Avaliacao do uso da mistura de helio e oxigenio no estudo da ventilacao de criancas com doenca pulmonar obstrutiva cronica

Objetivo: estudar a distribuição do radioaerossol 99m-Tc-DTPA quando o Heliox é utilizado como veículo de nebulização na cintilografia pulmonar ventilatória de crianças e adolescentes com diagnóstico de doença pulmonar obstrutiva crônica. Tipo de estudo: ensaio clínico randomizado e controlado. Material e métodos: entre março de 1996 e setembro de 1998, foram incluídos neste estudo todas as crianças e adolescentes, entre 5 e 18 anos, em acompanhamento pela Unidade de Pneumologia Pediátrica do Hospital de Clínicas de Porto Alegre (HCPA), com diagnóstico de doença pulmonar obstrutiva crônica e que necessitassem realizar cintilografia pulmonar ventilatória. Concomitante ao estudo cintilográfico foi realizado o estudo da função pulmonar (espirometria). Neste estudo, foi definido como obstrução ao fluxo aéreo quando os pacientes apresentassem um Coeficiente Expiratório Forçado no 1° segundo (CEF1) inferior a 0,75, e um índice no Fluxo Expiratório Forçado a 75% sobre a Capacidade Vital Forçada (FEF15/ CVF) inferior a 0,25. Os pacientes foram alocados de forma aleatória em dois grupos: Heliox (Hélio 80% e Oxigênio 20%), ou Oxigênio, de acordo com veículo utilizado na nebulização do radioaerossol 99mTc-DTPA na cintilografia pulmonar ventilatória. Os resultados da cintilografia foram expressos através do slope, ou inclinação da curva de aquisição cumulativa de radioatividade pulmonar, e pela concentração cumulativa máxima de radioatividade obtida nos campos pulmonares. Foi determinado, ainda, por difração de raios laser, o tamanho médio das partículas de 99mTcDTPA geradas quando se utilizou Heliox e Oxigênio como veículos da nebulização. Os grupos foram comparados entre si, elegendo-se como di ferença significativa um valor de "p" inferior a 0,05. As variáveis contínuas foram expressas através das médias e desviospadrão (±DP), e comparadas através do teste T de Student. As variáveis categóricas foram expressas em percentagem (%) ou sob a forma descritiva e comparadas pelo teste Quiquadrado, usando a correção de Yates ou teste exato de Fischer, quando necessário. Resultados: foram alocados dez pacientes em cada grupo, não havendo diferença entre eles no que se refere à distribuição de sexo, diagnósticos etiológicos e presença de desnutrição. As médias de peso, altura, superfície corpórea, assim como os resultados da espirometria nos grupos Heliox e Oxigênio, também não apresentaram diferenças estatisticamente significativas (p>0,05). Dos 20 pacientes participantes do estudo, dez apresentavam na espirometria uma redução do CEF1 e do FEF15/ CVF, definidos como tendo obstrução ao fluxo aéreo. Destes, 6 estavam no grupo do Heliox, e 4 no grupo do Oxigênio. O grupo Heliox apresentou uma média dos slopes de 5.039 (±1.652), que foi significativamente maior (p=0,018) que a média dos slopes do grupo do Oxigênio (3.410 ± 1.1 00). Os pacientes do grupo Heliox com redução do CEF 1 e do FEF1sl CVF apresentaram uma concentração cumulativa de radiação nos campos pulmonares (2.755.891 ±.80 1.859 contagens) significativamente maior (p0.05). Of the 20 patients included in the study, 10 had reduction in the CEF1 and in the FEF75/ CVF index ofthe pulmonary function study, and were classified as having airway obstruction flow. Six ofthem were in the Heliox group and 4 in the Oxygen group. The mean slope in the Heliox group was 5,039 (±.1,652), with a significant difference (p=0.018) when compared to the mean slope ofthe Oxygen group (3,410 ±1,100). The patients with reduction at the CEF1 and FEF75/ CVF index in the Heliox group obtained a mean cumulative radiation in the lung fields of 2,755,891 ±801,859 counts, and showed a significant difference (p<0.05) when compared to the patients of the same group without reduction at the CEF 1 and FEF1sl CVF index (1,598,075 ±675,310 counts). The patients with reduction at the CEF, and FEF1sl CVF index in the Heliox group obtained a mean slope of 5.697 ±1.365, and showed a significant difference (p=0.017) when compared to the mean slope ofthe patients with reduction at the CEF1 and FEF75/ CVF index in the Oxygen group (3,467 ±651). The patients of the Oxygen group with and without airway obstruction flow in the pulmonary function study did not show any difference when they were compared on the basis of either the means of the slopes (p=0.903) or the means ofthe cumulative radiation in the lung fields (p=0.960). The patients o f the Heliox group and Oxygen group without airway obstruction flow at the pulmonary function study did not show any statistical difference when the were compared on the basis of either the means of the slopes (p= 0.507) or the means of the cumulative radiation in the lung fields (p=O. 795). The mean diameter of the parti eles o f 99mTc- DTP A generated when Heliox was used at a flow of 10 liters by minute as a vehicle of the scintigraphic study was 2.13 (±0.62J..L), with a statistical difference (p=0.004) when compared with the mean diameter o f the parti eles generated when Oxygen was used as a vehicle (0,88 ±0,99 J.l). Conclusions: When Heliox was used as a vehicle of radioaresol of 99mTc-DTP~ in the Scintigraphic study of children and adolescents with chronic obstructive lung disease, it showed a better distribution o f the 99mTc-DTPA and in the radiation activity into the lungs than that obtained when Oxygen was used. The benefits of Heliox over Oxygen in the capacity of inhaling parti eles are more evident in the presence of lower airway obstruction flow. When Oxygen and Heliox were used as a vehicle to inhale radioactive particles in patients without airway obstruction we could not demonstrate any difference in the distribution and in the radiation activity into the lungs. The mean diameters ofthe particles o f 99mTc-DTPA generated by Heliox and Oxygen showed a significant difference. In spite of this, the mean diameters observed in both groups were included in the recornmended range (between I and 5 u). Therefore, the observed differences between the particles generated by both gases could notjustify the effects ofHeliox demonstrated in this study

