Predictors for prescription of noninvasive ventilation in the postoperative period of cardiac surgery: a systematic review.

INTRODUCTION: The postoperative (PO) period after cardiac surgery is associated with the occurrence of respiratory complications. Noninvasive positive pressure ventilation (NIPPV) is largely used as a ventilatory support strategy after the interruption of invasive mechanical ventilation. However, the variables associated with NIPPV prescription are unclear. OBJECTIVE: To describe the literature on predictors of NIPPV prescription in patients during the PO period of cardiac surgery. MATERIALS AND METHODS: This systematic review was registered on the International Prospective Register of Systematic Reviews (PROSPERO) platform in December 2021 (CRD42021291973). Bibliographic searches were performed in February 2022 using the PubMed, Lilacs, Embase and PEDro databases, with no year or language restrictions. The Predictors for the prescription of NIPPV were considered among patients who achieved curative NIPPV. RESULTS: A total of 349 articles were identified, of which four were deemed eligible and were included in this review. Three studies were retrospective studies, and one was a prospective safety pilot study. The total sample size in each study ranged from 109 to 1657 subjects, with a total of 3456 participants, of whom 283 realized NIPPV. Curative NIPPV was the only form of NIPPV in 75% of the studies, which presented this form of prescription in 5-9% of the total sample size, with men around 65 years old being the majority of the participants receiving curative NIPPV. The main indication for curative NIPPV was acute respiratory failure. Only one study realized prophylactic NIPPV (28% of 32 participants). The main predictors for the prescription of curative NIPPV in the PO period of cardiac surgery observed in this study were elevated body mass index (BMI), hypercapnia, PO lung injury, cardiogenic oedema and pneumonia. CONCLUSIONS: BMI and lung alterations related to gas exchange disturbances are major predictors for NIPPV prescription in patients during the PO period of cardiac surgery. The identification of these predictors can benefit clinical decision-making regarding the prescription of NIPPV and help conserve human and material resources, thereby preventing the indiscriminate use of NIPPV.

Utilización de soportes respiratorios no invasivos post extubación en pacientes adultos críticos: revisión narrativa SRNI post extubación en adultos críticos / Use of Non-Invasive Respiratory Support in Critically Ill Patients Post-Extubation: a Narrative Review NIRS Post-Extubation in Critically Ill Adults

La tasa de reintubación orotraqueal luego de la extubación se registra entre un 10 a 20%. La aplicación de soportes respiratorios no-invasivos (SRNI) posterior a la extuba-ción como cánula nasal de alto-flujo, ventilación no invasiva (dos niveles de presión) y presión positiva continua en la vía aérea demostraron ser seguras y efectivas post ex-tubación. El período pre-destete representa un momento crucial en el manejo de los pa-cientes críticos ya que el fracaso de la extubación, definido como la necesidad de reintu-bación dentro de los 2 a 7 días, demostró peores resultados al aumentar la mortalidad entre un 25-50%. Esta situación conlleva al requerimiento de ventilación mecánica prolongada, neumonía asociada a la ventilación mecánica y estancias prolongadas de internación. Por lo tanto, es esencial identificar a los pacientes que se beneficiarán utilizando SRNI post extubación.

The rate of re-intubation after extubation is recorded at 10-20%. The use of non-invasive respiratory support (NIRS) post-extubation such as high-flow nasal cannula, non-invasive ventilation (bilevel pressure) and continuous positive airway pressure (CPAP) have been shown to be safe and effective post-extubation. The pre-weaning period represents a crucial time in the management of critically ill patients, as extubation failure, defined as the need for reintubation within 2-7 days, showed worse outcomes with mortality increasing by 25-50%. This situation leads to the requirement for prolonged mechanical ventilation, ventilator-associated pneumonia and long lengths of hospital stay. Therefore, it is essential to identify patients who will benefit from NIRS post extubation.

Mortality Rates Among Hospitalized Patients With COVID-19 Infection Treated With Tocilizumab and Corticosteroids: A Bayesian Reanalysis of a Previous Meta-analysis.

Importance: A World Health Organization (WHO) meta-analysis found that tocilizumab was associated with reduced mortality in hospitalized patients with COVID-19. However, uncertainty remains concerning the magnitude of tocilizumab's benefits and whether its association with mortality benefit is similar across respiratory subgroups. Objective: To use bayesian methods to assess the magnitude of mortality benefit associated with tocilizumab and the differences between respiratory support subgroups in hospitalized patients with COVID-19. Design, Setting, and Participants: A bayesian hierarchical reanalysis of the WHO meta-analysis of tocilizumab studies published in 2020 and 2021 was performed. Main results were estimated using weakly informative priors to exert little influence on the observed data. The robustness of these results was evaluated using vague and informative priors. The studies featured in the meta-analysis were randomized clinical tocilizumab trials of hospitalized patients with COVID-19. Only patients receiving corticosteroids were included. Interventions: Usual care plus tocilizumab in comparison with usual care or placebo. Main Outcomes and Measures: All-cause mortality at 28 days after randomization. Results: Among the 5339 patients included in this analysis, most were men, with mean ages between 56 and 66 years. There were 2117 patients receiving simple oxygen only, 2505 receiving noninvasive ventilation (NIV), and 717 receiving invasive mechanical ventilation (IMV) in 15 studies from multiple countries and continents. Assuming weakly informative priors, the overall odds ratios (ORs) for survival were 0.70 (95% credible interval [CrI], 0.50-0.91) for patients receiving simple oxygen only, 0.81 (95% CrI, 0.63-1.03) for patients receiving NIV, and 0.89 (95% CrI, 0.61-1.22) for patients receiving IMV, respectively. The posterior probabilities of any benefit (OR <1) were notably different between patients receiving simple oxygen only (98.9%), NIV (95.5%), and IMV (75.4%). The posterior probabilities of a clinically meaningful association (absolute mortality risk difference >1%) were greater than 95% in patients receiving simple oxygen only and greater than 90% in patients receiving NIV. In contrast, the posterior probability of this clinically meaningful association was only approximately 67% in patients receiving IMV. The probabilities of tocilizumab superiority in the simple oxygen only subgroup compared with the NIV and IMV subgroups were 85% and 90%, respectively. Predictive intervals highlighted that only 72.1% of future tocilizumab IMV studies would show benefit. The conclusions did not change with different prior distributions. Conclusions and Relevance: In this bayesian reanalysis of a previous meta-analysis of 15 studies of hospitalized patients with COVID-19 treated with tocilizumab and corticosteroids, use of simple oxygen only and NIV was associated with a probability of a clinically meaningful mortality benefit from tocilizumab. Future research should clarify whether patients receiving IMV also benefit from tocilizumab.

