicable. Recommendations Unit design, equipment, organization, staffing as well as admission and discharge criteria for different levels of pediatric intensive care are updated.

Personal Protective Equipments (PPEs) are used to safeguard the health of workers. Airborne aerosol with size below 5 micron can enter lower respiratory system directly whereas bigger size particles either settles on surrounding equipment and become fomites. COVID 19 can stay in air after 3 hours with airborne spread in health care with fomites especially plastic showing infection up to 72 hours. Examples of PPE include items as mask, gloves, shield, goggles, gowns and full body suits. All health care workers need to be taught the correct sequence of wearing and taking off the PPE in order to avoid contamination.

Objective In children, pulmonary and cardiac diseases are closely associated, and their integrated evaluation is important. Flexible fiber-optic bronchoscopy (FFB) can be used for both diagnostic and therapeutic purposes in pediatric cardiac intensive care units (PCICU). The objective of this study was to evaluate the utility of FFB in children with congenital heart disease (CHD). Materials and methods A retrospective, descriptive study was conducted at a tertiary care center in pediatric patients who underwent FFB in PCICU over a period of 6 years (2012-2017). Results Total 71 bronchoscopies were done in 58 patients with CHD with median age and weight of 2.5 months and 3.4 kg, respectively. Total of 20 different cardiac lesions were present among patients who underwent FFB. While 38 (53.5%) and 30 (42.3%) procedures were performed in pre-op and postoperative patients, respectively, 3 intraoperative bronchoscopies were also performed. The main indications for FFB were persistent atelectasis (42/71), prolonged oxygen requirement (13/71), stridor (8/71), and suspected airway anomaly (6/71). Tracheobronchitis was the commonest bronchoscopy finding (51/71, 71.8%) followed by tracheobronchomalacia (27/71, 38.3%). Cause of stridor detected in 7/8 cases. Associated preoperative and postoperative respiratory complications were detected and necessary interventions were done. These included slide tracheoplasty (5/58), tracheostomy (5/58), antibiotic change based on bronchoalveolar lavage (BAL) cultures (11/71), and continued positive pressure ventilation (4/71). Nonconsequential complications were transient hypoxemia (10/71), bleeding (2/71), and transient bradycardia (1/71). Conclusion Bedside FFB is a safe and a valuable diagnostic tool that also helps in guiding interventions in children with cardiac diseases. How to cite this article Sachdev A, Chhawchharia R, Gupta D, Gupta N, Joshi R, Agarwal N. Flexible Fiber-optic Bronchoscopy-directed Interventions in Children with Congenital Heart Diseases. Indian J Crit Care Med 2020;24(5):340-343.

Objective The aim of the study was to investigate the association of urinary albumin:creatinine ratio (ACR) with regard to the outcome of sepsis patients and to study the trends of ACR with severity of disease, organ dysfunction, microcirculation status, the use of inotrope, and mechanical ventilation use, and length of pediatric intensive care unit (PICU) stay. Materials and methods In the prospective observational study, the patients with varying categories of sepsis admitted in the PICU with stay >24 hours were enrolled consecutively. Urine samples were collected at the time of admission (ACR1), 12 hours (ACR2), and 24 hours (ACR3). Results One hundred and thirty-eight patients including 56 cases of sepsis, 31 of severe sepsis, 22 of septic shock, and 29 of multiorgan dysfunction syndrome (MODS) cases were analyzed. There were 29 (21%) deaths. ACR (median, IQR) was significantly higher in nonsurvivors [ACR1 198.9 (111.2–329.4) vs 124.5 (59.37–294.5), p 0.03], [ACR2 213.8 (112.5–350) vs 117.8 (62.6–211.9) p 0.008], [ACR3 231.8 (99.9–441.2 vs 114.4 (44.1–240.3), p 0.005]. The ACR is increased progressively with the increasing severity of sepsis (p < 0.001). The performance of ACR operative characteristics was compared with that of PRISM and PELOD scores. In deceased, ACR was significantly correlated with blood pH, lactate, and base deficit. A cutoff value of ACR 102.7 mg/g had sensitivity 86.2%, specificity 40.4%, positive predictive value 27.8%, and negative predictive value 91.7%. The use of inotropes, mechanical ventilation (>48 hours), and mortality was significantly higher in patients with ACR >102 mg/g. The probability of death varied from 17.6 to 19% in the first 24 hours of admission. ACR was significantly cheaper as compared to PRISM score and PELOD score estimations. Conclusion Urinary ACR, a cost-effective tool, correlates with the severity of sepsis and associated morbidity and mortality in children. How to cite this article Sachdev A, Raheja K, Gupta N, Chugh P. Association of Urinary Albumin:Creatinine Ratio with Outcome of Children with Sepsis. Indian J Crit Care Med 2020;24(6):465–472.

