Impacto de la cánula nasal de alto flujo y la ventilación no invasiva en la fisiología deglutoria: revisión de la literatura / Impact of high-flow nasal cannula and non-invasive ventilation on swallowing physiology: a literature review

El proceso deglutorio requiere de una adecuada coordinación entre respiración y deglución. En el contexto clínico, el uso de dispositivos ventilatorios no invasivos, como la cánula nasal de alto flujo (CNAF) o la ventilación no invasiva (VNI), ha cobrado gran relevancia durante los últimos años. Sin embargo, existe escasa información respecto a la interferencia que estos dispositivos podrían ocasionar en la fisiología deglutoria. En este contexto, y con el objetivo de describir el impacto de la CNAF y la VNI en la fisiología deglutoria, se realizó una revisión de la literatura en PubMed, Medline, Embase, Web of Science, Lilacs y Scielo. Se incorporaron estudios que incluyeran población ≥18 años, con uso de CNAF o VNI. Se excluyeron estudios en población con antecedentes de disfagia, necesidad de intubación, presencia de enfermedad neurológica, neuromuscular o respiratoria, entre otros. Los resultados de los estudios muestran que la CNAF podría disminuir el número de degluciones (en flujos ≥ 20 L/min; p<0,05),disminuir el tiempo medio de activación de la respuesta deglutoria proporcional al flujo empleado (p<0,05), incrementar el riesgo aspirativo en flujos altos (>40 L/min, p<0,05) e incrementar en promedio la duración del cierre del vestíbulo laríngeo (p<0,001). La VNI modo BiPAP, por su parte, podría aumentar el riesgo aspirativo debido al incremento en la tasa de inspiración post deglución (SW-I, p<0,01). Si bien la evidencia disponible es limitada, los resultados aportan información relevante a considerar en el abordaje de usuarios que utilicen estos dispositivos ventilatorios. Futuras investigaciones deberían ser desarrolladas para fortalecer la evidencia presentada.

Deglutition requires adequatecoordination between breathing and swallowing. In the clinical context, the use of non-invasive ventilatory devices such as high-flow nasal cannulas(HFNC) or non-invasive ventilation (NIV) has become highlyrelevantin recent years. However, there is little information regarding howthese devices could interferewith the physiologyof deglutition. This study aimedto describe the impact of HFNC and NIV on swallowing physiology. To this end, aliterature review was carried out usingPubMed, Medline, Embase, Web of Science, Lilacs,and Scielo. Studies performed onpopulations≥18 years old where HFNC or NIV were used were included. Studies where thepopulation hada history of dysphagia, need for intubation, and presentedneurological, neuromuscular,or respiratory diseases, among others, were excluded. The results show that HFNC could decrease the swallowing rate(with flows≥ 20 L/min; p<.05), decrease the mean activation time of the swallowing reflex in proportion to the flow (p<.05), increase the risk of aspiration when usinghigherflows (>40 L/min, p<0.05),and increase the average duration of the laryngeal vestibuleclosure(p<.001).NIV, particularly BiPAP, could increase the risk of aspiration due to the higherrate of post-swallowing inspiration (SW-I, p<.01). Although the evidence available on this matter is limited, theseresults offerrelevant information that should beconsideredwhen working with patients who use these ventilatory devices. Furtherresearch should be carriedoutto strengthen the evidence that is provided in this study.

Factors associated with recurrent wheezing in the first year of life among premature newborns from Neonatal Intensive Care Units / Fatores associados à sibilância recorrente no primeiro ano de vida entre recémnascidos prematuros provenientes de Unidades de Terapia Intensiva Neonatais

