Premature newborn positionings and physiologic parameters - a randomized clinical study / Posicionamentos de recém-nascidos prematuros e parâmetros fisiológicos - um estudo clínico randomizado

Abstract Introduction Multiple studies have shown the effects of prone (PP), supine (SP) and kangaroo (KP) positions on clinical and physiological outcomes in preterm newborns, but none compared these three types of positioning between them. Objective To investigate the influence of these positionings on heart rate, respiratory rate, peripheral oxygen saturation (SpO2) and alertness status in clinically stable preterm newborns (NBs) admitted to a neonatal intensive care unit. Methods In a randomized clinical trial, clinically stable NBs with gestational ages from 30 to 37 weeks who were breathing spontaneously were allocated in three positioning groups: PP, SP and KP. Heart rate, breathing frequency, SpO2 and alertness status were evaluated immediately before and after 30 minutes of positioning. Results In all, 66 NBs were assessed (corrected age: 35.48 ± 1.94 weeks; weight: 1840.14 ± 361.09 g), (PP: n = 22; SP: n = 23; KP: n = 21). NBs in the PP group showed a significant improvement in peripheral SpO2 (97.18 ± 2.16 vs 95.47 ± 2.93 vs 95.57 ± 2.95, p = 0.03) compared with the SP and KP groups. Conclusion In clinically stable preterm NBs, the PP was associated with better peripheral oxygen saturation than the SP or KP. In addition, there was a reduction in heart rate within prone position group and in the KP group there was an increase in the number of NBs in the deep sleep classification.

Resumo Introdução Vários estudos têm demonstrado os efeitos das posições prona (PP), supina (SP) e canguru (KP) sobre os resul-tados clínicos e fisiológicos em recém-nascidos prematuros, mas nenhum comparou esses três tipos de posicionamento. Objetivo Investigar a influência desses posicionamentos na frequência cardíaca, frequência respiratória, saturação periférica de oxigênio (SpO2) e estado de alerta em recém-nascidos pré-termo (RN) clinicamente estáveis internados em uma unidade de terapia intensiva neonatal. Métodos Em um ensaio clínico randomizado, RN clinicamente estáveis com idade gestacional de 30 a 37 semanas e respirando espontaneamente foram alocados em três grupos de posicionamento: PP, SP e KP. Frequência cardíaca e respiratória, SpO2 e estado de alerta foram avaliados imediatamente antes e após 30 minutos de posicionamento. Resultados Ao todo, foram avaliados 66 RNs (idade corrigida: 35,48 ± 1,94 semanas; peso: 1840,14 ± 361,09 g), (PP: n = 22; SP: n = 23; KP: n = 21). Os RNs do grupo PP apresentaram melhora significativa na SpO2 periférica (97,18 ± 2,16 vs 95,47 ± 2,93 vs 95,57 ± 2,95, p = 0,03) em comparação aos grupos SP e KP. Conclusão Em RN prematuros clinicamente estáveis, o PP foi associado à melhor saturação periférica de oxigênio do que o SP ou KP. Além disso, houve redução da frequência cardíaca no grupo de posição prona e no grupo KP houve aumento do número de RNs na classificação sono profundo.

Experiencia de una Unidad de Ventilación Mecánica Pediátrica Prolongada en un hospital público de Chile / Experience in a Pediatric Prolonged Mechanical Ventilation Unit from a public hospital in Chile

Introducción: Los pacientes hospitalizados con altas dependencias tecnológicas respiratorias son cada vez más frecuentes y generan largas estadías en unidades de cuidados intensivos. Las estrategias que mitiguen su impacto han sido escasamente descritas. Objetivo: Describir 6 años de experiencia de una Unidad de Ventilación Mecánica Prolongada Pediátrica.Métodos: Estudio retrospectivo. Se incluyeron todos los niños ingresados a la Unidad entre 10-2012 y 12-2018. Se realizó estadística descriptiva e inferencial, analizando tiempos de hospitalización y reingresos. Se compararon distintas variables según tipo de patología y ventilación mecánica.Resultados: 113 pacientes registraron 310 ingresos a la Unidad. Edad de ingreso: 2,2 años (0,6-8,8); varones: el 60,2 %. Patologías: enfermedad neuromuscular (el 22,1 %), enfermedad pulmonar crónica (el 20,4 %), daño neurológico (el 34,5 %), obstrucción de vía aérea superior (el 9,7 %), cardiopatía (el 3,5 %), síndrome de Down (el 9,7 %). Se utilizaron 10 507 días/cama; con índice ocupacional del 92,6 %, el 54,8 % de traslados a la Unidad de Cuidados Intensivos y el 66,1 % de reingresos. Hospitalización media: 16 días (6,5-49,0); diferencias en edad de ingreso según patologías (p = 0,032). Hubo más reingresos en niños con daño neurológico y síndrome de Down (p = 0,004). Los niños con asistencia ventilatoria invasiva presentaron más días de hospitalización (p < 0,001) y reingresos (p < 0,001).Conclusión: El índice ocupacional fue superior al 90 %; permitió mayor disponibilidad de camas intensivas y egresar a todos los pacientes. Los niños con asistencia ventilatoria invasiva se hospitalizaron más tiempo y reingresaron más