Objective: The objective is to study the intra- and postoperative cardiopulmonary complications, metabolic derangements, and mortality in the recipients of orthotopic liver transplantation (OLT). Materials and Methods: Medical records of all children who underwent OLT at our institution from January 2003 to December 2019 were reviewed, and the clinical and laboratory data were collected. Results: Eighty-two patients (48 males) underwent living-related OLT and one received cadaveric liver. The median age of recipients was 6 years (range: 4 months–16 years). The two common indications for OLT were biliary atresia (n = 27, 32.9%) and Wilson's disease (n = 20, 24.3%). Common metabolic problems during intraoperative phase included hypokalemia (43.9%) and hyperglycemia (57.3%). The mean duration of postoperative ventilation was 35.8 ± 51.4 h. Fifty-two patients were extubated within 24 h of surgery. Pleural effusion was most common present in 52 patients postoperatively. It did not interfere with mechanical ventilation. Hypertension, hypotension, and oliguria were recorded in 28, 31, and 22 patients, respectively. There were 11 graft rejection episodes. Ten children required re-operations. There were 4 (4.8%) early deaths, aged ≤1 year, in the first 2 weeks of transplantation. Conclusion: Medical and surgical complications are common in patients after liver transplantation. Intensive monitoring and laboratory workup help in detection of these complications. Early and 1-year survival rates are comparable to that in the developed world.

Childhood allergies pose huge economic burden and adverse effects on quality of life. Serum IgE has been considered a surrogate allergy marker for decades. Availability of several over-the-counter allergy tests add to confusion of partially trained caregivers. The present review focuses on current status of allergy testing in Indian scenario. Various in-vitro and in-vivo diagnostic modalities are available for allergy detection. Skin prick tests are useful for aero-allergies whereas oral challenge tests are best for identifying suspected food allergies. An allergy test should be individualized based on clinical features, diagnostic efficacy, and cost-benefit analysis.

In recent past, revolution in medical technology resulted in improved survival rates and outcomes of critically ill children. Unfortunately, its impact relating to morbidity is not well documented. Although survival rates of these critically ill children who are medically fragile and technology-dependent have improved, we as health professionals are still in the learning curve to improve the quality of life of these children at home. Factors such as support from society, infrastructure, and funding play an important role in technology-dependent child care at home. In this review, commonly prescribed home-based medical technologies such as home ventilation, enteral nutrition, renal replacement therapy, and peripherally inserted central catheter, which are useful for quick revision, are described.

Background: Lung function testing is recommended for the management of asthma. Due to certain limitations of conventional spirometry in vulnerable patients, forced oscillation technique (FOT) has been studied with promising results. As there is a paucity of data from developing world, we planned to conduct this study in children using FOT. To assess airway reversibility after inhaled salbutamol in asymptomatic children with suspected asthma. Settings: This study was conducted at pediatric asthma clinic of a tertiary care referral hospital in North India. Design: This was a prospective interventional study over 1-year period. Subjects and Methods: Asymptomatic children between 2 and 18 years of age, with history suggestive of asthma, were eligible for participation. Baseline and postbronchodilator pulmonary functions were assessed using FOT. Airway resistance and reactance were monitored at various frequencies. SPSS version 17 was used for statistical analysis. Results: Among the 345 enrolled children, baseline mean ± standard deviation total airway resistance (R5), central airway resistance (R19), peripheral airway resistance (R5–R19), reactance (X5), and resonant frequency (Fres) were 6.85 ± 2.60, 5.23 ± 1.93, 1.6 ± 1.16, and − 2.54 ± 1.36 cmH2O/L/s and 17.28 ± 3.06 Hz. The median (interquartile range) percentage change after inhaled salbutamol was 19.9 (11.40, 29.12), 22.86 (6.88, 38.76), 14.08 (3.40, 22.62), 39.20 (8.20, 62.39), and 15.79 (8.33, 27.27) in respective parameters. All changes were statistically significant. The studied respiratory variables were in maximum negative correlation with height, followed by body mass index. Conclusions: FOT is a simple technique for monitoring lung functions in children during asthma management.