Noninvasive ventilation and high-flow nasal cannula in patients with acute hypoxemic respiratory failure by covid-19: A retrospective study of the feasibility, safety and outcomes.

BACKGROUND: Noninvasive ventilation (NIV) and High-flow nasal cannula (HFNC) are the main forms of treatment for acute respiratory failure. This study aimed to evaluate the effect, safety, and applicability of the NIV and HFNC in patients with acute hypoxemic respiratory failure (AHRF) caused by COVID-19. METHODS: In this retrospective study, we monitored the effect of NIV and HFNC on the SpO2 and respiratory rate before, during, and after treatment, length of stay, rates of endotracheal intubation, and mortality in patients with AHRF caused by COVID-19. Additionally, data regarding RT-PCR from physiotherapists who were directly involved in assisting COVID-19 patients and non-COVID-19. RESULTS: 62.2 % of patients were treated with HFNC. ROX index increased during and after NIV and HFNC treatment (P < 0.05). SpO2 increased during NIV treatment (P < 0.05), but was not maintained after treatment (P = 0.17). In addition, there was no difference in the respiratory rate during or after the NIV (P = 0.95) or HFNC (P = 0.60) treatment. The mortality rate was 35.7 % for NIV vs 21.4 % for HFNC (P = 0.45), while the total endotracheal intubation rate was 57.1 % for NIV vs 69.6 % for HFNC (P = 0.49). Two adverse events occurred during treatment with NIV and eight occurred during treatment with HFNC. There was no difference in the physiotherapists who tested positive for SARS-COV-2 directly involved in assisting COVID-19 patients and non-COVID-19 ones (P = 0.81). CONCLUSION: The application of NIV and HFNC in the critical care unit is feasible and associated with favorable outcomes. In addition, there was no increase in the infection of physiotherapists with SARS-CoV-2.

Uso de ventilación no invasiva luego de la discontinuación de la ventilación mecánica invasiva en pacientes adultos / Use of noninvasive ventilation after discontinuation of invasive mechanical ventilation in adult patients

Introducción: la discontinuación de la ventilación mecánica invasiva en las Unidades de Cuidados Intensivos es un objetivo fundamental y primario, en pos de evitar las complicaciones asociadas a ella. El uso de ventilación no invasiva en este contexto resulta de utilidad en tres escenarios específicos: a) como prevención de fallo de extubación, b) como cambio de interface, c) en fallo instalado. No existe evidencia suficiente sobre el tiempo de uso habitual de la VNI en esta subpoblación, las variables que se utilizan para elegirla, las causas de fallo de la VNI y la mortalidad asociada en estos pacientes. Objetivos: describir epidemiológicamente a los pacientes adultos con uso de VNI posextubación y su evolución hasta el alta hospitalaria. Describir la indicación de VNI, el tiempo de uso, las tasas de reintubación y mortalidad intrahospitalaria. Materiales y métodos: cohorte retrospectiva de pacientes internados en la UCI de adultos del Hospital Italiano de San Justo que utilizaron VNI posextubación. A partir de la historia clínica electrónica se registraron variables epidemiológicas previas al ingreso en la UCI y datos evolutivos durante la internación. El período analizado abarca desde el 17 de diciembre de 2016 hasta el 01 de agosto de 2018. Resultados: se incluyeron 48 pacientes en el presente estudio. La mediana de edad fue de 76 años (RIQ 62,75-83,25). El 58,33% eran hombres. El índice de comorbilidad de Charlson tuvo un valor de mediana de 5 (RIQ 3-6). Del total de pacientes reclutados, 33 utilizaron VNI como prevención de fallo de extubación (68,75%), 13 como cambio de interface (27,08%) y solo 2 como fallo instalado (4,16%). La mediana de días de uso de VNI fue 1 (RIQ 0-5) en prevención de fallo, 1 (RIQ 1-2) en cambio de interface y en fallo instalado 13,5 días (RIQ 8,75-18,25). Ocho pacientes fueron reintubados (16,66%). La mortalidad fue del 9,1% en el grupo de prevención de fallo y 7,7% en el grupo de cambio de interface, respectivamente. En cuanto al grupo que la usó a partir del fallo instalado, la tasa de mortalidad fue del 50% (total de dos pacientes). Conclusiones: la VNI como método de discontinuación de la VMI se utiliza principalmente tanto para la prevención de fallo como para cambio de interfaz. El tiempo de uso de VNI posextubación es, en general, limitado. Se necesitan futuros trabajos que identifiquen las horas requeridas de uso de VNI posextubación. (AU)