Introduction: Hospitalized patients with high respiratory technology dependency are increasingly common and result in lengthy stays in intensive care units. Strategies mitigating its impact have been scarcely described.Objective: To describe a 6-year experience in a Pediatric Prolonged Mechanical Ventilation Unit.Methods: Retrospective study. All children admitted to the unit between October 2012 and December 2018 were included. Descriptive and inferential statistical methods were used, analyzing lengths of stay and readmissions. Different outcome measures were compared according to the type of pathology and mechanical ventilation.Results: A total of 113 patients had 310 admissions to the unit. Age at admission: 2.2 years (0.6-8.8); males: 60.2 %. Pathologies: neuromuscular disease (22.1 %), chronic lung disease (20.4 %), neurological damage (34.5 %), upper airway obstruction (9.7 %), heart disease (3.5 %), Down syndrome (9.7 %). A total of 10 507 bed-days were used; with a 92.6 % occupancy rate, 54.8 % of transfers to the intensive care unit, and 66.1 % of readmissions. Mean length of stay: 16 days (6.5-49.0); differences in age at admission observed by pathology (p = 0.032). More readmissions were observed in children with neurological damage and Down syndrome (p = 0.004). Children with invasive ventilation were observed to have a longer length of stay (p < 0.001) and more readmissions (p < 0.001).Conclusion: The occupancy rate at the PMVU was over 90 %, which allowed more available intensive care beds and discharging all patients. Children with invasive ventilation had a longer length of stay and more readmissions.

Sponsored multicentric clinical research conducted in Brazil in the respiratory area - losses and gains / Pesquisas clínicas multicêntricas patrocinadas realizadas na área respiratória no Brasil - Perdas e ganhos

Summary Objective: To evaluate the sponsored centers for clinical trial in the respiratory care setting in Brazil: profile; logistics and structure. Methods: Principal investigators (29) and subinvestigators (30) of 39 research centers completed the questionnaires that addressed personal identification and training of researchers, the centers' facilities and advantages and/or disadvantages of performing sponsored trials. Results: 75.6% of the centers were located in southern and southeastern Brazil. Most principal investigators were men with a mean age of 53.4 years. The clinical trials in the respiratory care setting focus on asthma and chronic obstructive pulmonar disease (COPD). 80% of the researchers cited delay of the Conep and Anvisa as a barrier to performing research. The advantages of participating in clinical trials were updating knowledge of the researcher and the team, and additional income for the team. The main disadvantages mentioned by the researchers included low financial compensation for the performed workload, and time availability. The median number of professionals per research center was six people, predominantly physicians. Conclusion: The number of research centers in the respiratory care setting in Brazil is still relatively small. The teams have good training for performing the clinical trials. Asthma and COPD are the most studied diseases in sponsored clinical trials. The main barrier is delay by the Conep and Anvisa. The factors that lead investigators to participate range from being updated along with the team, to site and staff financial issues; the main disadvantage is the low compensation for the required workload demand.

Resumo Objetivo: avaliar nos centros de pesquisas clínicas patrocinadas na área respiratória no Brasil o perfil, a logística e a estrutura. Método: questionários foram respondidos por pesquisadores principais (29) e subinvestigadores (30) de 39 centros de pesquisa relativos a identificação e formação dos pesquisadores, instalações dos centros e vantagens e desvantagens quanto à participação nas pesquisas patrocinadas. Resultados: setenta e cinco por cento (75,6%) dos centros se localizavam nas regiões Sul e Sudeste do Brasil. A maioria dos investigadores principais eram homens com média de idade de 53,4 anos. As pesquisas na área respiratória se concentravam no estudo da asma e da doença pulmonar obstrutiva crônica (DPOC). Oitenta por cento dos pesquisadores citaram a demora na Comissão Nacional de Ética em Pesquisa (Conep) e na Agência Nacional de Vigilância Sanitária (Anvisa) como fator de entrave para a realização das pesquisas. As vantagens em participar das pesquisas clínicas foram a atualização própria ou da equipe envolvida, com rendimento adicional para a equipe. A principal desvantagem apontada pelos pesquisadores foi a baixa compensação financeira em relação ao volume de trabalho e disponibilidade de tempo. A mediana de profissionais por centro de pesquisa foi de seis pessoas, com predominância de médicos. Conclusão: o número de centros na área respiratória no Brasil ainda é relativamente pequeno. As equipes apresentam boa formação para a realização das pesquisas. Asma e DPOC são as doenças mais estudadas pelas pesquisas clínicas patrocinadas. O principal entrave é a demora da Conep e da Anvisa. Os fatores que levam os investigadores a participarem variam desde atualização própria/equipe até questões financeiras para a equipe e o centro; a principal desvantagem relatada é a baixa remuneração diante da demanda de trabalho exigida.

Applications of ultrasonography in respiratory intensive care.

Emerging evidence suggests that ultrasonography of lung is a fast, inexpensive, widely available bed-side diagnostic tool which is useful for quick and early diagnosis of respiratory diseases. It is useful in the differential diagnosis of pulmonary infiltrates and has good accuracy in identifying consolidation and alveolar-interstitial syndrome. This technique can also be useful in the immediate evaluation of patients with dyspnoea or acute respiratory failure in the respiratory intensive care unit and helps in monitoring treatment response. Ultrasonography of lung has also been found to be useful in the diagnosis of pulmonary embolism, traumatic lung contusion and lung consolidation as well. There is a need for developing specific guidelines for establishing the standards of training and education regarding lung ultrasonography in India.

