Fitness checklist model for spontaneous breathing tests in pediatrics.

OBJECTIVE: To evaluate whether a model of a daily fitness checklist for spontaneous breathing tests is able to identify predictive variables of extubation failure in pediatric patients admitted to a Brazilian intensive care unit. METHODS: This was a single-center, cross-sectional study with prospective data collection. The checklist model comprised 20 items and was applied to assess the ability to perform spontaneous breathing tests. RESULTS: The sample consisted of 126 pediatric patients (85 males (67.5%)) on invasive mechanical ventilation, for whom 1,217 daily assessments were applied at the bedside. The weighted total score of the prediction model showed the highest discriminatory power for the spontaneous breathing test, with sensitivity and specificity indices for fitness failure of 89.7% or success of 84.6%. The cutoff point suggested by the checklist was 8, with a probability of extubation failure less than 5%. Failure increased progressively with increasing score, with a maximum probability of predicting extubation failure of 85%. CONCLUSION: The extubation failure rate with the use of this model was within what is acceptable in the literature. The daily checklist model for the spontaneous breathing test was able to identify predictive variables of failure in the extubation process in pediatric patients.

Fitness checklist model for spontaneous breathing tests in pediatrics / Modelo de checklist de, aptidão para teste de respiração espontânea em pediatria

ABSTRACT Objective: To evaluate whether a model of a daily fitness checklist for spontaneous breathing tests is able to identify predictive variables of extubation failure in pediatric patients admitted to a Brazilian intensive care unit. Methods: This was a single-center, cross-sectional study with prospective data collection. The checklist model comprised 20 items and was applied to assess the ability to perform spontaneous breathing tests. Results: The sample consisted of 126 pediatric patients (85 males (67.5%)) on invasive mechanical ventilation, for whom 1,217 daily assessments were applied at the bedside. The weighted total score of the prediction model showed the highest discriminatory power for the spontaneous breathing test, with sensitivity and specificity indices for fitness failure of 89.7% or success of 84.6%. The cutoff point suggested by the checklist was 8, with a probability of extubation failure less than 5%. Failure increased progressively with increasing score, with a maximum probability of predicting extubation failure of 85%. Conclusion: The extubation failure rate with the use of this model was within what is acceptable in the literature. The daily checklist model for the spontaneous breathing test was able to identify predictive variables of failure in the extubation process in pediatric patients.

RESUMO Objetivo: Avaliar se um modelo de checklist diário de aptidão para o teste de respiração espontânea é capaz de identificar variáveis preditivas de falha no processo de extubação em pacientes pediátricos internados em uma unidade de terapia intensiva brasileira. Métodos: Estudo unicêntricotransversal, com coleta prospectiva de dados. O modelo de checklist foi elaborado com 20 itens e aplicado para avaliação de aptidão para o teste de respiração espontânea. Resultados: A amostra foi composta de 126 pacientes pediátricos em ventilação mecânica invasiva, 85 do sexo masculino (67,5%), para os quais foram aplicadas 1.217 avaliações diárias à beira do leito. A pontuação total ponderada do modelo de predição apresentou o maior poder de discriminação para a realização do teste de respiração espontânea, com índices de sensibilidade e especificidade para a falha de aptidão de 89,7% ou sucesso de 84,6%. O ponto de corte sugerido pelo checklist foi 8, com probabilidade de falha de extubação inferior a 5%. Observou-se que a falha aumentou progressivamente com o aumento da pontuação obtida, com probabilidade máxima de predição de falha de extubação de 85%. Conclusão: A taxa de falha de extubação com a utilização desse modelo ficou dentro do que é aceitável na literatura. O modelo de checklist diário para aptidão do teste de respiração espontânea foi capaz de identificar variáveis preditivas de falha no processo de extubação em pacientes pediátricos.

High flow nasal cannula in asthmatic children with suspected COVID-19 / Cânula nasal de alto fluxo em crianças asmáticas com suspeita de COVID-19

Abstract Introduction: The use of a high-flow nasal cannula as an alternative treatment for acute respiratory failure can reduce the need for invasive mechanical ventilation and the duration of hospital stays. Objective: The present study aimed to describe the use of a high-flow nasal cannula in pediatric asthmatic patients with acute respiratory failure and suspected COVID-19. Methods: To carry out this research, data were collected from medical records, including three patients with asthma diagnoses. The variables studied were: personal data (name, age in months, sex, weight, and color), clinical data (physical examination, PRAM score, respiratory rate, heart rate, and peripheral oxygen saturation), diagnosis, history of the current disease, chest, and laboratory radiography (arterial blood gases and reverse-transcriptase polymerase chain reaction). Clinical data were compared before and after using a high-flow nasal cannula. Results: After the application of the therapy, a gradual improvement in heart, respiratory rate, PaO2/FiO2 ratio, and the Pediatric Respiratory Assessment Measure score was observed. Conclusion: The simple and quick use of a high-flow nasal cannula in pediatric patients with asthma can be safe and efficient in improving their respiratory condition and reducing the need for intubation.