BACKGROUND: Limited adult data suggest that airway driving pressure might better reflect the potential risk for lung injury than tidal volume based on ideal body weight, and the parameter correlates with mortality in ARDS. There is a lack of data about the effect of driving pressure on mortality in pediatric ARDS. This study aimed to evaluate the effect of driving pressure on morbidity and mortality of children with acute hypoxemic respiratory failure. METHODS: This retrospective cohort study was performed in a tertiary level pediatric ICU. Children who received invasive mechanical ventilation for acute hypoxemic respiratory failure (defined as [Formula: see text] < 300 within 24 h after intubation), in a 2-y period were included. The cohort was divided into 2 groups based on the highest dynamic driving pressure (ΔP, calculated as the difference between peak inspiratory pressure and PEEP) in the first 24 h, with a cutoff value of 15 cm H(2)O. RESULTS: Of the 380 children who were mechanically ventilated during the study period, 101 children who met eligibility criteria were enrolled. Common diagnoses were pneumonia (n = 51), severe sepsis (n = 24), severe dengue (n = 10), and aspiration pneumonia (n = 7). In comparison to the group with high ΔP (ie, ≥ 15 cm H(2)O), children in the group with low ΔP (ie, < 15 cm H(2)O) had significantly lower median (interquartile range) duration of ventilation (5 [4–6] d vs 8 [6–11] d, P < .001], ICU length of stay (6 [5–8] d vs 12 [8–15] d, P < .001], and more ventilator-free days at day 28 (23 [20–24] vs 17 [0–22] d, P < .001). Logistic regression analysis also suggested driving pressure as an independent predictor of morbidity after adjusting for confounding variables. However, there was no statistically significant difference in mortality between the 2 groups (17% in low ΔP vs 24% in high ΔP, P = .38). Subgroup analysis of 65 subjects who fulfilled ARDS criteria yielded similar results with respect to mortality and morbidity. CONCLUSIONS: Below a threshold of 15 cm H(2)O, ΔP was associated with significantly decreased morbidity in children with acute hypoxemic respiratory failure.

Spirometry, a gold standard technique for measuring lung functions, has been restricted to a select cohort of patients in current COVID-19 pandemic due to the enhanced risk of disease dissemination. To monitor pulmonary functions in various obstructive (e.g., asthma) and restrictive diseases (e.g., COVID-19 pneumonia) on in- and out-patients serially, there is an urgent requirement of an alternate reliable test. Impulse Oscillometry (IOS) measures lung functions by working at tidal volumes and thus reduces the risk of potential aerosol generation. Feasibility of IOS in smaller children and its ability to detect parenchymal and peripheral airway involvement are other advantages over conventional spirometry. IOS could be a potential solution to periodically monitor lung functions in current pandemic situation to keep a check on diseases affecting lung functionality.

Objective: It was hypothesized that heated humidified high flow nasal cannula (HFNC) is non-inferior to non- invasive ventilation (NIV) for preventing reintubation in high risk children. Design: Prospective randomized clinical non-inferiority trial Setting: Single centre study in a 12-bed multidisciplinary paediatric intensive care unit (PICU) in Delhi. Patients: All children (1month -18years) receiving invasive mechanical ventilation longer than 48 hours and ready for scheduled extubation. Intervention: Heated humidified high flow nasal cannula(HFNC) or Non-invasive ventilation (NIV) Measurements and Main Results: Of total 230 patients enrolled, 139 were analysed (3 left against medical advice), out of which 70 (50.4%) received NIV and 69 (49.6%) HFNC. Mean duration of intubation was 150.8 ±74.3 hours in NIV group vs 138.5 ±81.9 hours in HFNC group (p= 0.16). Out of 139 children, 15(10.8%) were re-intubated; 6 (8.6%) in the NIV group vs 9 (13%) in the HFNC group (absolute difference 4.4%; p= 0.42). Median time to re-intubation did not differ between the group; NIV group 4 hours (IQR 1.7-12.5hours) vs HFNC group 3.7 hours (IQR 2-4hours) (absolute difference, 0.3 hours; p= 0.50). Mean post extubation PICU length of stay was significantly lower in HFNC group (3.5 ±2.5 days) vs NIV group (4.1± 2.3days; p= 0.01). There were multiple reasons for failure of assigned intervention which were comparable in both groups. These included : stridor, impaired consciousness (fall in GCS>2), haemodynamic instability, inability to clear airway, increased work of breathing, hypoxemia, respiratory acidosis. There was no mortality in either group within 48 hours of extubation. Conclusion: Among high-risk children who had undergone extubation, HFNC therapy was found to be non-inferior to NIV with respect to the re-intubation rate.

Status Asthmaticus is a common reason for Emergency Room visits in children. Most of the asthma flares are successfully managed by use of β agonist and steroids. If these therapies fail to halt the progression of asthma, a number of medical therapies may be used to treat it. However, the data supporting the use of these therapies are conflicting. We present successful use of Extracorporeal Membrane Oxygenation and isoflurane in a child with Refractory Status Asthmaticus.

Hyperleukocytosis in pertussis has a correlation with disease severity. We describe a 5-week-old infant with severe pertussis and hyperleukocytosis requiring mechanical ventilation. Baby developed refractory hypoxemia. Two cycles of exchange transfusion were done on different occasions. Exchange transfusion resulted in significant improvement in oxygenation and hemodynamic parameters. Exchange transfusion is a viable treatment option in pertussis hyperleukocytosis complicated by refractory hypoxemia or persistent features of Systemic Inflammatory Response Syndrome.