Desmame de ventilação mecânica em pacientes com apneia do sono. Relato de caso e revisão da literatura / Ventilator weaning in patients with sleep apnea. Case report and literature review

Em pacientes sob ventilação mecânica, a equipe assistente, não raro, defronta-se com um subgrupo particular de indivíduos que apresenta repetidos episódios de apneia, quando em modo de suporte ventilatório. Realizou-se uma busca na literatura com o objetivo de avaliar a melhor estratégia de desmame ventilatório nesses pacientes e discutir o papel da polissonografia nesse contexto. Paciente do gênero feminino, 71 anos, internada por um quadro de insuficiência cardíaca congestiva descompensada e pé diabético infectado, evoluiu com parada cardiorrespiratória. Foi reanimada e admitida em unidade de terapia intensiva, onde apresentou melhora clínica gradual. Os fármacos vasoativos foram suspensos e iniciou desmame ventilatório. Nesse momento, passou a apresentar repetidos episódios de apneia quando em modo de pressão de suporte e quadro clínico de delirium. Extubou-se por duas vezes e, finalmente, obteve compensação clínica, a ponto de ter alta para enfermaria e, dentro de 1 mês, alta hospitalar. O número de artigos encontrados, o pequeno número de pacientes avaliados, o delineamento inadequado, dentre outros fatores, não permitem conclusão isenta de incertezas, quando se trata de avaliar a melhor estratégia de retirada da assistência ventilatória nesses pacientes. A presença de apneia per se não parece contraindicar a progressão do desmame ventilatório, decanulação ou extubação. A polissonografia, se disponível, está indicada, mesmo no contexto de unidade de terapia intensiva. O desmame em modo neurally adjusted ventilatory assist parece ser promissor em pacientes com apneia do sono suspeita ou confirmada...

In patients requiring mechanical ventilation, staff assistant is frequently confronted with a particular subgroup of individuals who have repeated episodes of apnea when in pressure support mode. We performed a literature search to define the best approach to ventilator weaning in these patients, and discuss the proper role of polysomnography in this context. Female patient, 71 years old, admitted for decompensated heart failure and infected diabetic foot, had a heart arrest. She was resuscitated and admitted thereafter in the intensive care unit, where she presented with clinical improvement; vasoactive drugs were discontinued, and ventilator weaning was initiated. In that moment, the patient developed multiple apnea episodes during pressure support mode ventilation, and delirium. Despite endotracheal tube self-extubation twice, the patient got better and finally was transferred to the clinical ward, and discharged within a month. The number of studies found, the small number of patients enrolled, and the inappropriate study designs do not guarantee an unflawed conclusion. The presence of apnea per se does not seem to contraindicate the progression of ventilator weaning, decannulation, or extubation. Polysomnography, if available, should be indicated, even in the intensive care unit environment. Ventilator weaning in neurally adjusted ventilatory assisted mode seems to be very promising in patients with suspected or confirmed sleep apnea syndromes...

Development of an assessment tool to measure students' perceptions of respiratory care education programs: item generation, item reduction, and preliminary validation

Students who perceived their learning environment positively are more likely to develop effective learning strategies, and adopt a deep learning approach. Currently, there is no validated instrument for measuring the educational environment of educational programs on respiratory care [RC]. The aim of this study was to develop an instrument to measure students' perception of the RC educational environment. Based on the literature review and an assessment of content validity by multiple focus groups of RC educationalists, potential items of the instrument relevant to RC educational environment construct were generated by the research group. The initial 71 item questionnaire was then field-tested on all students from the 3 RC programs in Saudi Arabia and was subjected to multi-trait scaling analysis. Cronbach's alpha was used to assess internal consistency reliabilities. Two hundred and twelve students [100%] completed the survey. The initial instrument of 71 items was reduced to 65 across 5 scales. Convergent and discriminant validity assessment demonstrated that the majority of items correlated more highly with their intended scale than a competing one. Cronbach's alpha exceeded the standard criterion of >0.70 in all scales except one. There was no floor or ceiling effect for scale or overall score. This instrument is the first assessment tool developed to measure the RC educational environment. There was evidence of its good feasibility, validity, and reliability. This first validation of the instrument supports its use by RC students to evaluate educational environment

Patterns of admitted cases to respiratory intensive care unit at Zagazig University Hospitals, Egypt

Background: It is well accepted that early appropriate referral of patients to an ICU can significantly reduce early and possibly late mortality in the critically ill. At the same time improper selection of patients for ICU, often limits bed availability in ICUs. This in turn, adversely affects the dynamics of the whole hospital

Objective: To determine the admission pattern and outcome of patients in the Respiratory Intensive Care Unit [RICU] of Zagazig University Hospitals, Egypt. Design. The study was carried out as a prospective analytical study

Patients and methods: All cases admitted to RICU during the period from March 2010 to October 2010. They were 200 cases [126 males [63%] and 74 females [37%]] with an age range from 11 to 86 years. They were classified according to the causes of admission to RICU into 162 cases due to primary respiratory causes [81%] and 38 cases due to secondary respiratory causes [19%]. On admission the following were carried out for all patients: full medical history, chest examination, assessment of Glasgow Coma Scale [GCS] and Acute Physiology and Chronic Health Evaluation II [APHCHE II] score, arterial blood gases analysis, plain chest and heart X-ray, computerized tomography [CT] electrocardiography [ECG] or echocardiography [ECHO] study when needed and assessment of the outcome