Nutritional Status, Breastfeeding, and Evolution of Infants with Acute Viral Bronchiolitis

Acute viral bronchiolitis is a common respiratory infectious disease of infancy. A prospective study was carried out with 175 infants aged up to six months to evaluate their nutritional and breastfeeding status as possible risk factors for unfavourable evolution of previously-healthy infants from a care hospital. Immunofluorescence test for virus and anthropometric assessment were performed. Outcomes were length of oxygen-use, length of hospital stay, and type of hospital unit needed. Seventy-three percent of the infants were well-nourished, 6% undernourished, 8.6% at a nutritional risk, 10.9% overweight, and 1.7% obese. Eighty-one percent of the undernourished and nutritionally at-risk infants and 72% of the well-nourished, overweight, and obese infants did not receive exclusive breastfeeding. The median length of hospital stay was four days and of oxygen-use was 60 hours. The nutritional status did not affect the clinical course of previously-healthy infants with acute viral brochiolitis. The duration of exclusive breastfeeding, but not type of breastfeeding, was inversely related to the length of oxygen-use and the length of hospital stay. Shorter exclusive breastfeeding was observed in infants who were assigned to a paediatric ward or to an intensive care unit. In conclusion, longer duration of breastfeeding was associated with better clinical outcomes

Two-thumb technique is superior to two- finger technique in cardiopulmonary resuscitation of simulated out-of- hospital cardiac arrest in infants