Abstract Objectives: to determine the prevalence and factors associated with recurrent wheezing in the first year of life among premature newborns from Neonatal Intensive Care Units, in the city of Montes Claros, northern Minas Gerais. Methods: cross-sectional study, with data collection from medical records of a follow-up clinic, interviews with mothers and, eventually, search in hospital records. Bivariate analyzes were carried out between sociodemographic and clinical characteristics and recurrent wheezing. Variables associated up to the level of 20% were analyzed by binary logistic regression, and associations defined by the Odds Ratio and respective 95% confidence intervals. Only variables associated with a 5% significance level were maintained in the final model of logistic regression. Results: among 277 infants studied, about one fifth (21.3%) were extremely low birth weight preterm and more than half (60.7%) had birth weight below 1500 grams. The prevalence of recurrent wheezing was 14.4% (CI95% = 10.3-18.4). Mechanical ventilation (OR = 2.12; CI95% = 1.09-4.76; p = 0.030) and oxygen therapy time ≥ 15 days (OR = 2.49; CI95%= 1.12-5.00; p = 0.010) were the risk factors for the event. Conclusions: there is a high prevalence of recurrent wheezing in the evaluated group and the associated variables reiterate the risk of prolonged oxygen therapy and mechanical ventilation for premature newborns.

Resumo Objetivos: determinar a prevalência e fatores associados à sibilância recorrente no primeiro ano de vida entre recém-nascidos prematuros egressos de Unidades de Terapia Intensiva Neonatais, na cidade de Montes Claros, norte de Minas Gerais. Métodos: estudo transversal, com coleta de dados em prontuários de ambulatório de seguimento, entrevistas com mães e, eventualmente, consultas aos prontuários hospitalares. Foram realizadas análises bivariadas entre as características sociodemográficas e clínicas e a sibilância recorrente. As variáveis associadas ao desfecho até um nível de significância de p ≤20% foram analisadas por regressão logística binária e as associações definidas pelas Odds Ratios e respectivos intervalos de confiança de 95%. Somente variáveis associadas a um nível de significância de 5% foram mantidas no modelo final de regressão logística. Resultados: entre 277 crianças estudadas, cerca de um quinto (21,3%) eram prematuros de extremo baixo peso e mais da metade (60,7%) tinha peso de nascimento abaixo de 1500 gramas. A prevalência de sibilância recorrente foi de 14,4% (IC95%=10,3-18,4). Ventilação mecânica (OR=2,12; IC95%= 1,09-4,76; p=0,030) e tempo de oxigenioterapia ≥15 dias (OR=2,49; IC95%=1,12-5,00; p=0,010) foram os fatores de risco para o evento. Conclusão: existe uma elevada prevalência de sibilância recorrente no grupo avaliado e as variáveis associadas reiteram o risco do uso prolongado de oxigenioterapia e da ventilação mecânica para recém-nascidos prematuros.

Influência da cardiopatia congênita no desenvolvimento neuropsicomotor de lactentes / Influencia de la cardiopatía congénita en el desarrollo neuropsicomotor de los lactantes / Influence of congenital heart disease on the neuropsychomotor development of infants

RESUMO As cardiopatias congênitas (CC) estão entre as principais causas de morbimortalidade na primeira infância e os lactentes com essa condição podem apresentar atrasos no desenvolvimento neuropsicomotor (DNPM). O objetivo deste estudo foi avaliar a influência da CC no DNPM de lactentes. Trata-se de um estudo observacional com avaliação do desenvolvimento neuropsicomotor realizada pela Bayley Scales of Infant and Toddler Development (BSID-III). As condições maternas e clínicas dos lactentes foram verificadas no relatório de alta médica e na caderneta de saúde da criança, e a condição socioeconômica das famílias pelo Critério da Classificação Econômica Brasil. Para associar as variáveis clínicas e o DNPM foram utilizados o coeficiente de correlação de Spearman e o teste de razão de verossimilhança. Foram avaliados 18 lactentes, com predomínio do sexo feminino (72,2%). A maioria das mães (47,1%) possuía ensino médio completo ou superior incompleto, com média da idade de 27,2±5,5 anos. Houve correlação das escalas do BSID-III com as variáveis quantitativas analisadas: escala motora com o peso (p=0,02 e r=0,54) e com uso de oxigenoterapia (p=0,009 e r=−0,591); já para as variáveis qualitativas as associações foram entre: escala motora e condição socioeconômica (p=0,015), escala motora e comunicação interatrial - (CIA) (p=0,023) e escala da linguagem e CIA (p=0,038). A CC influenciou o DNPM, principalmente no aspecto motor. Além disso peso, diagnóstico de CIA, uso de oxigenoterapia e condição socioeconômica foram considerados como principais fatores de risco para o atraso no DNPM.