Results: Two hundred cases were admitted during the study period: 57% were referred by chest physicians, 14.5% from other hospitals, 13.5% from other departments and others from chest ward and emergency room [ER]. The mean GCS and APHACHE II score were 12.7 +/- 3.97 and 14.4 +/- 6.5 respectively. The length of stay in RICU was 7.2 +/- 7.4 days. Analysis of outcome of the cases showed that 70 patients [35%] were transferred to chest ward, 61patients [30.5%] died and 54 patients [27.0%] were discharged to home. There was a significant difference between cases with primary [1[ry]] and secondary [2[ry]] respiratory causes regarding outcome [P < 0.005] with mortality rate [26.6%] among cases with 1[ry] respiratory causes while in cases with 2[ry] respiratory causes were 60.4%. Outcome as regards source of admission showed that the highest percentage of death occurred among cases referred from chest ward and non chest physicians [63.7% and 62.5%] respectively. There was a significant association between outcome and duration of stay [P < 0.001]. Concerning the outcome on using mechanical ventilation, the mortality rate in mechanically ventilated patients was 52.05% while in non mechanically ventilated patients it was 47.5%

Conclusion: This study showed that the best prognosis of admitted patients to RICU was for those who were transferred earlier especially those transferred by chest physicians and patients with 1[ry] respiratory diseases than those with 2[ry] respiratory diseases. Also, cases with high Glasgow Coma Scale and low APACH II score and those with a short duration of stay in RICU, especially without the need for mechanical ventilation had a good prognosis. Therefore, considering those aspects in the clinical practice would be reflected as a better outcome on dealing with RICU patients

Estrategia de hospitalización abreviada en el síndrome bronquial obstructivo del lactante. Experiencia de tres años en Unidades de Terapia Inhalatoria. / Strategy brief hospitalization in infant wheezing bronchitis. Experience of three years in Inhalation Therapy Units

Introducción: el síndrome broncoobstructivo del lactante (SBOL) constituye el principal motivo de consulta por patología respiratoria en menores de 2 años en el invierno. Desde el año 2008 se implementaron en Montevideo y área metropolitana diez Unidades de Terapia Inhalatoria (UTIs) en un régimen de hospitalización abreviada. Se describen las características clínicas de esta población y el tratamiento instituido. Material y métodos: fueron enrolados en forma prospectiva los niños entre 1 y 24 meses con diagnóstico de SBOL moderado, sin factores de riesgo, que ingresaron a las UTIs durante los meses de invierno, entre 2008 y 2010. Fueron tratados siguiendo un algoritmo terapéutico que incluyó dos horas con salbutamol inhalado y una tercera hora con adrenalina nebulizada, según la respuesta terapéutica; se administró prednisolona a los niños con dos episodios previos o más. Resultados: se incluyeron 2.183 pacientes. La estadía media fue de 3 horas; la mediana del escore de tal al ingreso fue 5 y al egreso de 3. Requirieron 2 horas de tratamiento con salbutamol 819 niños (38%); 707 pacientes (32%) completaron tres horas y 419 (19%) recibieron además corticoides. Fueron derivados al domicilio desde la UTI 1.314 pacientes (62%), y un 13% adicional luego de observación en emergencia, con un 8% de reconsultas. Los pacientes que recibieron hasta dos horas de tratamiento tuvieron más probabilidad de alta (p<0,005). Conclusiones: la estrategia de hospitalización abreviada, mediante la protocolización de un tratamiento aplicable en el primer y segundo nivel de atención, resultó útil para el manejo del SBOL.

Continuous positive airway pressure versus continuous negative pressure around the chest for patients with acute exacerbation of chronic obstructive pulmonary disease in the intensive care unit: A pilot study.

Introduction. With chronic obstructive pulmonary disease (COPD) exacerbations, continuous positive airway pressure (CPAP) has been used to overcome the threshold load provided by intrinsic positive end expiratory pressure and decrease the inspiratory work of breathing. In this pilot study, we observed whether a continuous negative pressure (CNP) around the thorax and upper abdomen with a shell and wrap would provide a similar level of relief in dyspnoea. Methods. In eight patients with COPD in the intensive care unit receiving CPAP, CNP was alternated twice with CPAP (30 minutes each time). We measured heart rate, respiratory rate, blood pressure, arterial oxygen tension (PaO2), arterial carbon dioxide tension (PaCO2), pH and dyspnoea score, and asked each patient which system was more comfortable. Results. Comparing CPAP with CNP, we found no significant difference in all measured parameters except PaCO2 which was lower with CNP. Seven out of eight patients found that CNP was more comfortable. Conclusions. The CNP was similar to CPAP except CNP was more comfortable.