Resumo Introdução: A utilização da cânula nasal de alto fluxo como alternativa de tratamento para a insuficiência respiratória aguda pode diminuir a necessidade de utilização de ventilação mecânica invasiva e reduzir os dias de internamento. Objetivo: Descrever a utilização da cânula nasal de alto fluxo em pacientes pediátricos asmáticos com insuficiência respiratória aguda e suspeita de COVID-19. Métodos: Para a realização dessa pesquisa foram coletados dados de prontuários, sendo três pacientes com diagnóstico de asma incluídos. As variáveis estudadas foram: dados pessoais (nome, idade em meses, sexo, peso e cor) e clínicos (exame físico, PRAM Escore, frequência respiratória, frequência cardíaca, e saturação periférica de oxigênio), diagnóstico, história da moléstia atual, radiografia de tórax e exames laboratoriais (gasometria arterial e Reverse-Transcriptase Polymerase Chain Reaction). Foram comparados dados clínicos antes e após a utilização da cânula nasal de alto fluxo. Resultados: Após a aplicação da terapia foi possível observar melhora gradativa da frequência cardíaca e respiratória, relação PaO2/FiO2 e do escore Pediatric Respiratory Assessment Measure. Conclusão: A utilização simples e rápida da cânula nasal de alto fluxo em pacientes pediátricos com asma pode ser segura e eficiente para melhora do quadro respiratório, diminuindo a necessidade de intubação.

Atelectasis and lung changes in preterm neonates in the neonatal period: a blind radiological report and clinical findings. / Atelectasia e alterações pulmonares em recém-nascidos prematuros no período neonatal: laudo radiológico cego e achados clínicos.

OBJECTIVE: To determine the occurrence and characteristics of atelectasis, opacities, hypolucency and pulmonary infiltrates observed on chest X-rays of preterm infants in a neonatal intensive care unit. METHODS: This was a cross-sectional observational study. From August to December 2017, all chest radiographs of newborn infants were analyzed. The study included the chest radiographs of preterm neonates with gestational ages up to 36 weeks in the neonatal period that showed clear changes or suspected changes, which were confirmed after a radiologist's report. Radiological changes were associated with possible predisposing factors. RESULTS: During the study period, 450 radiographs were performed on preterm neonates, and 37 lung changes were identified and classified into 4 types: 12 (2.66%) changes were described as opacities, 11 (2.44%) were described as atelectasis, 10 (2.22%) were described as pulmonary infiltrate, and 4 (0.88%) were described as hypolucency. A higher occurrence of atelectasis was noted in the right lung (81.8%). Among the abnormal radiographs, 25 (67.6%) newborn infants were receiving invasive mechanical ventilation. CONCLUSION: Considering the radiological report, no significance was found for the observed changes. Atelectasis was not the most frequently observed change. The predisposing factors for these changes were extreme prematurity, low weight, male sex, a poorly positioned endotracheal tube and the use of invasive mechanical ventilation.

OBJETIVO: Verificar a ocorrência e as características de atelectasias, opacidades, hipotransparências e infiltrados pulmonares evidenciados ao raio X de tórax dos recém-nascidos prematuros, de uma unidade de terapia intensiva neonatal. MÉTODOS: Trata-se de estudo observacional transversal. No período de agosto a dezembro de 2017 foram analisadas todas as radiografias de tórax de recém-nascidos. Foram incluídas no estudo as radiografias de tórax de recém-nascidos prematuros com idade gestacional até 36 semanas, no período neonatal que apresentassem alterações evidentes na imagem ou suspeita de alterações, que fossem confirmadas após laudo do médico radiologista. As alterações radiológicas foram associadas com possíveis fatores predisponentes. RESULTADOS: No período, foram realizadas 450 radiografias nos recém-nascidos prematuros, sendo que, em 37, foram descritas quatro alterações: 12 (2,66%) descritas como opacidades, 11 (2,44%) como atelectasias, 10 (2,22%) como infiltrados pulmonares e 4 (0,88%) como hipotransparências. Observou-se maior ocorrência das atelectasias no pulmão direito (81,8%). Dentre as radiografias com alterações, 25 (67,6%) recém-nascidos estavam sob o uso da ventilação mecânica invasiva. CONCLUSÃO: Considerando o laudo radiológico, as alterações observadas têm ocorrências sem diferença estatisticamente significante. A atelectasia não foi a alteração mais encontrada. Os fatores que podem ter predisposto ao aparecimento das alterações foram a prematuridade extrema, o baixo peso, o sexo masculino, o mal posicionamento da cânula endotraqueal e o uso de ventilação mecânica invasiva.