BACKGROUND: To compare the 2-finger and 2-thumb chest compression techniques on infant manikins in an out-of- hospital setting regarding efficiency of compressions, ventilation, and rescuer pain and fatigue. METHODS AND RESULTS: In a randomized crossover design, 78 medical students performed 2 minutes of cardiopulmonary resuscitation with mouth-to- nose ventilation at a 30:2 rate on a Resusci Baby QCPR infant manikin (Laerdal, Stavanger, Norway), using a barrier device and the 2-finger and 2-thumb compression techniques. Frequency and depth of chest compressions, proper hand position, complete chest recoil at each compression, hands-off time, tidal volume, and number of ventilations were evaluated through manikin-embedded SkillReporting software. After the interventions, standard Likert questionnaires and analog scales for pain and fatigue were applied. The variables were compared by a paired t-test or Wilcoxon test as suitable. Seventy-eight students participated in the study and performed 156 complete interventions. The 2-thumb technique resulted in a greater depth of chest compressions (42 versus 39.7 mm; P<0.01), and a higher percentage of chest compressions with adequate depth (89.5% versus 77%; P<0.01). There were no differences in ventilatory parameters or hands-off time between techniques. Pain and fatigue scores were higher for the 2-finger technique (5.2 versus 1.8 and 3.8 versus 2.6, respectively; P<0.01). CONCLUSIONS: In a simulation of out-of- hospital, single-rescuer infant cardiopulmonary resuscitation, the 2-thumb technique achieves better quality of chest compressions without interfering with ventilation and causes less rescuer pain and fatigue

Da Conferência Internacional de Sepse em Pediatria 2005 ao Consenso Sepsis-3

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Choque séptico em pediatria : o estado da arte

Objective Review the main aspects of the definition, diagnosis, and management of pediatric patients with sepsis and septic shock. Source of data A search was carried out in the MEDLINE and Embase databases. The articles were chosen according to the authors' interest, prioritizing those published in the last five years. Synthesis of data Sepsis remains a major cause of mortality in pediatric patients. The variability of clinical presentations makes it difficult to attain a precise definition in pediatrics. Airway stabilization with adequate oxygenation and ventilation if necessary, initial volume resuscitation, antibiotic administration, and cardiovascular support are the basis of sepsis treatment. In resource-poor settings, attention should be paid to the risks of fluid overload when administrating fluids. Administration of vasoactive drugs such as epinephrine or norepinephrine is necessary in the absence of volume response within the first hour. Follow-up of shock treatment should adhere to targets such as restoring vital and clinical signs of shock and controlling the focus of infection. A multimodal evaluation with bedside ultrasound for management after the first hours is recommended. In refractory shock, attention should be given to situations such as cardiac tamponade, hypothyroidism, adrenal insufficiency, abdominal catastrophe, and focus of uncontrolled infection. Conclusions The implementation of protocols and advanced technologies have reduced sepsis mortality. In resource-poor settings, good practices such as early sepsis identification, antibiotic administration, and careful fluid infusion are the cornerstones of sepsis management.Objetivo Revisar os principais aspectos da definição, diagnóstico e manejo do paciente pediátrico com sepse e choque séptico. Fontes de dados Uma pesquisa nas plataformas de dados Medline e Embase foi feita. Os artigos foram escolhidos segundo interesse dos autores, priorizaram-se as publicações dos últimos 5 anos. Síntese dos dados A sepse continua a ser uma causa importante de mortalidade em pacientes pediátricos. A variabilidade de apresentação clínica dificulta uma definição precisa em pediatria. A estabilização da via aérea com adequada oxigenação, e ventilação se necessário, ressuscitação volêmica inicial, administração de antibióticos e suporte cardiovascular são a base do tratamento da sepse. Em cenários de poucos recursos, deve-se atentar para os riscos de sobrecarga hídrica na administração de fluidos. A administração de drogas vasoativas como adrenalina ou noradrenalina, se faz necessária na ausência da resposta ao volume na primeira hora. O seguimento do tratamento do choque deve seguir alvos como restauração dos sinais vitais e clínicos de choque e controle do foco de infecção. Recomenda-se a avaliação multimodal, com auxílio da ecografia à beira-leito para manejo após as primeiras horas. No choque refratário, deve-se atentar para situações como tamponamento cardíaco, hipotireoidismo, insuficiência adrenal, catástrofe abdominal e foco de infecção não controlado. Conclusões Implantação de protocolos e avançadas tecnologias propiciou uma redução da mortalidade da sepse. Em cenários de poucos recursos, as boas práticas, como reconhecimento precoce da sepse, administração de antibióticos e cuidadosa infusão de fluidos, são os pilares do manejo da sepse

Epidemiology and outcomes of septic shock in children with complex chronic conditions in a developing country PICU