RESUMEN Las cardiopatías congénitas (CC) se encuentran entre las principales causas de morbimortalidad en la primera infancia, y los lactantes con esta afección pueden tener retrasos en el desarrollo neuropsicomotor (DNPM). El presente estudio tuvo el objetivo de evaluar la influencia de las CC en el DNPM de los lactantes. Este es un estudio observacional en el cual se evaluó el desarrollo neuropsicomotor utilizando la Bayley scales of infant and toddler development (BSID-III). Las condiciones maternas y clínicas de los lactantes se obtuvieron en el informe de alta médica y en la libreta de salud del niño, y el estado socioeconómico de las familias en el Criterio de Clasificación Económica de Brasil. Para asociar las variables clínicas y el DNPM, se utilizaron el coeficiente de correlación de Spearman y la prueba de razón de probabilidad. Se evaluaron a 18 lactantes, con un predominio del sexo femenino (72,2%). La mayoría de las madres (47,1%) tenían la secundaria completa o la educación superior incompleta, con una edad promedio de 27,2±5,5 años. Hubo una correlación entre las escalas BSID-III y las variables cuantitativas analizadas: escala motora con el peso (p=0,02 y r=0,54) y con el uso de oxigenoterapia (p=0,009 y r=−0,591); para las variables cualitativas, las asociaciones fueron entre: escala motora y estado socioeconómico (p=0,015), escala motora y comunicación interauricular (CIA) (p=0,023) y escala de lenguaje y CIA (p=0,038). Las CC influyeron en el DNPM, principalmente en el aspecto motor. Además, el peso, el diagnóstico de CIA, el uso de oxigenoterapia y el estado socioeconómico fueron considerados los principales factores de riesgo para el retraso en el DNPM.

ABSTRACT Congenital heart defects (CHD) are among the main causes of morbidity and mortality in infants who has this impairment may present delays in neuropsychomotor development (NPMD). This study assesses the influence of CHD on NPMD of infants. This is an observational study assessing neuropsychomotor development performed by Bayley Scales of Infant and Toddler Development - BSID-III. The Brazilian Economic Classification Criteria was used to verify the socioeconomic status of the families and also the maternal and infants' clinical conditions were verified in the medical discharge report and in the child's health handbook. For the association between the quantitative and qualitative variables with the NPMD, the Spearman's correlation coefficient and the likelihood ratio test were used. A total of 18 infants were assessed, with a predominance of females (72.2%). Most mothers (47.1%) had complete high school or incomplete higher education, with a mean age of 27.2±5.5 years. There was a correlation between the BSID-III scales and the quantitative variables analyzed: motor scale with weight (p=0.02 and r=0.54) and oxygen therapy (p=0.009 and r=−0.591); besides that, the qualitative variables correlation were: motor scale and socioeconomic condition (p=0.015), motor scale and Interatrial Communication - IAC (p=0.023) and language with IAC scales (p=0.038). CHD influences the delay of NPMD, mainly for motor aspect. Furthermore, weight, diagnosis of IAC, use of oxygen therapy and socioeconomic status were considered the main risk factors for the delay in NPMD.

Eficácia e segurança da oxigenoterapia com cânula nasal de alto fluxo na insuficiência respiratória hipercápnica moderada aguda / Efficacy and safety of high-flow nasal cannula oxygen therapy in moderate acute hypercapnic respiratory failure