Introduction: the discontinuation of invasive mechanical ventilation in the intensive care unit is a fundamental and primary objective, both of which aim to avoid the complications associated with it. The use of non-invasive ventilation in this context may follow three specific scenarios: a) as prevention of extubation failure, b) as interface change, c) in overt failure. There is not enough evidence on the time of use of NIV in this subpopulation, the variables used to guide its use, the causes of NIV failure and the associated mortality in these patients. Objectives: to describe the use of NIV after extubation in adult critically ill patients. Further, we aim to describe the time of NIV use, the mortality and reintubation rate of each subgroup. Materials and methods: retrospective cohort study including adult patients admitted to the ICU at Hospital Italiano de San Justo, who received NIV post-extubation. Using the electronic health database, epidemiological variables were recorded prior to admission to the ICU and follow-up data during the hospitalization. The period analyzed was from December 17, 2016 to August 1, 2018. Results: 48 patients were included in the present analysis. Median age was 76 years (RIQ 62.75-83.25) and 58.33% were men. The Charlson comorbidity index had a median value of 5 (RIQ 3-6). Of the total number of patients recruited, 33 used NIV as prevention of extubation failure (68.75%), 13 as interface change (27.08%). ) and only 2 as overt extubation failure (4.16%).The median number of days of NIV use was 1 (RIQ 0-5) in failure prevention and 1 (RIQ 1-2) in the change of interface group. 8 patients were reintubated (16.66%). 9.1% and 7.7% of patients died in the groups that used NIV as prevention of extubation failure and change of interface respectively. Conclusions: NIV is frequently used in adult patients following extubation in our centre. Further studies are warranted to depict the necessary time of use to better allocate resources within the intensive care unit. (AU)

[Factors associated with the type of mask used during nocturnal NIV in patients with neuromuscular disorders]. / Facteurs associés au masque de ventilation non invasive nocturne chez les patients neuromusculaires adultes.

In subjects with neuromuscular diseases (NMD), the choice of facemask is essential for successful long-term noninvasive ventilation (NIV). While nasal masks usually represent the first line of treatment, almost a third of our subjects with NMD use an oro-nasal interface. Factors associated with the choice of mask remain poorly understood. We provide an original analysis of a previous prospective, multi-centric, Franco-Belgian survey investigating the factors associated with the type of nocturnal mask used in 116 adult NMD subjects treated with NIV. In these patients oro-nasal mask use was more often associated with non-Duchenne muscular dystrophy, older subjects, higher body mass index, better upper limb autonomy allowing independent mask removal and shorter periods of ventilation. Controlled prospective studies are needed to compare the efficacy and tolerance of different interfaces in this specific population.

Infecciones respiratorias agudas bajas en niños menores de 2 años: hospitalizaciones durante el invierno del año 2014 / Low acute respiratory infections in children under 2 years: 2014 winter hospitalizations / Infecções agudas das vias respiratórias inferiores em crianças menores de 2 anos: hospitalizações em 2014

Durante el invierno las infecciones respiratorias agudas bajas (IRAB) determinan un incremento en la demanda asistencial, afectando sobre todo a los niños más pequeños. El objetivo de la investigación fue describir las características clínicas, modalidades de tratamiento y evolución de los menores de 2 años hospitalizados en el Hospital Pediátrico-Centro Hospitalario Pereira Rossell por IRAB de etiología viral durante el invierno de 2014. Se realizó un estudio descriptivo, retrospectivo, describiendo las características de los menores de 2 años hospitalizados del 9/6 al 21/9/2014 por IRAB de probable etiología viral. Se describieron las características epidemiológicas y clínicas, el tratamiento realizado y la evolución de los pacientes. En el período evaluado egresaron 742 niños (34% de los egresos de la institución). Tenían una mediana de edad de 4 meses; 18% presentaba al menos un factor de riesgo de IRAB grave. Se identificó al virus respiratorio sincicial en 59,6%. La estadía hospitalaria tuvo una mediana de 4 días. En las salas de cuidados moderados se aplicó ventilación no invasiva a 46 niños, y oxigenación de alto flujo a 129 niños, logrando una mejoría clínica en el 87,0% y el 87,6% respectivamente. Ingresaron a unidades de cuidados intensivos 217 niños, 54% requirió asistencia ventilatoria mecánica. Dos pacientes fallecieron. En el período evaluado los niños pequeños con IRAB representaron una importante proporción de los egresos, con importante carga asistencial. La mayoría eran niños sin factores de riesgo. La aplicación de las técnicas de tratamiento en cuidados moderados fue efectiva, permitiendo disminuir la demanda de camas de cuidados intensivos.

During the winter, low acute respiratory infections (LARI) determine an increase in care demand, especially affecting younger children. The objective of the research was to describe the clinical characteristics, treatment modalities and evolution of children under 2 years of age hospitalized at the Hospital Pediátrico-Centro Hospitalario Pereira Rossell for viral etiology LARI during the 2014 winter. A descriptive, retrospective study was conducted, describing the characteristics of children under 2 years hospitalized between 9/6 and 9/21/2014 for LARI of probable viral etiology. The following features were described: epidemiological and clinical characteristics, treatment performed and patient's evolution. During the period evaluated, 742 children were discharged (34% of the institution's admissions). They had a median age of 4 months; 18% had at least one risk factor for severe LARI. Respiratory syncytial virus was identified in 59.6%. The hospital stay had a median of 4 days. In moderate care rooms noninvasive ventilation was applied to 46 children, and high flow oxygenation to 129 children, achieving clinical improvement in 87.0% and 87.6%, respectively. Two hundred and seventeen children were admitted 54% required mechanical ventilation. Two patients died. In the evaluated period small children with LARI represented a significant proportion of the discharges, with an important burden of care. The majority were children without risk factors. The application of treatment techniques in moderate care was effective, allowed a decrease in the demand for intensive care beds.