Objective To investigate the role of Complex Chronic Conditions (CCCs) on the outcomes of pediatric patients with refractory septic shock, as well as the accuracy of PELOD-2 and Vasoactive Inotropic Score (VIS) to predict mortality in this specific population. Methods This is a single-center, retrospective cohort study. All patients diagnosed with septic shock requiring vasoactive drugs admitted to a 13-bed PICU in southern Brazil, between January 2016 and July 2018, were included. Clinical and demographic characteristics, presence of CCCs and VIS, and PELOD-2 scores were accessed by reviewing electronic medical records. The main outcome was considered PICU mortality. Results 218 patients with septic shock requiring vasoactive drugs were identified in the 30-month period and 72% of them had at least one CCC. Overall mortality was 22%. Comparing to patients without previous comorbidities, those with CCCs had a higher mortality (26.7% vs 9.8%; OR = 3.4 [1.3–8.4]) and longer hospital length of stay (29.3 vs 14.8; OR 2.39 [1.1- 5.3]). Among the subgroups of CCCs, “Malignancy” was particularly associated with mortality (OR = 2.3 [1.0–5.1]). VIS and PELOD-2 scores in 24 and 48 hours were associated with mortality and a PELOD-2 in 48 hours > 8 had the best performance in predicting mortality in patients with CCC (AUROC = 0.89). Conclusion Patients with CCCs accounted for the majority of those admitted to the PICU with septic shock and related to poor outcomes. The high prevalence of hospitalizations, use of resources, and significant mortality determine that patients with CCCs should be considered a priority in the healthcare system

Early administration of two intravenous bolus of aminophylline added to the standard treatment of children with acute asthma

SummaryObjectivesEvaluate the efficacy of adding two intravenous bolus of aminophylline to the standard treatment of acute asthma episode in children admitted to the pediatric emergency room (PER).MethodsBetween March 2001 and February 2002, 60 children (2–5 years old), admitted to the PER at Hospital de Clínicas de Porto Alegre (Brazil), due to an episode of acute asthma, refractory to conventional therapy (an oral dose of steroids and at least three doses of inhaled albuterol, associated or not with oxygen) were enrolled in a randomized, double blind, placebo controlled clinical trial. The randomization was performed in blocks of 10 patients, who received a “bronchodilator solution” (either saline or aminophylline), in two doses: on arrival at the PER and again 6h later. The intervention group received aminophylline 5mg/kg/dose diluted in normal saline (NS) solution up to a 20mL volume, while the placebo group received plain NS, both in an infusion rate of 1cc/min. The main outcomes were total length of hospital stay, length of supplemental oxygen use, number of bronchodilator nebulizations and/or aerosol inhalations performed and patient destination. The groups were compared using the Students t-test, Mann–Whitney test and Chi-Square test, accepting p<0.05 as significant.ResultsComparing the main outcomes, we did not find differences between the placebo and aminophylline groups: 29.0±14.7 versus 26.2±13.4 beta-agonist nebulizations per patient (p=0.46); 2.4±10.6 versus 5.6±14.2 aerosol inhalations per patient (p=0.32); 24.7±30.0 versus 26.0±25.2h for oxygen supplement (p=0.86); 43.2±30.0 versus 43.6±23.7h for length of hospital stay (p=0.95). We also did not find differences between the two groups related to the blood pressure, heart rate, respiratory rate and oxygen saturation.ConclusionIn children aged 2–5 years admitted to a PER with asthma, two intravenous doses of 5mg/kg of aminophylline given 6h apart did not change the length of stay in hospital, the number of nebulizations given or the duration of oxygen therapy required. We are unable to tell whether there would be benefit with higher doses of aminophylline designed to give levels in the usual therapeutic range

Estrangulamento acidental em crianças por fechamento automático de vidro de carro