RESUMO Objetivo: Avaliar a eficácia e a segurança da oxigenoterapia com uso de cânula nasal de alto fluxo no tratamento da insuficiência respiratória hipercápnica moderada em pacientes que não conseguem tolerar ou têm contraindicações para ventilação mecânica não invasiva. Métodos: Estudo prospectivo observacional de 13 meses envolvendo participantes admitidos a uma unidade de terapia intensiva com insuficiência respiratória hipercápnica ou durante o processo de seu desenvolvimento. Os parâmetros clínicos e de troca gasosa foram registrados em intervalos regulares durante as primeiras 24 horas. Os parâmetros finais foram saturação de oxigênio entre 88 e 92%, juntamente da redução do esforço respiratório (frequência respiratória) e da normalização do pH (≥ 7,35). Os participantes foram considerados não responsivos em caso de necessidade de utilização de suporte ventilatório. Resultados: Trinta participantes foram tratados utilizando oxigenoterapia com cânula nasal de alto fluxo. Esta foi uma população mista com exacerbação de doença pulmonar obstrutiva crônica, edema pulmonar cardiogênico agudo, e insuficiência respiratória aguda pós-operatória e pós-extubação. Observou-se melhora não significante na frequência respiratória (28,0 ± 0,9 versus 24,3 ± 1,5; p = 0,22), que foi aparente nas primeiras 4 horas do tratamento. Ocorreu melhora do pH, embora só se tenham obtido níveis normais após 24 horas de tratamento com cânula nasal de alto fluxo (7,28 ± 0,02 versus 7,37 ± 0,01; p = 0,02). A proporção de não responsivos foi de 13,3% (quatro participantes), dos quais um necessitou e aceitou ventilação mecânica não invasiva, e três necessitaram de intubação. A mortalidade na unidade de terapia intensiva foi de 3,3% (um participante), e um paciente morreu após a alta para a enfermaria (mortalidade hospitalar de 6,6%). Conclusão: O oxigenoterapia com cânula nasal de alto fluxo é eficaz para a insuficiência respiratória hipercápnica moderada e ajuda a normalizar os parâmetros clínicos e de troca gasosa, com taxa aceitável de não responsivos que necessitaram de suporte ventilatório.

ABSTRACT Objective: To assess the efficacy and safety of high-flow nasal cannula oxygen therapy in treating moderate hypercapnic respiratory failure in patients who cannot tolerate or have contraindications to noninvasive mechanical ventilation. Methods: A prospective observational 13-month study involving subjects admitted to an intensive care unit with or developing moderate hypercapnic respiratory failure. Clinical and gas exchange parameters were recorded at regular intervals during the first 24 hours. The endpoints were a oxygen saturation between 88 and 92% along with a reduction in breathing effort (respiratory rate) and pH normalization (≥ 7.35). Subjects were considered nonresponders if they required ventilatory support. Results: Thirty subjects were treated with high-flow nasal cannula oxygen therapy. They consisted of a mixed population with chronic obstructive pulmonary disease exacerbation, acute cardiogenic pulmonary edema, and postoperative and postextubation respiratory failure. A nonsignificant improvement was observed in respiratory rate (28.0 ± 0.9 versus 24.3 ± 1.5, p = 0.22), which was apparent in the first four hours of treatment. The pH improved, although normal levels were only reached after 24 hours on high-flow nasal cannula therapy (7.28 ± 0.02 versus 7.37 ± 0.01, p = 0.02). The rate of nonresponders was 13.3% (4 subjects), of whom one needed and accepted noninvasive mechanical ventilation and three required intubation. Intensive care unit mortality was 3.3% (1 subject), and a patient died after discharge to the ward (hospital mortality of 6.6%). Conclusion: High-flow nasal cannula oxygen therapy is effective for moderate hypercapnic respiratory failure as it helps normalize clinical and gas exchange levels with an acceptable rate of nonresponders who require ventilatory support.

Retinopatia da prematuridade: análise de uma tentativa de redução de danos / Retinopathy of prematurity: analysis of a damage reduction attempt