Alternativas de tratamento para pacientes pediátricos em ventilação mecânica crônica / Care alternatives for pediatric chronic mechanical ventilation

OBJETIVO: Determinar o impacto da transferência de uma população pediátrica para unidades de dependentes de ventilação mecânica (UDVMs) ou para ventilação mecânica domiciliar (VMD) na disponibilidade de leitos na unidade de terapia intensiva (UTI) pediátrica. MÉTODOS: Estudo longitudinal retrospectivo de crianças hospitalizadas que necessitavam de VM prolongada na UDVM do Hospital Auxiliar de Suzano, um hospital público secundário do estado de São Paulo. Calculamos o número de dias que os pacientes passaram na UDVM e em VMD e analisamos sua sobrevida com o estimador Kaplan-Meier. RESULTADOS: Quarenta e um pacientes foram admitidos na UDVM em 7,3 anos. A mediana do tempo de internação na unidade foi de 239 dias (amplitude interquartil = 102-479). Desses pacientes, 22 vieram da UTI pediátrica, onde a transferência disponibilizou 8.643 leitos-dia (uma média de 14 novos pacientes por mês). A VMD de oito pacientes disponibilizou 4.022 leitos-dia no hospital em 4 anos (uma média de 12 novos pacientes por mês na UTI). A taxa de sobrevida dos pacientes em casa não foi significativamente diferente daquela verificada nos pacientes hospitalizados. CONCLUSÕES: Uma unidade hospitalar para dependentes de ventilação mecânica e a VMD podem melhorar a disponibilidade de leitos em UTIs. A taxa de sobrevida dos pacientes que recebem VMD não apresentou diferenças significativas em relação à dos pacientes que permanecem hospitalizados.

OBJECTIVE: To determine the impact of transferring a pediatric population to mechanical ventilator dependency units (MVDUs) or to home mechanical ventilation (HMV) on bed availability in the pediatric intensive care unit (ICU). METHODS: This is a longitudinal, retrospective study of hospitalized children who required prolonged mechanical ventilation at the MVDU located at the Hospital Auxiliar de Suzano, a secondary public hospital in São Paulo, Brazil. We calculated the number of days patients spent at MVDU and on HMV, and analyzed their survival rates with Kaplan-Meier estimator. RESULTS: Forty-one patients were admitted to the MVDU in 7.3 years. Median length of stay in this unit was 239 days (interquartile range = 102-479). Of these patients, 22 came from the ICU, where their transfer made available 8,643 bed-days (a mean of 14 new patients per month). HMV of eight patients made 4,022 bed-days available in the hospital in 4 years (a mean of 12 new patients per month in the ICU). Survival rates of patients at home were not significantly different from those observed in hospitalized patients. CONCLUSIONS: A hospital unit for mechanical ventilator-dependent patients and HMV can improve bed availability in ICUs. Survival rates of patients who receive HMV are not significantly different from those of patients who remain hospitalized.

Pneumonia associada à ventilação mecânica: medidas preventivas conhecidas pelo enfermeiro / Pneumonia associated with mechanical ventilation: preventive measures known by nurses / Neumonía asociada a la ventilación mecánica: medidas preventivas conocidas por el enfermero

A Pneumonia Associada à Ventilação Mecânica (PAV) tem sido cada vez mais comum nas UTIs, aumentando amortalidade e os custos hospitalares. Assim, este estudo descreve as medidas conhecidas pelas enfermeiras decuidados intensivos para prevenir PAV. Esta é uma pesquisa de abordagem descritiva e exploratória, qualitativa.Os sujeitos foram sete enfermeiros da UTI de um hospital universitário na cidade de Salvador, Bahia, durante o mêsde outubro de 2010. Os dados foram coletados através de entrevista semiestruturada. A aspiração endotraqueal é aúnica medida mencionada por todos os entrevistados; trocar o circuito de ventilação, higiene oral com clorexidina,reduziram o tempo de ventilação mecânica; elevação da cabeceira da cama e lavar as mãos foram citados com menorfrequência pelos participantes da pesquisa. Concluiu-se que as medidas preventivas contidas nas Diretrizes principaissão conhecidas pelas enfermeiras e elas demonstraram uma compreensão abrangente sobre os cuidados essenciaispara a prevenção da PAVM.

The Ventilator-Associated Pneumonia (VAP) has been increasingly common in ICUs, increasing mortality and hospitalcosts. Thus, this study describes the measures known to the intensive care nurses to prevent VAP. This is a survey ofdescriptive, exploratory and qualitative approach. The subjects were seven nurses in the ICU of a university hospitalin the city of Salvador, Bahia, during the month of October 2010. The data were collected through semi-structuredinterview. The endotracheal suction was the only measure mentioned by all respondents, while changing the ventilatorcircuit, oral hygiene with chlorhexidine, reduced time on mechanical ventilation, elevation of the headboard, andhand washing were cited less frequently by participants research. It was concluded that the nurses know the preventivemeasures contained in the main Guidelines and they demonstrated a comprehensive understanding about the careessential for the prevention of VAP.

La neumonía asociada a la ventilación mecánica (PAV) ha sido cada vez más común en las UCIs, aumentando lamortalidad y los costos hospitalarios. Este estudio describe las medidas conocidas por las enfermeras de cuidadosintensivos para prevenir la PAV. Esta investigación es de enfoque descriptivo y exploratorio y cualitativo. Los sujetosfueron siete enfermeros de la UCI de un hospital universitario en la ciudad de Salvador, Bahía, durante el mes deoctubre de 2010. Los datos fueron recolectados a través de entrevista semiestructurada. La aspiración endotraqueales la única medida mencionada por los encuestados, cambiando el circuito de ventilación, la higiene bucal conclorhexidina redujeron el tiempo de la ventilación mecánica, elevación de la cabecera de la cama y lavarse lasmanos, fueron citadas con menor frecuencia por los participantes en la encuesta. Se concluye que las medidaspreventivas contenidas en las Directrices principales son conocidas por las enfermeras y ellas demostraron unacomprensión global sobre los cuidados esenciales para la prevención de la PAVM.