Among the main causes of death in our country are car accidents, drowning and accidental burns. Strangulation is a potentially fatal injury and an important cause of homicide and suicide among adults and adolescents. In children, its occurrence is usually accidental. However, in recent years, several cases of accidental strangulation in children around the world have been reported. A 2-year-old male patient was strangled in a car window. The patient was admitted to the pediatric intensive care unit with a Glasgow Coma Scale score of 8 and presented with progressive worsening of respiratory dysfunction and torpor. The patient also presented acute respiratory distress syndrome, acute pulmonary edema and shock. He was managed with protective mechanical ventilation, vasoactive drugs and antibiotic therapy. He was discharged from the intensive care unit without neurological or pulmonary sequelae. After 12 days of hospitalization, he was discharged from the hospital, and his state was very good. The incidence of automobile window strangulation is rare but of high morbidity and mortality due to the resulting choking mechanism. Fortunately, newer cars have devices that stop the automatic closing of the windows if resistance is encountered. However, considering the severity of complications strangulated patients experience, the intensive neuro-ventilatory and hemodynamic management of the pathologies involved is important to reduce morbidity and mortality, as is the need to implement new campaigns for the education of parents and caregivers of children, aiming to avoid easily preventable accidents and to optimize safety mechanisms in cars with electric windows

Airway resistance and respiratory compliance in children with acute viral bronchiolitis requiring mechanical ventilation support

Background: Acute viral bronchiolitis (AVB) is a very frequent disease that affects the lower airways of young children increasing the inspiratory and expiratory resistance in variable degree as well as reducing the pulmonary compliance. It would be desirable to know whether these variables are associated with the outcome. Objectives: To evaluate the respiratory mechanics in infants with AVB requiring mechanical ventilation (MV) support and to evaluate if respiratory mechanics predict outcomes in children with AVB supported on MV. To evaluate the respiratory mechanics in infants with AVB submitted to MV. Materials and methods: A prospective observational study was conducted in two pediatric intensive care units (PICUs) between February 2016 and March 2017. Included were infants (1 month to 1 year old) admitted with AVB and requiring MV for >48 hours. Auto-PEEP, dynamic compliance (Cdyn), static compliance (Cstat), expiratory resistance (ExRes), and inspiratory resistance (InRes) were evaluated once daily on the second and third day of MV. Results: A total of 64 infants (median age of 2.8 months and a mean weight of 4.8 ± 1.7 kg) were evaluated. A mean positive inspiratory pressure (PIP) of 31.5 ± 5.2 cmH2O, positive end-expiratory pressure (PEEP) of 5.5 ± 1.4 cmH2O, resulting in a mean airway pressure (MAP) of 12.5 ± 2.2 cmH2O and delta pressure of 22.5 ± 4.4 cmH2O without difference between the two hospitals. Measurements of respiratory mechanics showed high values of InRes and ExRes (median 142 [IQ25–75 106–180] cmH2O/L/s and 158 [IQ25–75 130–195.3] cmH2O/L/s, respectively), accompanied by decreased Cdyn and Cstat (0.46 ± 0.19 and 0.81 ± 0.25 mL/kg/cmH2O, respectively). None of the variables was associated with mortality, length of MV, or length of PICU stay. Conclusion: Infants with AVB requiring MV support present very high InRes and ExRes values. These findings might be the reason for the aggressive ventilatory parameters, especially PIP, required to ventilate this group of children with lower airway obstruction. Clinical significance: Monitoring respiratory mechanics could represent a useful tool to guide the ventilatory strategy to be adopted in patients with AVB

Nutritional Status, Breastfeeding, and Evolution of Infants with Acute Viral Bronchiolitis

Acute viral bronchiolitis is a common respiratory infectious disease of infancy. A prospective study was carried out with 175 infants aged up to six months to evaluate their nutritional and breastfeeding status as possible risk factors for unfavourable evolution of previously-healthy infants from a care hospital. Immunofluorescence test for virus and anthropometric assessment were performed. Outcomes were length of oxygen-use, length of hospital stay, and type of hospital unit needed. Seventy-three percent of the infants were well-nourished, 6% undernourished, 8.6% at a nutritional risk, 10.9% overweight, and 1.7% obese. Eighty-one percent of the undernourished and nutritionally at-risk infants and 72% of the well-nourished, overweight, and obese infants did not receive exclusive breastfeeding. The median length of hospital stay was four days and of oxygen-use was 60 hours. The nutritional status did not affect the clinical course of previously-healthy infants with acute viral brochiolitis. The duration of exclusive breastfeeding, but not type of breastfeeding, was inversely related to the length of oxygen-use and the length of hospital stay. Shorter exclusive breastfeeding was observed in infants who were assigned to a paediatric ward or to an intensive care unit. In conclusion, longer duration of breastfeeding was associated with better clinical outcomes