Resumo Objetivo: Avaliar a eficácia de um protocolo de redução da saturação do oxigênio utilizado na suplementação dos recém-nascidos pré-termos (RNPT) internados em uma UTI neonatal para prevenir o aparecimento da Retinopatia da prematuridade (ROP). Métodos: Trata-se de estudo de coorte realizado em única UTI Neonatal. O primeiro grupo (pré-protocolo, n=30) fez uso de oxigênio com saturação de hemoglobina >95%. A partir da instituição de um novo protocolo de oxigenioterapia que manteve a saturação de hemoglobina entre 90% e 95% obteve-se o segundo grupo (pós-protocolo n=28). Todos os RNPT incluídos tinham idade gestacional de menor ou igual 32 semanas e/ou com peso de nascimento igual ou abaixo de 1500g, fizeram mapeamentos de retina a partir de 28 dias de vida e seguimento por até 45 semanas de idade gestacional corrigida. Resultados: Dos 58 casos estudados, excluindo-se os que foram a óbito (15/58; 26,8%) dos casos, ROP foi diagnosticado em 15/43 (34,9%) pacientes. A menor idade gestacional influenciou significativamente no aparecimento da ROP (p=0,002). Em relação ao número de casos de ROP e de óbitos não se observou diferença estatisticamente significativa entre os grupos. O tempo de oxigenioterapia foi significativamente associado com a presença de ROP em ambos grupos. Meninos foram seis vezes mais acometidos por ROP que as meninas. Conclusão: A redução da saturação de oxigênio não se mostrou eficaz para redução de número de casos de ROP.

Abstract Objective: To evaluate the efficacy of an oxygen saturation reduction protocol used to supplement preterm newborns (PTNB) hospitalized in a neonatal ICU to prevent the onset of retinopathy of prematurity (ROP). Methods: This is a cohort study performed in a single Neonatal ICU. The first group (pre-protocol, n = 30) used oxygen with hemoglobin saturation > 95%. Since the institution of a new oxygen therapy protocol that maintained hemoglobin saturation between 90% and 95%, the second group was obtained (post-protocol n = 28). All included preterm infants had a gestational age of less than or equal to 32 weeks and / or birth weight of 1500 g or less, retinal mappings from 28 days of life and follow up for up to 45 weeks of corrected gestational age. Results: 58 cases were studied, excluding those who died (15/58; 26.8%), ROP was diagnosed in 15/43 patients (34.9%). The lower gestational age significantly influenced the appearance of ROP (p = 0.002). Regarding the number of ROP cases and deaths, no statistically significant difference was observed between groups. Oxygen therapy time was significantly associated with the presence of ROP in both groups. Boys were six times more affected by ROP than girls. Conclusion: Reduction of oxygen saturation was not effective in reducing the number of cases of ROP.

Valores de referencia de oximetría de pulso en prematuros: seguimos en deuda / Reference values of pulse oximetry in preterm infants: still a debt

Oxygen therapy is frequent in prematures to treat respiratory conditions typically associated with them. Long-term use is mainly due to Bronchopulmonary Dysplasia (BPD). However, the use of oxygen has been controversial in the last decade especially given the associated risk of hyperoxemia in these children. Pulse oximetry (SpO2) is a fundamental tool to guide oxygen therapy. Different trials have found that, in prematures born ≤28 weeks of gestational age who requires oxygen, a restrictive SpO2 target (85-89%) vs a liberal one (91-95%) may cause a higher mortality rate and enterocolitis, but less serious retinopathy. These targets are not normal SpO2 values. Studies on SpO2 reference values in preterm infants are scarce, heterogeneous and they do not necessarily use highly accurate and latest generation pulse oximeters. This contributes to the variation of oxygen therapy among different centers and reinforces the relevance of having SpO2 reference values in preterm infants to safely guide oxygen therapy.

La terapia con oxígeno es frecuente en prematuros para el tratamiento de patología respiratoria propia de su condición. En forma crónica la principal causa de su uso es Displasia Broncopulmonar (DBP). Sin embargo, el uso de oxígeno en prematuros ha sido motivo de debate en la última década fundamentalmente por los riesgos asociados a estados de hiperoxemia. La oximetría de pulso (SpO2) es una herramienta fundamental para guiar la oxigenoterapia. En prematuros que nacen ≤28 semanas de edad gestacional que requieren oxígeno, distintos estudios han demostrado que una meta de SpO2 restrictiva (85-89%) vs liberal (91-95%) tendría mayor mortalidad y enterocolitis, pero menor retinopatía grave. Estas metas no son valores normales de SpO2. Los estudios sobre valores de referencia de SpO2 en prematuros son limitados, heterogéneos y no necesariamente con oxímetros de última generación de mayor precisión. Esto contribuye a que la oxigenoterapia sea variable entre distintos centros y refuerza la relevancia de contar con valores de referencia de SpO2 en prematuros para guiar con seguridad el uso de oxígeno.

