Análisis de la efectividad de la ventilación no invasiva en la insuficiencia respiratoria aguda en el paciente pediátrico

[spa] OBJETIVOS El objetivo principal de la tesis es determinar la efectividad de la ventilación no invasiva (VNI) e identificar factores pronósticos de fracaso en una cohorte general pediátrica. Los objetivos secundarios de la tesis son: 1. Estudiar si las cohortes establecidas según la clasificación cronológica presentan diferencias fisiológicas significativas anteriores al inicio de la VNI 2. Determinar la efectividad y los factores pronósticos de fracaso de la VNI de las tres cohortes (inicial, rescate y electiva) por separado 3. Evaluar la seguridad de la técnica, analizando su morbilidad y mortalidad asociadas MATERIAL Y MÉTODOS Diseño del estudio: Estudio de cohortes prospectivo realizado en UCIP del Hospital Sant Joan de Déu mediante muestreo consecutivo desde Enero 2005 - Diciembre 2009. Criterios de inclusión: • Pacientes de ambos sexos entre los 0-18 años con criterios de insuficiencia respiratoria aguda grave (IRA). Criterios de exclusión: • Pacientes con contraindicación para el uso de la VNI o con indicación paliativa. Variables a estudiar: Los datos de los pacientes fueron recogidas. Tipo de interfase, ventilador, modos (CPAP, BLPAP)y parámetros usados; variables fisiológicas (previo, 2ª hora, 8, 12 y 24 horas); el cociente SpO2/FiO2 (SF), fue calculado retrospectivamente, eliminándose valores con SatHb superior a 97; Tiempo de uso de la VNI, duración de la estancia en UCIP y hospital. Las complicaciones y mortalidad atribuibles a la VNI. El fracaso de la VNI se define como la necesidad de intubación. RESULTADOS En el análisis descriptivo de los 491 episodios, las variables demográficas definen una población diana para el uso de la VNI: Edad media de 36 a 46 meses, con predominio sexo masculino, sin enfermedad de base, la causa más frecuente de IRA es la INFECCIÓN RESPIRATORIA. Las complicaciones han sido poco frecuentes (5,5%). No hubo mortalidad asociada al uso de la VNI. En la cohorte general según el grupo de edad, se diferencian significativamente, mayores y menores de seis meses. El análisis multivariable las variables independientes halladas son edad, modalidad (CPAP/BLPAP), el tipo de fallo respiratorio tipo II, el menor valor de SF y menor descenso de la FC a las dos horas. En el análisis de las cohortes generadas según la clasificación cronológica se observan diferencias significativas en las variables fisiológicas y las necesidades de oxígeno previas al inicio de la VNI. En el análisis multivariable de la cohorte inicial se observa : Modalidad CPAP, valores bajos de SF y altos de FC a las 2 horas, la edad mayor a 6 meses , así como los valores más bajos de IPAP a las 2 horas son factores independientes de fracaso CONCLUSIONES Conclusiones principales 1. La ventilación no invasiva es una técnica efectiva para prevenir la intubación en Pediatria 2. Los factores pronósticos de fracaso en la cohorte general son: • Recibir tratamiento con CPAP en lugar de BLPAP • Tener un fallo respiratorio tipo II, un valor de SF a las 2 horas y un descenso de la FC menor yun valor de FC a las 2 horas mayor Conclusiones secundarias 1. Las cohortes generadas por la clasificación cronológica presentan diferencias significativas en las variables fisiológicas previas 2. La efectividad en la cohorte general aumenta con la edad 3. La efectividad y factores pronósticos en las cohortes inicial, rescate y electiva fue superior en la cohorte-r (84%) respecto cohorte-i (71%) y cohorte-e (77%). En la VNI inicial, son factores pronósticos de fracaso: • El valor más bajo de cociente SF, y el valor más alto de FC a las 2 horas • Pertenecer al grupo CPAP 4. La técnica es segura, siendo su morbilidad baja y muy leve, y la mortalidad asociada nula.[eng]Objectives The primary objective of our study was to confirm safety and effectiveness of non-invasive ventilation (NIV) in children with acute respiratory failure (ARF). Our secondary objective was identify predictive factors of failure for NIV in children after describing and analyzing separately the characteristics of first-line or initial NIV, rescue and elective post-extubation NIV. Methods Patients and setting A prospective cohort study was carried out from January 2005 to December 2009 in a tertiary hospital PICU admitting patients from birth to 18 years of age. Consecutive sampling was conducted on all admitted patients who presented ARF and received NIV. Exclusion criteria were presence of any contraindications to NIV and NIV used as a palliative measure. Ethics Committee of Hospital Sant Joan de Deu approval was obtained. Data collected The patient’s data and clinical variables of NIV support for each episode were documented; type interface, ventilator and ventilation mode used (CPAP, BLPAP); settings and physiological variables prior to starting NIV, at 2, 8, 12 and 24 hours of NIV treatment; therefore, the SpO2/FiO2 ratio (SF) was also calculated retrospectively using the some intervals; appearance of complications or contraindications; mortality; NIV duration; NIV outcome (success/failure) and PICU and hospital stay. Failure of NIV was defined as the need for intubation. Results Descriptive study During the study period our PICU admitted 2238 patients, needing respiratory support. Out of this group, 491 episodes of NIV were collected. This gives us a study sample of 282 initial NIV episodes, Patients who received NIV after extubation were divided in rescue NIV 75, and elective NIV 134. Effectiveness was 71, 84 and 77% respectively. Effectiveness decreases with age, older 2 years (85%), 6months-2 years (75%), younger than 6 months (65%). Skin sores were the most common complication observed. No mortality was associated to NIV use. Multivariate analysis Independent predictive factors for NIV failure are: receiving CPAP instead of bilevel, showing respiratory failure type II, and having lower SF ratio value, greater Heart rate value and lower decrease of Heart rate at 2 hours. Conclusions Non-invasive ventilation is a safe and effective respiratory support for children with ARF