Hand hygiene compliance and infection rates in respiratory intensive care unit

Hospital-acquired infections affect 5% to 10% of all hospitalized patients, and are the most common cause of preventable morbidity and mortality facing health care. It is estimated that 30% of hospitalacquired infections are avoidable with healthcare provider adherence to hand hygiene [HH] guidelines .Thus preventing patient-to-patient and healthcare worker-to-patient transmission of microorganisms can prevent most nosocomial infections. This work was conducted to study the effect of HH practices on hospital-acquired infections in the Respiratory Intensive Care Unit [RICU] at Ain Shams University Hospital. The study was done in three phases; the first was an observational study for HH practices among physicians and nurses and evaluation of HH resources during the period from December, 2008 to March, 2009, so termed pre-intervention phase. The second was the intervention phase, started by education and on job training for HH practices among physicians and nurses together with replenishing of HH resources in a two months period from April to May 2009. The third was the post-intervention phase, which extended from June to December 2009. The infection rates were calculated through the three phases and re-evaluation of the intervention was carried out by calculating the compliance rates before and after intervention. HH compliance increased significantly from 8.2% in the pre-intervention phase to 53.9% in postintervention phase. The HH practices increased in nurses more than doctors, nurses' compliance in preintervention phase was 42.4% and increased to 70.7% in the post-intervention phase. Doctors' compliance increased from 36.8% in pre-intervention to 55.3% in post-intervention. Overall patient infection rates declined from 63.7% to 50.2% during the study. Such simple, non costly methodologies can increase the compliance of HH practices which can decrease infection rates in RICU

Contenido arterial de oxígeno en pacientes con sepsis respiratoria ventilados / Level of arterial oxygen in patients with respiratory sepsis ventilated

Se realizó un estudio descriptivo y transversal en la Unidad de Cuidados Intensivos del Hospital General Docente Dr Juan Bruno Zayas de Santiago de Cuba durante el 2006, con vista a determinar el contenido arterial de oxígeno en pacientes con sepsis respiratoria que habían sido ventilados. Las fuentes de información utilizadas fueron la historia clínica y los resultados de la gasometría arterial. En las 3 determinaciones de gases sanguíneos efectuadas, se hallaron bajos valores significativos en el contenido arterial de oxígeno (p< 0,05); muestra de la importancia de este indicador como herramienta útil que permitió medir el estado de oxigenación arterial en dichos pacientes.

A descriptive and cross-sectional study was carried out at Intensive Care Unit of the Dr Juan Bruno Zayas Teaching General Hospital from Santiago de Cuba during 2006, in order to determine the level of arterial oxygen in patients with respiratory sepsis who had been ventilated. The used sources of information were medical records and results of arterial gasometry. In the three measurements of blood gases low significant values were found in the level of arterial oxygen (p <0,05), showing the significance of this indicator as useful tool to measure the state of arterial oxygenation in these patients.

Recomendaciones prácticas para el cuidado hospitalario del niño/adolescente con necesidades especiales y dependencias tecnológicas respiratorias / Practical recommendations for hospital care of child and adolescent with special respiratory needs

Junto con el aumento de la prevalencia de enfermedades respiratorias crónicas y Neuromusculares, surgen avances tecnológicos que permiten entregar prestaciones orientadas a mejorar la calidad y expectativa de vida de niños y adolescentes. Este artículo entrega recomendaciones practicas para el manejo intrahospitalario de pacientes con necesidades especiales de atención en salud y dependencias tecnológicas en cuidados respiratorios, centrados en la ventilación mecánica prolongada, técnicas complementarias y cuidados de traqueostomía.

Guía clínica para el diagnóstico y cuidado de niños/adolescentes con bronquiolitis obliterante post-infecciosa, 2009 / Clinical guide for diagnosis and care of children and adolescents with post-infectious bronchiolitis obliterans, 2009

Bronchiolitis obliterans in children is an infrequent clinical syndrome, characterized by chronic airflow obstruction associated to inflammatory changes and different degrees of fibrosis in the small airways. Etiologies are varied but the most frequent one is the association with viral infections, mainly adenovirus. There is no consensus regarding diagnostic criteria, but a spectrum of persistent symptoms together with a mosaic pattern, bronchiectasis and persistent atelectasis is considered useful. Pulmonary biopsy has been questioned because of its low yield, invasiveness and complications. No specific treatment is available, therefore its treatment is supportive. Probably the best strategy is the aggressive use of antibiotics, constant kinesic and nutritional support and early pulmonary rehabilitation. This clinical guide represents a multidisciplinary effort, based on current evidence, to provide practical tools for the diagnosis and care of children and adolescents affected by post-infectious bronchiolitis obliterans.