Durante o inverno, as infecções respiratórias agudas baixas (IRAB) determinam o aumento da demanda de cuidados, afetando especialmente as crianças menores. O objetivo da pesquisa foi descrever as características clínicas, as modalidades de tratamento e a evolução de crianças menores de dois anos hospitalizados no Hospital Pediátrico-Centro Hospitalario Pereira Rossell devido a IRAB de etiologia viral, durante o inverno de 2014. Foi realizado um estudo descritivo e retrospectivo, descrevendo as características das crianças menores de 2 anos hospitalizadas entre 9/6 e 21/9/2014 devido a IRAB de provável etiologia viral. Descreveram-se: características epidemiológicas e clínicas, tratamento realizado e evolução dos pacientes. Durante o período avaliado, 742 crianças foram hospitalizadas (34% dos ingressos da instituição). Tinham uma idade média de 4 meses; 18% tinham pelo menos um fator de risco para IRAB severa. O vírus sincicial respiratório foi identificado em 59,6%. A estadia hospitalaria teve uma mediana de 4 dias. Em salas de cuidados moderados, a ventilação não invasiva foi aplicada a 46 crianças e a oxigenação de alto fluxo a 129 crianças, atingindo melhora clínica em 87,0% e 87,6%, respectivamente. Foram internadas em unidades de terapia intensiva 217 crianças, 54% necessitaram de ventilação mecânica. Dois pacientes faleceram. No período avaliado, as crianças pequenas com IRAB representaram uma proporção significativa das despesas, com um carga importante de atendimento. A maioria carecia de fatores de risco. A aplicação de técnicas de tratamento em cuidados moderados foi eficaz, permitindo uma diminuição da demanda por leitos de terapia intensiva.

Ventilación no invasiva y oxigenoterapia de alto flujo en niños en salas de cuidados moderados. Experiencia en la Unidad de Cuidados Respiratorios Especiales Agudos del Hospital Pediátrico del CHPR durante 2013-2016 / Non-invasive ventilation and high-flow oxygen therapy in children in moderate care rooms. Experience at the Special Respiratory Acute Care at the CHPR from 2013 to 2016 / Ventilação não invasiva e oxigenoterapia de alto fluxo em crianças em consultórios de atenção de nível moderado. Experiência na Unidade de Cuidados Respiratórios Especiais Agudos do Hospital Pediátrico do CHPR durante 2013-2016

Resumen: Introducción: las infecciones respiratorias agudas bajas (IRAB) constituyen un importante problema de salud en invierno. El centro de referencia nacional en Uruguay ofrece a niños con IRAB ventilación no invasiva (VNI) y cánula nasal de alto flujo (CNAF) en cuidados moderados. Objetivo: describir las características clínicas, tratamiento y evolución de los niños asistidos en la Unidad de Cuidados Respiratorios Especiales Agudos (CREA) del Hospital Pediátrico de referencia nacional. Material y método: estudio retrospectivo, descriptivo. Se incluyeron todos los niños hospitalizados por IRAB asistidos en CREA que recibieron VNI y/o CNAF entre 1/1/13 y 31/12/16. Se revisaron historias clínicas. Variables: características clínicas, tratamientos, complicaciones, evolución y destino. Resultados: se asistieron 650 niños (348 con CNAF; 302 con VNI); sexo masculino 63% (407). Bronquiolitis 63% (406), se detectó virus respiratorio sincicial (VRS) en 60% (388). Media de edad en niños que recibieron CNAF 11 meses (9 días-108 meses); promedio duración de la técnica: 3 días. Requirieron ingreso a unidades de cuidados intensivos (UCI): 12% (43); asistencia ventilatoria mecánica (AVM): 6% (22). Media de edad en niños que recibieron VNI :12 meses (1-132 meses); media de duración de la técnica: 3 días. Requirieron ingreso a UCI 16% (49); AVM: 9,6% (29). No se registraron fallecimientos ni complicaciones graves. Conclusiones: el 85% de los niños completó su tratamiento en la Unidad CREA. El porcentaje de niños que requirió AVM fue bajo. La implementación de estas técnicas en cuidados moderados redujo la necesidad de ingreso a UCI y probablemente la necesidad de AVM.

Summary: Introduction: acute lower respiratory tract infections (LRTI) are a major health problem in winter. The National Reference Center in Uruguay offers children with LRTI, non-invasive ventilation (NIV) and high-flow nasal cannula (CNAF) in moderate care. Objective: to describe the clinical characteristics, treatment and evolution of the children assisted in Special Respiratory Care Acute (CREA unit), in a national pediatric reference hospital. Patients and methods: retrospective, descriptive study. All children hospitalized for LRTI assisted in CREA who received NIV and / or CNAF between 1/1/13 and 12/31/16 were included in the study. Clinical records were reviewed. Variables: clinical characteristics, treatment, complications, evolution and destination. Results: a total of 650 children were assisted (348 with CNAF, 302 with NIV); male sex 63% (407). Bronchiolitis 63% (406), Respiratory Syncytial Virus (RSV) was detected in 60% (388). Mean age in children receiving CNAF was 11 months (9 days - 108 months); mean duration of technique was 3 days. Required admission to intensive care unit (ICU): 12% (43); invasive ventilation (IV) 6% (22). Mean age in children receiving NIV 12 months (1-132 months); mean duration of technique 3 days. Required admission to the ICU 49 (16%); IV 29 (9.6%). There were no deaths or serious complications. Conclusions: 85% of this group of children completed their treatment in the CREA unit. The percentage of children who required IV was low. The implementation of these techniques in moderate care reduced the need to enter an ICU and the need for IV.