Perfil epidemiológico dos recém-nascidos prematuros com retinopatia da prematuridade no Hospital Regional de São José Dr. Homero de Miranda Gomes / Epidemiologic profile of preterm infants with retinopathy of prematurity in the Dr. Homero de Miranda Gomes Regional Hospital in São José

RESUMO Objetivo: Avaliar a prevalência da retinopatia da prematuridade (ROP) em recém-nascidos (RN) prematuros (Idade Gestacional (IG) < 37 semanas) e/ou peso ao nascimento (PN) £ 1500g e os que possuem fatores de risco, nascidos no HRSJ entre janeiro de 2007 e janeiro de 2011. Método: Estudo transversal, retrospectivo, analítico e observacional. Os dados foram obtidos a partir de prontuários no Hospital Regional de São José Dr. Homero de Miranda Gomes. Resultados: Observou-se a presença de retinopatia em 37,81% dos RNs, sendo o estágio 1 o mais prevalente. Verificou-se que não houve diferença estatística entre os sexos (p=0,993). A presença da ROP foi maior no grupo com PN < 1000 gramas (83,33%), avaliados com mais de 6 semanas de vida e com IG menor que 32 semanas (49,48%). Os fatores de risco com significado estatístico foram: oxigenioterapia, ventilação mecânica, persistência do canal arterial, asfixia perinatal, síndrome do desconforto respiratório, transfusão sanguínea, hemorragia intraventricular, sepsis, infecção neonatal e doença da membrana hialina. Conclusão: Conclui-se que o fator sexo e gestação múltipla não tiveram significância estatística. Os RNs com menor PN e IG tem um maior risco de desenvolver ROP. Em relação à oxigenioterapia, a prevalência nos expostos é maior e proporcional ao tempo de utilização de oxigênio.

ABSTRACT Objectives: To evaluate the prevalence of retinopathy of prematurity (ROP) in premature newborns (gestational age < 37 weeks) and / or birth weight £ 1,500g and those with risk factors, born at the Dr. Homero de Miranda Gomes Regional Hospital in São José (HRSJ) between January 2007 and January 2011. Methods: Cross-sectional, retrospective, observational and analytical study. Data were obtained from medical records at the HRSJ. Results: The presence of 37.81% of retinopathy in newborns was observed, with stage 1 being the most prevalent. No statistical difference was found between the sexes (p = 0.993). The presence of ROP was higher in the group with PN < 1,000 grams (83.33%), evaluated over 6sixweeks of age and with gestational ages less than 32 weeks (49.48%). Risk factors with statistical significance were: oxygen therapy, mechanical ventilation, patent ductus arteriosus, perinatal asphyxia, respiratory distress syndrome, blood transfusions, intraventricular hemorrhage, sepsis, neonatal infection and hyaline membrane disease. Conclusion: It is concluded that: the gender factor and multiple pregnancy were not statistically significant. The newborns with lower birth weight and gestational age have an increased risk for developing ROP. Regarding oxygentherapy, the prevalence is higher in the exposed and proportional to the period of oxygen.

Clinical efficacy of high-flow nasal cannula compared to noninvasive ventilation in patients with post-extubation respiratory failure

BACKGROUND/AIMS: Post-extubation respiratory failure (PERF) is associated with poor clinica l outcomes. High-f low nasa l cannula (HF NC) ox ygen therapy has been used in patients with respiratory failure, but the clinical benefit in patients with PERF remains unclear. The aim of this study was to evaluate the clinical efficacy of HFNC compared to noninvasive ventilation (NIV) in patients with PERF. METHODS: A historic retrospective cohort analysis was performed in 28 beds in the medical Intensive Care Unit (ICU) at a single medical center in South Korea. In total, 73 patients with PERF were enrolled: 39 patients who underwent NIV from April 2007 to March 2009 and 34 patients who received HFNC from April 2009 to May 2011. RESULTS: The rate of avoidance of reintubation was not different between the HFNC group (79.4%) and NIV group (66.7%, p = 0.22). All patients with HFNC tolerated the device, whereas five of those with NIV did not tolerate treatment (p = 0.057). The mean duration of ICU stay was significantly shorter in the HFNC group than in the NIV group (13.4 days vs. 20.6 days, p = 0.015). There was no difference in ICU or in-hospital mortality rate. CONCLUSIONS: HFNC is likely to be as effective as, and better tolerated than, NIV for treatment of PERF.

