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992 www.pccmjournal.org October 2017 • Volume 18 • Number 10 receiving MV or MV plus NIV, and those receiving prolonged NIV had higher rates of complications. For the purposes of this study, the authors include HFNC along with positive airway pressure support (CPAP or bi-level positive airway pressure [BiPAP]) as forms of NIV. It remains controversial what the specific physiologic effects of HFNC are in different age groups and disease processes (11). However, that HFNC use is recorded in the PC4 dataset presents an opportunity for future study. In summary, these data provide the broadest overview published to date of NIV use in children with cardiac disease, reflecting over 9,000 patient encounters, and the results present important insights into how common and variable NIV use in this ICU population—both medically and surgically treated. The PC4 collaborative includes some of the busiest and most prominent cardiac programs in North America and is likely representative of the “state of the art” in contemporary pediatric cardiac intensive care. NIV is clearly very common, and yet, NIV use is highly variable across centers, indicating a lack of standard approaches for initiation of NIV, evaluation of its effectiveness, and impact on overall outcomes. The current analysis of the PC4 database does not link NIV use to quality of care outcomes or understanding of the specific indications for NIV use (e.g., elective postextubation use vs rescue therapy). PC4 and similar multicenter collaboratives are ideally positioned to use their understanding of current practice as the basis for prospective studies on which populations benefit from NIV, including key questions such as what type of NIV (CPAP/BiPAP vs HFNC) is best in specific situations and which NIV strategies improve outcomes and shorten length of stay. Thus, although the current PC4 report provides a foundation for understanding what the participating centers are doing, the critical next steps will be to use the PC4 infrastructure to address the questions of what we should be doing with NIV in the CICU.