Resumo: Introdução: as infecções respiratórias agudas baixas (IRAB) são um importante problema de saúde no inverno. O centro de referência nacional no Uruguai oferece ventilação não invasiva (NIV) e cânula nasal de alto fluxo (CNAF) em cuidados moderados às crianças com IRAB. Objetivo: descrever as características clínicas, tratamento e evolução das crianças atendidas na Unidade Especial de Tratamento Respiratório Agudo (CREA) do Hospital de Referência Nacional de Pediatria. Pacientes e métodos: estudo retrospectivo, descritivo. No estudo foram incluídas todas as crianças hospitalizadas por causa da IRAB atendidas no CREA que receberam VNI e / ou CNAF entre 1/1/13 e 31/12/16. Foram revisadas as histórias clínicas. Variáveis: características clínicas, tratamentos, complicações, evolução e destino. Resultados: 650 crianças foram atendidas (348 com CNAF, 302 com NIV); sexo masculino 63% (407). Bronquiolite 63% (406), o Vírus Respiratório Sincicial (VRS) foi detectado em 60% (388). Idade média em crianças que receberam CNAF: 11 meses (9 dias-108 meses); Duração média da técnica: 3 dias. Necessidade para admissão nas unidades de terapia intensiva (UTI): 12% (43); assistência ventilatória mecânica (MAV) 6% (22). Idade média em crianças que receberam VNI: 12 meses (1-132 meses); duração média da técnica: 3 dias. Deveram ser admitidos na UTI: 16% (49); AVM 9,6% (29). Nenhuma morte ou complicações sérias foram registradas. Conclusões: 85% das crianças completaram o tratamento na unidade CREA. A porcentagem de crianças que necessitaram de AVM foi baixa. A implementação dessas técnicas em cuidados moderados reduziu a necessidade de internação na UTI e, provavelmente, a necessidade de MAV.

Noninvasive Ventilation During Immediate Postoperative Period in Cardiac Surgery Patients: Systematic Review and Meta-Analysis.

OBJECTIVE: To verify the effectiveness of noninvasive ventilation compared to conventional physiotherapy or oxygen therapy in the mortality rate and prevention of pulmonary complications in patients during the immediate postoperative period of cardiac surgery. METHODS: Systematic review and meta-analysis recorded in the International Prospective Register of Ongoing Systematic Reviews (number CRD42016036441). The research included the following databases: MEDLINE, Cochrane Central, PEDro, LILACS and manual search of the references of studies published until March 2016. The review included randomized controlled trials with patients during the immediate postoperative period of cardiac surgery, which compared the use of noninvasive ventilation, BiLevel modes, continuous positive airway pressure, intermittent positive pressure breathing and positive pressure ventilation with conventional physiotherapy or oxygen therapy, and assessed the mortality rate, occurrence of pulmonary complications (atelectasis, pneumonia, acute respiratory failure, hypoxemia), reintubation rate, ventilation time, time spent in the intensive care unit (ICU), length of hospital stay and partial pressure of oxygen. RESULTS: Among the 479 selected articles, ten were included in the systematic review (n=1050 patients) and six in the meta-analysis. The use of noninvasive ventilation did not significantly reduce the risk for atelectasis (RR: 0.60; CI95% 0.28-1.28); pneumonia (RR: 0.20; CI95% 0.04-1.16), reintubation rate (RR: 0.51; CI95%: 0.15-1.66), and time spent in the ICU (-0.04 days; CI95%: -0.13; 0.05). CONCLUSION: Prophylactic noninvasive ventilation did not significantly reduce the occurrence of pulmonary complications such as atelectasis, pneumonia, reintubation rate and time spent in the ICU. The use is still unproven and new randomized controlled trials should be carried out.

Noninvasive ventilation during immediate postoperative period in cardiac surgery patients: systematic review and meta-analysis

Abstract Objective: To verify the effectiveness of noninvasive ventilation compared to conventional physiotherapy or oxygen therapy in the mortality rate and prevention of pulmonary complications in patients during the immediate postoperative period of cardiac surgery. Methods: Systematic review and meta-analysis recorded in the International Prospective Register of Ongoing Systematic Reviews (number CRD42016036441). The research included the following databases: MEDLINE, Cochrane Central, PEDro, LILACS and manual search of the references of studies published until March 2016. The review included randomized controlled trials with patients during the immediate postoperative period of cardiac surgery, which compared the use of noninvasive ventilation, BiLevel modes, continuous positive airway pressure, intermittent positive pressure breathing and positive pressure ventilation with conventional physiotherapy or oxygen therapy, and assessed the mortality rate, occurrence of pulmonary complications (atelectasis, pneumonia, acute respiratory failure, hypoxemia), reintubation rate, ventilation time, time spent in the intensive care unit (ICU), length of hospital stay and partial pressure of oxygen. Results: Among the 479 selected articles, ten were included in the systematic review (n=1050 patients) and six in the meta-analysis. The use of noninvasive ventilation did not significantly reduce the risk for atelectasis (RR: 0.60; CI95% 0.28-1.28); pneumonia (RR: 0.20; CI95% 0.04-1.16), reintubation rate (RR: 0.51; CI95%: 0.15-1.66), and time spent in the ICU (-0.04 days; CI95%: -0.13; 0.05). Conclusion: Prophylactic noninvasive ventilation did not significantly reduce the occurrence of pulmonary complications such as atelectasis, pneumonia, reintubation rate and time spent in the ICU. The use is still unproven and new randomized controlled trials should be carried out.

Neonatal outcomes based on mode and intensity of delivery room resuscitation.