Background Policy Deployment and Daily Management are two critical vehicles of Total Quality Management implementation in a company. Integration of these two vehicles has been discussed and adequately addressed in a few companies that have been practicing Total Quality Management for a long time. However, most companies often face challenges and difficulties in ensuring smooth and seamless transfer of Policy Deployment plans into Daily Management activities. Case description The challenge is even bigger in service sector which embarked on the Total Quality Management journey barely 5–6 years ago. The service sector has traditionally used Balanced Scorecard which has relatively weaker emphasis on the means to achieve the targets. The authors of this report have found a customized and unique model whose success has been demonstrated through deployment in two customer-facing processes in a large life insurance company in India. The traditional approach used in manufacturing industry has been simplified and customized for the effective application in the service sector. Discussions & Evaluation The traditional approach used in manufacturing industry has been simplified and customised for the effective application in the service sector. A survey was done to identify the issues and the approach was modified and implemented in couple of key customer-facing processes. Conclusion The phenomenal results have led to a big ‘pull’ from other process owners to replicate this approach across all operational and support processes. Initial ‘reluctant participants’ of the process have now become the ‘champions’ and truly the ‘change catalysts’ for this approach. The process is now being replicated in several other processes across several Industrial sectors.

Extracorporeal membrane oxygenation (ECMO) is a standard modality to treat refractory hypoxemia in pediatric acute respiratory distress syndrome (ARDS) in developed countries. However, it’s usage is limited in developing countries like India, where very few tertiary care PICU centres have used it with success. We report a case of 11 months old infant with necrotising bacterial pneumonia with severe ARDS and septic shock who failed on conventional and high frequency mechanical ventilation, but was successfully managed with veno-arterial ECMO support.

Objective: The objective of the study was to evaluate the etiology of hospital-acquired hyponatremia (HAH) and its effects on morbidity and mortality in the Pediatric Intensive Care Unit (PICU) patients. Design: This study design was a prospective observational case–control study. Setting: this study was conducted at tertiary care PICU. Materials and Methods: All consecutive cases admitted with at least one measured serum sodium (PNa) value were evaluated. Those with normal admission PNa were followed till they develop hyponatremia (PNa < 35 mEq/L) 7 days or PICU discharge whichever was earlier. Results: During the study period, 123 (19.6%) cases developed HAH and 126 patients remained isonatremic (control group). The admission PNa 138.8 ± 3.03 mEq/L decreased to 132 ± 2.58 mEq/L (drop of 6.68 ± 3.39 mEq/L, P < 0.001) in HAH cases. The use of antidiuretic hormone (ADH)-stimulating drugs (odds ratio [OR]: 2.83, P = 0.01), postsurgical status (OR: 2.95, P = 0.006), and fluid intake ml/kg (OR: 1.0, P = 0.001) were found to be significant risk factors in HAH group on multivariate analysis. HAH cases had prolonged PICU stay (P = 0.000) and mechanical ventilation (P = 0.01), but no difference in the mortality when compared to controls. Conclusions: HAH is associated with increased fluid intake, presence of ADH-stimulating drugs or conditions, and postsurgical status and has an adverse effect on the outcome of PICU patients.

Rickettsial infections are relatively less common in children, probably due to low index of suspicion and unavailability of diagnostic facilities. Scrub typhus is the predominant type of rickettsial illness identified in our country. Infections with other rickettsial species are rarely reported in Indian children. We report a case of a 3 year child with acute febrile illness with rash and multiorgan dysfunction. Weil Felix test was strongly positive for OX 19, with negative scrub typhus IgM antibody test, suggesting a murine typhus infection. There were few salient differences in clinical and laboratory parameters, compared to scrub. Treatment of rickettsial infections is inexpensive and highly effective especially in early course of the disease. Differential diagnosis of rickettsial infection should be kept in a child presenting with fever, rash and multisystem involvement and adding empirical doxycycline at admission may be considered.

Flexible fiberoptic bronchoscopy a vital diagnostic and therapeutic procedure for assessing the airway. Its logistics, clinical indications and utility need to be elucidated in pediatric context. Pediatric flexible fibreoptic bronchoscopy is useful for diagnosis of airway anomalies, bronchoalveolar lavage for diagnostic and therapeutic purposes, and interventions like foreign body removal. Newer ultra-thin bronchoscopes can be used to perform this procedure in children of all ages. Pediatric flexible bronchoscopy is a valuable diagnostic and therapeutic tool in the hands of skilled personnel when used judiciously.