Oxigenoterapia ¿humidificada o no? / Humidified oxygen or not?

El oxígeno es uno de los principales medicamentos utilizados en las terapias intensivas a nivel mundial. La terapia con este gas, esta indicada para corregir la deficiencia de oxigeno en la sangre arterial con el objetivo de mitigar la hipoxia tisular. Sin embargo existe gran controversia respecto a la humidificacion del mismo utilizando diversos dispositivos. El presente trabajo es un estudio sobre la humidificacion del oxigeno inhalado con dispositivos de bajo flujo basado en la evidencia, tendiente a unificar criterios con fundamentacion cientifica, para mejorar la practica y disminuir los riesgos proporcionando una terapia de oxigeno adecuada.

Actualización en presentación y patogénesis de la displasia broncopulmonar / Update on presentation and pathogenesis of brochopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) remains as the most frequent chronic lung disease seen among babies with very low birth weight, contributing to their morbidity and mortality. An increase in the survival of very immature babies due to improvement in pre and post natal care, has resulted in an increase in the number of newborns with BDP, although there have been no changes in the actual incidence of the disease. Objective: Lo describe the evolution of DBP in recent decades, the current definition, and to describe and analyze the risk factors involved in the pathogenesis of this disease. Until a few years ago, the terms BPD and chronic lung disease were used as synonyms. After the workshop sponsored by the National Institute of Health in the United States in 2001, it was recommended that the term BPD be used to describe the pulmonary sequelae of immature babies. Classic severe BPD, as described by Northway et al over forty years ago, has evolved into milder forms of chronic pulmonary damage, the so-called "new BPD", characterized by impairment of alveolarizacion and vascularization of the immature lung in response to multiple injuries. BPD is a multifactorial disease where major risk factors are related to pulmonary immaturity, hyperoxia, baro/volutrauma, as well as inflamation and infection. Genetic susceptibility has recently been shown to be another important risk factor. Conclusion: Bronchopulmonary Dysplasia continues to be the most frequent sequelae affecting low birth weight infants. In the past four decades, the disease has been better defined, and new pathogenetic risk factors have been established.

La Displasia Broncopulmonar (DBP) continúa siendo la enfermedad pulmonar crónica más frecuente que afecta al recién nacido de muy bajo peso, contribuyendo a su morbilidad y mortalidad. El aumento en la sobrevida de los recién nacidos muy inmaduros, debido a la mejoría en el cuidado pre y post natal, ha aumentado el número de recién nacidos con displasia, sin cambios en su incidencia. El objetivo de esta revisión es representar los cambios en la presentación clínica de la DBP en las últimas décadas y describir la definición recientemente instituida, junto con analizar y actualizar los factores de riesgos involucrados en la patogénesis de esta enfermedad. Hasta hace algunos años el término DBP o Enfermedad Pulmonar Crónica se usaban como sinónimos; sin embargo luego del taller patrocinado por Instituto Nacional de Salud de Estados Unidos en el año 2001, se recomendó utilizar el término de DBP para describir las secuelas pulmonares del recién nacido muy inmaduro. La DBP clásica severa descrita por Northway y cols hace más de 40 años, ha evolucionado a formas más leves de daño pulmonar crónico, la denominada "Nueva DBP", caracterizada por un deterioro y/o detención de la alveolarización y vascularización del pulmón inmaduro en respuesta a múltiples injurias. La DBP es una enfermedad multifactorial siendo los principales factores de riesgo la inmadurez pulmonar, la hiperoxia, el baro-volutrauma, y la inflamación-infección. Recientemente se ha demostrado que la susceptibilidad genética puede ser otro factor de riesgo. La ventilación mecánica continúa siendo un importante factor de riesgo, por lo cual debe ser utilizada con precaución y sólo cuando esté claramente indicada. La persistencia del ductus arterioso se ha asociado también a DBP, por lo cual el cierre farmacológico precoz podría disminuir la incidencia de esta complicación. Conclusión: La DBP continúa siendo la secuela pulmonar crónica más frecuente que afecta al RN de muy bajo peso...