OBJECTIVE: To examine outcomes of neonates based on the mode and intensity of resuscitation received in the delivery room (DR). STUDY DESIGN: A retrospective study of 439 infants with birth weight ⩽1500 g receiving DR resuscitation at two hospital centers in Philadelphia, Pennsylvania. RESULTS: Of 439 infants, 22 (5%) received routine care, 188 (43%) received noninvasive positive pressure ventilation (PPV) and 229 (52%) received endotracheal tube (ETT) intubation in the DR. Adjusted odds for respiratory distress syndrome was associated with lower rates in infants requiring lower intensity of DR resuscitation (P<0.001). Noninvasive PPV vs ETT was associated with decreased odds of developing intraventricular hemorrhage and retinopathy of prematurity (P<0.05). Routine vs noninvasive PPV or ETT had decreased odds of developing bronchopulmonary dysplasia (P<0.05). CONCLUSION: Decreased intensity of DR resuscitation was associated with a decreased risk of specific morbidities.

Hospitalizaciones por IRAB de probable etiología viral en niños durante el año 2012: estrategia asistencial / Child hospitalizations for acute lower respiratory infections probably caused by virus in 2012: a healthcare strategy

Introducción: en el Hospital Pediátrico del Centro Hospitalario Pereira Rossell (HP-CHPR) durante los meses fríos, las infecciones respiratorias agudas bajas (IRAB) determinan gran demanda asistencial. Para afrontarlas se pone en práctica una estrategia de diagnóstico y tratamiento denominada Plan de Invierno (PI), que se planifica anualmente, en función de las características de los pacientes tratados en años anteriores. Objetivos: describir las características epidemiológicas, clínicas y evolutivas de los niños que requirieron admisión por IRAB en el HP-CHPR durante los meses fríos del 2012 y describir las principales acciones de la estrategia Plan Invierno del año 2012 (PI-2012). Metodología: se describieron las características epidemiológicas, clínicas y evolutivas de los menores de 24 meses que egresaron del HP-CHPR, en el marco de la estrategia PI-2012, por IRAB de probable etiología viral. Se describió las principales acciones de la estrategia de diagnóstico y tratamiento realizada. Resultados: durante el PI-2012 egresaron 887 niños (25,5% de los egresos hospitalarios). La mediana de edad fue 4 meses. Menos de 10% tenía factores de riesgo para enfermedad grave. El virus respiratorio sincitial (VRS) fue el más frecuentemente identificado. Se aplicó un protocolo de diagnóstico y tratamiento. Se pusieron en práctica técnicas especiales de tratamiento en salas de cuidados moderados. Se aplicó ventilación no invasiva (VNI) en 87 niños, con éxito en 80% de los casos. Se realizó oxigenación de alto flujo (OAF) a 22 niños, con éxito en 100%. Requirieron ingreso a terapia intensiva (CTI) 149 niños, 55,7% requirió asistencia ventilatoria mecánica (AVM). Dos pacientes fallecieron en salas de cuidados moderados, cuatro en CTI. Conclusiones: las IRAB representaron una causa muy importante de morbimortalidad durante el período descripto. Los niños que requirieron ingreso hospitalario eran en su mayoría pequeños. Un porcentaje importante cursó una enfermedad grave, requiriendo modalidades especiales de tratamiento. Es importante continuar en la búsqueda de la mejor estrategia terapéutica para estos niños.

Introduction: during the colder months, acute lower respiratory infections (ALRI) determine a considerable increase in the demand for care at the Pereira Rossell Pediatric Hospital (HP-CHPR). In order to respond to such demand the hospital implements a diagnosis and treatment strategy called Winter Plan (WP), which is planned annually based on the characteristics of patients treated in previous years. Objectives: to describe the epidemiological and clinical characteristics and evolution of children with ALRI who required hospitalization in the HP-CHPR during the cold months of 2012, and to describe the main actions of the 2012 Winter Plan strategy (2012 WP). Methodology: epidemiological, clinical and evolution characteristics of children under 24 months discharged from HP-CHPR within the 2012WP strategy were described. The strategy’s main action for diagnosis and treatment were described. Results: 887 children were discharged during the 2012 WP strategy, representing 25.5% of hospital discharges. Median age was 4 months. Less than 10% presented risk factors for severe disease. Respiratory syncytial virus (RSV) was the most frequently identified virus. A protocol for diagnosis and treatment was applied. Special techniques for treatment were implemented in transitional care rooms. 87 children were administered non-invasive ventilation, which was successful in 80% of cases. High-flow oxygen was used in 22 children, being this successful in all patients. 149 children required admission to intensive care unit (ICU) , 55.7% needed mechanical ventilation assistance. Two patients died in the medium unit and four in the ICU. Conclusions: ALRI represent a major cause of morbidity and mortality during the period described . Most children who required hospitalization were young. A significant percentage presented a severe disease, requiring special treatment modalities. It is important to continue searching for the best therapeutic strategy for these children.

Estudio comparativo de dos modos de ventilación no invasiva para retirar la asistencia respiratoria mecánica en lactantes post-operatorios de cirugía cardiovascular / Comparative study of two modalities of non-invasive ventilation for the weaning from mechanical ventilation of post-cardiovascular surgery infants

La mejor estrategia en el post-quirúrgico de cardiopatías congénitas para promover la extubación precoz y destete de asistencia respiratoria mecánica (ARM) con ventilación no invasiva (VNI) todavía no ha sido establecida. El objetivo es comparar eficacia de la presión positiva continua en la vía aérea (CPAP) vs presión positiva con dos niveles en la vía aérea (BIPAP) en la extubación electiva de estos pacientes. Es un estudio prospectivo entre el 1 de junio de 2008 y 31 marzo de 2010. Se randomizaron los pacientes para extubación electiva: modo CPAP o BIPAP. Se registraron datos demográficos y del procedimiento quirúrgico, entre otros. El fracaso de VNI fue definido como reintubación dentro de las 72 hs posteriores a la extubación o más de un criterio de intubación. Durante el periodo de estudio 1438 pacientes fueron admitidos en UCI35. En el grupo BIPAP se randomizaron 53 pacientes, de los cuales se extubaron exitosamente 49 (92%), pero 4 se reintubaron debido a falla cardiaca. En el grupo CPAP se randomizaron 46 y fallaron en la extubación 18 (39%) debido a múltiples episodios de desaturación y apneas. De éstos, 11 requirieron reintubación endotraqueal y ARM. En 7 pacientes, se pasó a modo BIPAP y permanecieron extubados, aunque el cruzamiento no fue parte del diseño de este estudio. En el destete de ARM de los pacientes post-quirúrgicos de cardiopatías congénitas, el uso de BIPAP fue más efectivo que CPAP. En esta última modalidad se presentaron mayor número de fracasos de VNI (AU)