A low-cost, easy-to-assemble device to prevent infant hyperthermia under conditions of high thermal stress

High ambient temperature and humidity greatly increase the risk of hyperthermia and mortality, particularly in infants, who are especially prone to dehydration. World areas at high risk of heat stress include many of the low-and middle-income countries (LMICs) where most of their inhabitants have no access to air conditioning. This study aimed to design, evaluate, and test a novel low-cost and easy-to-assemble device aimed at preventing the risk of infant hyperthermia in LMICs. The device is based on optimizing negative heat transfer from a small amount of ice and transferring it directly to the infant by airflow of refrigerated air. As a proof of concept, a device was assembled mainly using recycled materials, and its performance was assessed under laboratory-controlled conditions in a climatic chamber mimicking realistic stress conditions of high temperature and humidity. The device, which can be assembled by any layperson using easily available materials, provided sufficient refrigerating capacity for several hours from just 1–2 kg of ice obtained from a domestic freezer. Thus, application of this novel device may serve to attenuate the adverse effects of heat stress in infants, particularly in the context of the evolving climatic change trends. © 2021 by the authors. Licensee MDPI, Basel, Switzerland

Lung Recruitment Maneuvers Assessment by Bedside Lung Ultrasound in Pediatric Acute Respiratory Distress Syndrome

The use of recruitment maneuvers (RMs) is suggested to improve severe oxygenation failure in patients with acute respiratory distress syndrome (ARDS). Lung ultrasound (LUS) is a non-invasive, safe, and easily repeatable tool. It could be used to monitor the lung recruitment process in real-time. This paper aims to evaluate bedside LUS for assessing PEEP-induced pulmonary reaeration during RMs in pediatric patients. A case of a child with severe ARDS due to Haemophilus influenzae infection is presented. Due to his poor clinical, laboratory, and radiological evolution, he was placed on venovenous extracorporeal membrane oxygenation (ECMO). Despite all measures, severe pulmonary collapse prevented proper improvement. Thus, RMs were indicated, and bedside LUS was successfully used for monitoring and assessing lung recruitment. The initial lung evaluation before the maneuver showed a tissue pattern characterized by a severe loss of lung aeration with dynamic air bronchograms and multiple coalescent B-lines. While raising a PEEP of 30 mmH2O, LUS showed the presence of A-lines, which was considered a predictor of reaeration in response to the recruitment maneuver. The LUS pattern could be used to assess modifications in the lung aeration, evaluate the effectiveness of RMs, and prevent lung overdistension

Non-invasive ventilation practices in children across Europe

To describe the diversity in practice in non-invasive ventilation (NIV) in European pediatric intensive care units (PICUs)