Chronic lung disease in newborns.

Chronic lung disease (CLD) or bronchopulmonary dysplasia (BPD) occurs in preterm infants who require respiratory support in the first few days of birth. Apart from prematurity, oxygen therapy and assisted ventilation, factors like intrauterine/postnatal infections, patent ductus arteriosus, and genetic polymorphisms also contribute to its pathogenesis. The severe form of BPD with extensive inflammatory changes is rarely seen nowadays; instead, a milder form characterized by decreased alveolar septation due to arrest in lung development is more common. A multitude of strategies, mainly pharmacological and ventilatory, have been employed for prevention and treatment of BPD. Unfortunately, most of them have not been proved to be beneficial. A comprehensive protocol for management of BPD based on the current evidence is discussed here.

Newborn emphysema attributed to medical actions (3 case report) / 法医学杂志

Three cases of newborn emphysema were reported. Parenchymatous emphysema, interstitial emphysema and bullous emphysema were all found in the three cases. One of the three cases showed accumulation of air in interstitial tissue. The air penetrated into septa of the lung at the beginning, then it probably split the hilus pulmonis to reach mediastinum as well as subcutaneous tissues of the chest, neck, abdomen, inguinal region and scrotum. The oxygen inhalation under pressure during first-aid may be the cause of the newborn emphysema.

Daño pulmonar agudo asociado a ventilación mecánica / Ventilator associated acute lung injury

Mechanical ventilation plays a central role In the critical care setting; but its use is closely related with some life threatening complications as nosocomial pneumonia and low cardiac performance. One of the most severe complications is called ventilator-associated lung injury (VALI) and it includes: Barotrauma, volutrauma, atelectrauma, biotrauma and oxygen-mediated toxic effects and it is related with an inflammatory response secondary to the stretching and recruitment process of alveoli within mechanical ventilation. The use of some protective ventilatory strategies has lowered the mortality rate 10% approximately.

La importancia de la asistencia mecánica ventilatoria (AMV) en la Unidad de Cuidados Intensivos (UCI) es indiscutible; sin embargo, su uso está ligado con complicaciones como neumonía nosocomial y deterioro del rendimiento cardiaco, que en algunas ocasiones ponen en peligro la vida del enfermo. Una de las complicaciones más graves es el daño pulmonar asociado a la ventilación mecánica (DPVM). El DPVM se caracteriza por la presencia de edema pulmonar rico en proteínas. Se recomienda establecer cierto número de estrategias de protección pulmonar (EPP) para prevenir este tipo de lesión. Una vez instituidas, las EPP han demostrado una disminución de la mortalidad de aproximadamente 10%.

Retinopathy of prematurity--risk factors.

OBJECTIVE: Improved survival of low birth weight, premature babies have increased the incidence of retinopathy of prematurity. This hospital-based, prospective, study was undertaken to determine its incidence and risk factors in our neonatal unit. METHODS: Neonates with gestational age < or = 35 weeks and/or birth weight < or = 1500 gm born over a one-year period were examined by indirect ophthalmoscopy between 2 to 4 weeks after birth, and followed up till retinal vascularisation was complete. Maternal and neonatal risk factors were noted and data analyzed by statistical package SPSS-10.0. RESULTS: Sixty babies were thus examined. The incidence of retinopathy was 21.7% in the cohort, 33.3% in babies < or = 32 weeks gestation and 36.4% in babies weighing < or = 1250 gm. Oxygen (p=0.01), sepsis (p=0.04) and apnoea (p=0.02) were independent risk factors. Retinopathy was significantly more severe in babies with hyaline membrane disease (p=0.02) and lower birth weight (p=0.02). Severe disease was never seen before 6.5 weeks of age. CONCLUSION: Indirect ophthalmoscopy should be performed at 4 weeks of post natal age in all preterm babies with birth weight < or = 1500 gm, and intensified in the presence of risk factors like oxygen administration, apnoea and septicemia.