The best strategy for early extubation and weaning from mechanical respiration (MV) with non-invasive ventilation (NIV) in post-surgical congenital heart defect patients has not been established yet. The aim of this study was to compare the efficacy of continuous positive airway pressure CPAP) vs bi-level positive airway pressure (BIPAP) in the elective extubation of these patients. A prospective study was conducted between June 1, 2008 and March 31, 2010. Patients that were candidates for elective extubation were randomized to CPAP or BIPAP. Data on demographics and surgical procedure, among others, were recorded. Failure of NIV was defined as the need for reintubation within 72 hours after extubation or more than one criterion for intubation. Over the study period, 1438 patients were admitted to ICU 35. Fifty-three patients were randomized to BIPAP, of whom 49 (92%) were successfully extubated; however, four were reintubated due to heart failure. Forty-six patients were randomized to CPAP. Extubation failed in 18 (39%) due to multiple episodes of desaturation and apneas. Eleven of 18 required endotracheal reintubation and mechanical ventilation. Seven patients were switched to BIPAP and remained extubated, although the switch was not part of the study design. In the weaning of post-surgical congenital heart defect patients from MV, BIPAP was more effective than CPAP. In the latter modality, the incidence of NIV failure was higher (AU)

Ventilación no invasiva en menores de dos años internados en sala con infección respiratoria aguda baja. Posibles factores predictivos de éxito y de fracaso / Non invasive ventilation in children under two years interned in room with acute lower respiratory infection. Possible predictors of success and failure

Objetivos: describir los resultados de la aplicación de ventilación no invasiva en los años 2009 y 2010 en niños menores de dos años con infección respiratoria aguda baja y analizar posibles factores predictivos de éxito o fracaso. Diseño: observacional, prospectivo, analítico. Población: menores de 2 años cursando IRAB con insuficiencia respiratoria y escore de Tal >= 8, o Tal >= 6 sin respuesta al tratamiento. Se excluyeron aquellos con peso < 7 kg, hemodinamia inestable, depresión neuropsíquica, neumotórax, neumomediastino y/oacidosis mixta. Resultados: se incluyeron 185 niños, mediana de edad 9 meses, peso promedio 8,6 kg. Se constató éxito en 151 niños (81,6%). No se observaron diferencias estadísticamente significativas en la edad, peso y severidad al ingreso entre el grupo de niñoscon éxito versus fracaso terapéutico. A las 2 horas la frecuencia respiratoria (FR) mayor a 60 rpm, la frecuencia cardíaca (FC) mayor 140 cpm y la presión de soporte mayor a 9 se asoció con fracaso (p<0,05).El análisis multivariado mostró que a las 2 h la FR > 60rpm incrementó el riego de fracaso 6.4 veces (IC951,9–21,7); la FC > 140 cpm 4,3 (IC95 1,5-11,8) y la PS>9 lo incrementó 8,7 veces (IC95 2,3-32,2). Conclusión: el aumento de la FR, la FC y la PS a las 2 horas constituyen posibles factores predictivos de fracaso terapéutico. Futuras investigaciones son necesarias para confirmar estos hallazgos e individualizar las indicaciones de esta técnica en estos pacientes.

Ventilación no invasiva en menores de dos años internados en sala con infección respiratoria aguda baja. Posibles factores predictivos de éxito y de fracaso / Non invasive ventilation in children under two years interned in room with acute lower respiratory infection. Possible predictors of success and failure

Objetivos: describir los resultados de la aplicación de ventilación no invasiva en los años 2009 y 2010 en niños menores de dos años con infección respiratoria aguda baja y analizar posibles factores predictivos de éxito o fracaso. Diseño: observacional, prospectivo, analítico. Población: menores de 2 años cursando IRAB con insuficiencia respiratoria y escore de Tal >= 8, o Tal >= 6 sin respuesta al tratamiento. Se excluyeron aquellos con peso < 7 kg, hemodinamia inestable, depresión neuropsíquica, neumotórax, neumomediastino y/oacidosis mixta. Resultados: se incluyeron 185 niños, mediana de edad 9 meses, peso promedio 8,6 kg. Se constató éxito en 151 niños (81,6%). No se observaron diferencias estadísticamente significativas en la edad, peso y severidad al ingreso entre el grupo de niñoscon éxito versus fracaso terapéutico. A las 2 horas la frecuencia respiratoria (FR) mayor a 60 rpm, la frecuencia cardíaca (FC) mayor 140 cpm y la presión de soporte mayor a 9 se asoció con fracaso (p<0,05).El análisis multivariado mostró que a las 2 h la FR > 60rpm incrementó el riego de fracaso 6.4 veces (IC951,9–21,7); la FC > 140 cpm 4,3 (IC95 1,5-11,8) y la PS>9 lo incrementó 8,7 veces (IC95 2,3-32,2). Conclusión: el aumento de la FR, la FC y la PS a las 2 horas constituyen posibles factores predictivos de fracaso terapéutico. Futuras investigaciones son necesarias para confirmar estos hallazgos e individualizar las indicaciones de esta técnica en estos pacientes.