La bronquiolitis obliterante (BO) es un síndrome clínico poco frecuente en niños, caracterizado por la obstrucción crónica al flujo de aire asociado a cambios inflamatorios y distintos grados de fibrosis en la vía aérea pequeña. Si bien existen muchas etiologías, la causa más frecuente se asocia a infecciones respiratorias virales, principalmente adenovirus. No existe un consenso para establecer su diagnóstico; sin embargo, se considera un espectro de síntomas persistentes asociados a un patrón en mosaico, bronquiectasias y atelectasias persistentes. El papel de la biopsia pulmonar ha sido cuestionado por su bajo rendimiento, invasividad y complicaciones. No existe un tratamiento específico por lo que el manejo es soporte. Probablemente la mejor estrategia constituya el empleo de antibióticos en forma agresiva, soporte kinésico y nutricional constante y una precoz rehabilitación pulmonar. Estas guías clínicas representan un esfuerzo multidisciplinario, basado en evidencias actuales para brindar herramientas prácticas para el diagnóstico y cuidado de niños y adolescentes con BO post infecciosa.

Estudio de las percepciones y actitudes del personal de una unidad hospitalaria frente a enfermos terminales / Perceptions and attitudes of a respiratory unit staff facing terminal ill patients

In order to promote the humanization of health at the National Institute of Thorax, this work is proposed to make a descriptive and exploratory study of qualitative type with the intention of knowing the functions, perceptions, values and attitudes of the staff of the Respiratory Medical Surgical Unit to faced of the patients who live their process of death in hospital. We are also interested in to identifying strengths, weaknesses and needs felt by the team in caring for these terminal ill patients and the treatment use with the body of the deceased. This information will implement measures that will help to dignify the death in this Unit. It is based on 26 interviews (65 percent) of the staff who work in this unit. Interviewees described her/his work as "good" especially in the control of physical symptoms of the patient and family care issues. They admit, however, there are other needs, especially the psychological and spiritual, that they not serve very well. This is the result of a poor training received to resolve high emotional situations and to establish a therapeutic communication with the patient.

Enmarcado en el objetivo de promover la humanización de la salud en el Instituto Nacional del Tórax, este trabajo se propuso realizar un estudio descriptivo exploratorio de tipo cualitativo con la finalidad de conocer las funciones, percepciones, valores y actitudes del personal de la Unidad Médico Quirúrgico Respiratorio ante los pacientes que viven su proceso de muerte en el hospital. Nos interesaba también, identificar las fortalezas, carencias y necesidades sentidas por el equipo de trabajo en la atención de estos pacientes terminales y en el tratamiento que se realiza con el cuerpo del fallecido. Esta información permitirá implementar medidas que ayuden a dignificar la muerte en esta Unidad. Se realizaron un total de 26 entrevistas semiestructuradas, correspondientes a un 65 por ciento de los funcionarios que laboran en esta Unidad. Los participantes califican su trabajo como "bueno" especialmente en el control de síntomas físicos del paciente y atención a la familia. Reconocen sin embargo, que hay otras necesidades, especialmente las psicológicas y espirituales que no se atienden con excelencia, como consecuencia de la escasa preparación recibida para enfrentar y resolver situaciones de alto contenido emocional y establecer una comunicación terapéutica con el paciente.

Serum troponin levels, APACHE II score and mortality rate for non-cardiac reasons in RCU patients

Estimating the severity of disease and prognosis for patients hospitalized in intensive care units may be important in selection of diagnostic procedures and treatment regimens. For this purpose, various ranking methods have been used in these units which have their benefits and shortcomings. n this study, all patients admitted to the respiratory intensive care unit [RCU] of Labbafi Nejad Hospital during the year 2005 with no signs of cardiac disease or history of cardiopulmonary resuscitation were evaluated. All patients had their serum troponin level checked in the first hour of hospitalization in the unit and upon first medical examination acute physiologic and chronic health evaluation [APACHE] II scores were determined for them. In total, 87 patients were eligible for entering the study. There were significant correlations between serum troponin levels and APACHE II score [p=0.0001]. There was also a significant correlation between elevated troponin levels and mortality rate. Multivariate statistical analysis showed that APACHE II scores and serum troponin levels each are independent variables affecting prognosis among hospitalized patients in the respiratory intensive care unit. Determination of serum troponin levels in non-cardiac patients admitted to respiratory intensive care unit can be a helpful prognostic factor

Noise levels in Greek hospitals.

High noise levels have been recognized as a serious problem in hospital environments during both night- and daytime, and have been associated with a negative impact on patients' health status. The aim of this study was to measure and detect differences in noise levels between an ICU and a pulmonary ward in two general hospitals in Greece. Methods: Noise measurements were recorded in one-hour intervals using the Cirrus CR: 245/R2 Environmental Noise Analyzer in a 30-bed pulmonary ward and in a 16-bed general ICU for seven consecutive days. Results: Noise levels detected in the ward were significantly lower than those detected in the ICU (52.6 +/- 8.2 dB vs 59 +/- 2.2 dB, P Conclusion: Noise levels measured in the ward and in the ICU were high, significantly exceeding the highest permitted values for hospitals. The latter was more obviously recorded in the ICU.