Atelectasia e alterações pulmonares em recém-nascidos prematuros no período neonatal: laudo radiológico cego e achados clínicos / Atelectasis and lung changes in preterm neonates in the neonatal period: a blind radiological report and clinical findings

RESUMO Objetivo: Verificar a ocorrência e as características de atelectasias, opacidades, hipotransparências e infiltrados pulmonares evidenciados ao raio X de tórax dos recém-nascidos prematuros, de uma unidade de terapia intensiva neonatal. Métodos: Trata-se de estudo observacional transversal. No período de agosto a dezembro de 2017 foram analisadas todas as radiografias de tórax de recém-nascidos. Foram incluídas no estudo as radiografias de tórax de recém-nascidos prematuros com idade gestacional até 36 semanas, no período neonatal que apresentassem alterações evidentes na imagem ou suspeita de alterações, que fossem confirmadas após laudo do médico radiologista. As alterações radiológicas foram associadas com possíveis fatores predisponentes. Resultados: No período, foram realizadas 450 radiografias nos recém-nascidos prematuros, sendo que, em 37, foram descritas quatro alterações: 12 (2,66%) descritas como opacidades, 11 (2,44%) como atelectasias, 10 (2,22%) como infiltrados pulmonares e 4 (0,88%) como hipotransparências. Observou-se maior ocorrência das atelectasias no pulmão direito (81,8%). Dentre as radiografias com alterações, 25 (67,6%) recém-nascidos estavam sob o uso da ventilação mecânica invasiva. Conclusão: Considerando o laudo radiológico, as alterações observadas têm ocorrências sem diferença estatisticamente significante. A atelectasia não foi a alteração mais encontrada. Os fatores que podem ter predisposto ao aparecimento das alterações foram a prematuridade extrema, o baixo peso, o sexo masculino, o mal posicionamento da cânula endotraqueal e o uso de ventilação mecânica invasiva.

ABSTRACT Objective: To determine the occurrence and characteristics of atelectasis, opacities, hypolucency and pulmonary infiltrates observed on chest X-rays of preterm infants in a neonatal intensive care unit. Methods: This was a cross-sectional observational study. From August to December 2017, all chest radiographs of newborn infants were analyzed. The study included the chest radiographs of preterm neonates with gestational ages up to 36 weeks in the neonatal period that showed clear changes or suspected changes, which were confirmed after a radiologist's report. Radiological changes were associated with possible predisposing factors. Results: During the study period, 450 radiographs were performed on preterm neonates, and 37 lung changes were identified and classified into 4 types: 12 (2.66%) changes were described as opacities, 11 (2.44%) were described as atelectasis, 10 (2.22%) were described as pulmonary infiltrate, and 4 (0.88%) were described as hypolucency. A higher occurrence of atelectasis was noted in the right lung (81.8%). Among the abnormal radiographs, 25 (67.6%) newborn infants were receiving invasive mechanical ventilation. Conclusion: Considering the radiological report, no significance was found for the observed changes. Atelectasis was not the most frequently observed change. The predisposing factors for these changes were extreme prematurity, low weight, male sex, a poorly positioned endotracheal tube and the use of invasive mechanical ventilation.

Effectiveness of Hammock Positioning in Reducing Pain and Improving Sleep-Wakefulness State in Preterm Infants.