Uso de VNI en una unidad de cuidados intensivos cardiovasculares pediátricos. Factores de riesgo asociados al fracaso / Use of NIV in a pediatric cardiovascular intensive care unit. Risk factors associated with failure

Objetivo: Describir el uso de Ventilación No Invasiva (VNI) en pacientes internados en una Unidad de Cuidados Intensivos (UCI) cardiovascular (CCV) pediátrica e identificar factores de riesgo que lleven al fracaso, definido como requerimiento de ARM a las 72 hs. Diseño: Estudio observacional analítico, de cohorte retrospectiva. Material y Método: Se estudiaron 340 niños internados en UCI 35 del Hospital Garrahan durante el período 2005-2008 con indicación de VNI por insuficiencia cardiaca (IC), como rescate en el fallo post-extubación y como destete de ARM: se registraron datos demográficos, período pre (PREQ) o postquirúrgico (POP), tipo de interfase, la presencia de atelectasias (ATL), paresia diafragmática (PD), hipertensión pulmonar (HTP), infecciones, defecto residual quirúrgico (DR), lesiones cutáneas (LC), disfunción ventricular (DV), síndromes genéticos (SG), y obstrucción de vías aéreas superiores (VAS), tiempo de exposición a la VNI y fracaso de la VNI. Se utilizó fuente de datos primarios, las variables continuas fueron tratadas con Test de Student o Wilcoxon de acuerdo a su distribución, las variables categóricas con Chi2, se realizó análisis de regresión logística univariado (ARLU) con Wald Test y para el control simultáneo de confundidores, análisis de regresión logística multivariado (ARLM). En todos los casos se tomó como punto de corte 0,05 para asociación estadísticamente significativa (AES). Resultados: Se estudiaron 182 niñas y 158 varones, edad mediana 4,2 meses (r 0,5-216), peso mediana 4,7 kilos(r 2- 64). En el período prequirúrgico (PREQ) 20 y 320 en post quirúrgico(POP). La indicación más frecuente: destete en un 86,76%, la interfase más utilizada fue la cánula nasal (CN) 99,71%, el tiempo de VNI fue de 1 a 11 días con una mediana de 2 días. Se presentaron lesiones cutáneas en un 5,29% y se consideró fracaso en un 17,65%. En el modelo de regresión logística multivariado (MRLM), fueron identificadas como factores de riesgo de fracaso: ATL OR: 2,99 (IC 95%1,23-7,25); edad<=6meses OR: 3,50 (IC95% 1,59-7,73); infecciones OR: 6,93 (IC95% 1,77-27,14); DV, OR: 10,88 (IC 95% 4,44-26,68); el tener obstrucción de VAS OR: 11,66 (IC 95% 4,47-26,68) Conclusiones: Los factores de riesgo que explicaron el fracaso de la VNI en el MRLM fueron la presencia de atelectasia, la edad menor o igual a seis meses, las comorbilidades infecciosas, así como la disfunción ventricular y la obstrucción de VAS. Si bien faltan aún estudios controlados en pediatría, la consideramos una alternativa terapéutica de soporte respiratorio útil y en expansión tanto en el periodo pre como en el post quirúrgico de CCV pediátrica y neonatal (AU)

Objective: To assess the use of non-invasive ventilation (NIV) in patients in the pediatric cardiovascular intensive care unit (ICU) and to identify risk factors that lead to failure, defined as need for mechanical respiratory assistance within 72 hours. Study design: An observational analytical retrospective cohort study. Material and Methods: We studied 340 children with heart failure hospitalized in the ICU 35 of the Garrahan Hospital between 2005 and 2008 who needed NIV as rescue therapy for post-extubation failure and weaning from mechanical respiration. Demographic data, pre- or postsurgical period, type of interface, presence of atelectasis, diaphragmatic paresis, pulmonary hypertension, infections, residual defect, skin lesions, ventricular dysfunction, genetic syndromes, and upper respiratory tract obstruction, time of NIV exposure and NIV failure were recorded. A primary data source was used. According to their distribution, the continuous variables were analyzed uzing the Student's t test or the Wilcoxon test and for categorical variables the Chi-square test was used. Univariate logistic regression analysis was performed using the Wald Test and multivariate logistic regression analysis was done to simultaneously control for confounding factors. In all cases, p< 0.05 was considered as statistically significant. Results: 182 girls and 158 boys with a mean age of 4.2 months (r 0.5-216) and a mean weight of 4.7 kg (r 2- 64) were studied. The period was presurgical in 10 and postsurgical in 320. The most frequent indication was weaning (86.76%), the most-frequently used interface was a nasal tube (99.71%), and time on NIV was between 1 and 11 days with a median of 2 days. Skin lesion were observed in 5.29% and NIV was considered a failure in 17.65%. In the model of multivariate logistic regression the following risk factors were identified: atelectasis, OR: 2.99 (95% CI 1.23-7.25); age ≤ 6 months OR: 3.50 (95% CI 1.59- 7.73); infections, OR: 6.93 (95% CI 1.77-27.14); ventricular dysfunction, OR: 10.88 (95% CI 4.44-26.68); upper respiratory tract obstruction, OR: 11,66 (95% CI 4.47-26.68). Conclusions: Risk factors for NIV failure found with the multivariate logistic regression model were the presence of atelectasis, age ≤ 6 months, infectious comorbidities, as well as ventricular dysfunction and upper respiratory tract obstruction. Although controlled trials are lacking in the pediatric population, we consider NIV to be a useful therapeutic alternative for respiratory support both pre- and postsurgically in pediatric and neonatal cardiovascular disease (AU)