Hacerse entender: la experiencia de pacientes sometidos a ventilación mecánica sin efectos de sedación / Make yourself clear: experience for submitted patients to mechanical ventilation without sedation side effects

La ventilación mecánica es un método de soporte de la vida de personas en estado crítico. Tradicionalmente se ha empleado en pacientes bajo el efecto de sedación continua lo que significa para ellos una total abstracción de su situación actual. Tal práctica depara un traumático despertar, ampliamente informado en la literatura, tanto por los efectos adversos de los medicamentos sedantes, como por las implicaciones sicológicas de haber sido objeto y no sujeto de cuidado. Este trabajo, por el contrario, está enfocado en pacientes con ventilación mecánica, sin sedación. Objetivo: describir las diferentes formas de comunicación empleadas por pacientes cuya experiencia en una Unidad de Cuidado Intensivo ha sido la ventilación mecánica sin efectos de sedación continúa. Metodología: se realizó una investigación con enfoque fenomenológico, durante el 2006, que contó con la participación de siete hombres y dos mujeres con edades entre 24 y 75 años de edad. La técnica de recolección de la información fue la entrevista en profundidad. Resultados: la descripción de cada experiencia permitió entender cómo el ser humano, estando críticamente enfermo, con una vía aérea artificial como medio de vida, activa un importante número de formas para hacerse entender. Conclusión: se demostró la importancia que tiene para el paciente ser tratado como sujeto activo en su experiencia de comunicación con el personal de salud y sus familiares, dado que fue significativa la multiplicidad de herramientas no verbales empleadas que contribuyeron a una percepción positiva de la experiencia.

The mechanical ventilation mechanism is a support method used to safeguard the life of people in a cri¬tical state. Traditionally, it has been used in patients under the effects of continuous sedation, which implies a total abstraction of their current situation for the patients; such scenarios afford the patients a traumatic one to wake up, broadly informed in the literature, for the adverse effects of the sedative me¬dications, like the psychological implications that it can cause independent of quality of care. Objective: to describe the different communication forms used for patients whose experience in an intensive critical care unit has involved the mechanical ventilation without continues sedation effects. Methodology: the investigation was carried out with phenomenological focus during 2006 and had the participation of seven men and two women with ages between 24 and 75 years of age. The technique of information gathering was the in-depth interview. Results: The description of each experience allowed understanding of the human being critically sick with an artificial air way as living medium, requesting active ways to be made unders¬tood. Conclusion: it demonstrated the importance for the patient to be treated as an active subject by means of the communication with the health personnel and relatives. Many non verbal tools were employed and their contribution brought upon a positive perception of the experience.

Performance evaluation of APACHE II score for an Indian patient with respiratory problems.

BACKGROUND & OBJECTIVES: Realising the utility of scoring systems in mortality prediction of critically ill patients admitted to intensive care units (ICUs), studies worldwide have expressed a need to validate the Acute Physiology and Chronic Health Evaluation (APACHE) II score for databases of respective countries. Literature available in this area in the Indian context is scanty. The present study was undertaken to evaluate the performance of APACHE II score in prediction of mortality risk, as well as in determination of model validity in critically ill Indian patients with respiratory problems. METHODS: The study was prospectively carried out over 18 months at respiratory ICU of a tertiary Institute in New Delhi, which admitted consecutive medical (with lung ailments) and surgical (who had undergone any elective thoracic surgical procedure under general anaesthesia) patients. Based on chief indication of ICU admission, the medical patients were further divided into sub-groups I (respiratory) and II (non-respiratory). APACHE II points were assigned to all patients for calculating their individual predicted risks of mortality. Standard mortality ratio (SMR) was computed with 95 per cent confidence intervals (CI). Calibration of model was analysed by calculating Lemeshow and Hosmer goodness of fit X(2) statistic and by plotting calibration curve, whereas discrimination was evaluated by calculating area under a receiver operating characteristic (ROC) curve. RESULTS: Of the 393 consecutive patients admitted to respiratory ICU during the study period, 63 were left out on account of exclusion criteria. Mean APACHE II score of the remaining 330 patients was 12.87+/-8.25 and range from 1 to 47. There were 287 (87%) survivors and 43 (13%) non-survivors, whose mean APACHE II scores, being respectively 11.34+/-6.75 (range 1-37) and 23.09+/-10.01 (range 5-47), were significantly different (P<0.01). The study had a predicted mortality of 7.9 per cent and an SMR value of 1.65 (95% CI from 0.4 to 3.0). Mean APACHE II score of those having medical ailments was significantly higher (P<0.01) than surgical patients. The non-respiratory sub-group had a significantly higher (P<0.01) mean APACHE II score than respiratory sub-group. 59 per cent of patients did not get APACHE II points owing to being <45 yr of age. In addition, against 10 immunocompromised patients, 77 others did not get APACHE II points despite having apparently compromised immunity due to co-existence of tuberculosis (TB), diabetes mellitus, dual pathologies or past history of anti-TB treatment. Observed and predicted mortality rose with 5-point APACHE II score, but did not correlate for patients of any comparable group. Average ICU stay of 16 days for those with medical disease was significantly longer (P<0.01) than 9.5 days for surgical patients. APACHE II scoring system showed a poor calibration and discrimination ability for Indian respiratory patients. INTERPRETATION & CONCLUSION: Despite the rise in observed and predicted mortality with 5-point APACHE II score, predicted mortality did not correlate with observed mortality for critically ill patients admitted to an Indian respiratory ICU. The scoring system also showed a poor calibration as well as discrimination. The model may be more useful for Indian patients by lowering down the cut-off value in allotment of age points and by awarding the weightage to factor like co-existing immunocompromised state.