BACKGROUND: Hammock positioning is now frequently used with preterm infants admitted to ICUs. However, few studies have investigated the extent to which hammock positioning reduces pain and improves the sleep-wakefulness state compared with traditional positioning. METHODS: Twenty-six clinically stable newborns with gestational ages from 30 to 37 weeks who were breathing spontaneously were randomly assigned to 2 groups: a hammock-positioning group (n = 13), in which newborns were placed in hammocks in the lateral position, and a traditional-positioning group (n = 13), in which they were kept nested, also in the lateral position. The following variables were evaluated at the beginning and the end of the treatment: pain (with the Premature Infant Pain Profile, and Neonatal Facial Coding System), sleep-wakefulness state (with the Brazelton Neonatal Behavioral Assessment Scale), heart rate, breathing frequency, and peripheral SpO2 . RESULTS: The subjects in the hammock-positioning group showed an improvement in pain compared with the traditional-positioning group(Premature Infant Pain Profile score, 2.62 ± 1.89 vs 2.31 ± 1.97, ΔP = .008) and sleep-wakefulness state score (2.08 ± 0.64 vs 1.23 ± 0.44, Δ P < .001), reduced heart rate (151.69 ± 5.44 vs 142.77 ± 5.18 beats/min, Δ P < .001), breathing frequency (52.31 ± 4.05 vs 50.23 ± 2.55 beats/min, Δ P = .024), and increased peripheral SpO2 (94.69 ± 2.14 vs 98.00 ± 1.22%, Δ P < .001). CONCLUSIONS: Hammock positioning was an effective treatment option to reduce pain and improve sleep-wakefulness state. It also helped to reduce heart rate and breathing frequency, and to increase peripheral SpO2 , which made it a treatment option for preterm infants.

A manobra de recrutamento alveolar em crianças submetidas à ventilação mecânica em unidade de terapia intensiva pediátrica / Alveolar recruitment maneuver in mechanic ventilation pediatric intensive care unit children

Recentes mudanças foram introduzidas na forma de ventilar crianças com doenças que determinam o quadro de insuficiência respiratória aguda hipoxêmica. Há evidências que estratégias ventilatórias menos agressivas, melhoram a sobrevida de pacientes com grave lesão pulmonar. Estudos experimentais evidenciaram relação entre modalidades ventilatórias inapropriadas e retardo na melhora e até mesmo piora da lesão pulmonar aguda. A partir desta concepção, surge uma estratégia ventilatória protetora, combinada à manobra de recrutamento alveolar. Acredita-se, que esta associação na prática clínica, determina importante redução da morbidade e mortalidade, bem como, prevenção das lesões induzidas pela ventilação mecânica. Sua indicação relaciona-se com quadros de lesão pulmonar aguda, geralmente decorrente de pneumonia ou sepse, que cursam com grave hipoxemia. Suas principais contra-indicações são instabilidade hemodinâmica, presença de pneumotórax e hipertensão intracraniana. Estudos experimentais demonstraram efeitos benéficos da manobra sobre a oxigenação e colapso alveolar. Estudos em adultos demonstraram melhora da função pulmonar e reversão da hipoxemia. Em crianças, a manobra demonstrou significativa redução da fração inspirada de oxigênio e do colapso alveolar, menor dependência ao oxigênio, melhora da complacência pulmonar e menor índice de displasia broncopulmonar. Porém, os estudos em pediatria são limitados. Faz-se necessária maior investigação sobre o tema e evidências de sua aplicação clínica. Foi realizada revisão da literatura, com pesquisa de livros-texto e nas bases de dados da MEDLINE, Pubmed, Cochrane library, SciELO e Ovid, no período de 1998 até 2009, em português e inglês. Foram incluídas publicações acerca da manobra de recrutamento alveolar em adultos e crianças, artigos de revisão, estudos experimentais e ensaios clínicos utilizando as palavras-chave: estratégia ventilatória protetora, manobra de recrutamento alveolar, pediatria ...

Recent changes were introduced in acute hypoxemic respiratory failure children ventilation methods. There are evidences that less aggressive ventilation strategies can improve severe pulmonary injury survival. Experimental trials evidenced a relationship between inappropriate ventilatory measures and delayed acute pulmonary injury improvement, or even worsening. From this, a protective ventilatory measure arises in combination with alveolar recruitment maneuver. This association is believed in clinical practice to determine importantly reduced morbidity and mortality as well as reduced mechanic ventilation-induced injuries. It is indicated for acute lung injury patients, generally from pneumonia or sepsis, with severe hypoxemia. Its main contraindications are homodynamic instability, pneumothorax and intracranial hypertension. Experimental trials showed beneficial maneuver effects on both oxygenation and alveolar collapse. Adult studies showed improved pulmonary function with hypoxemia reversion. In children, the maneuver lead to significant inspired oxygen fraction and alveolar collapse reductions, less oxygen dependency, improved pulmonary complacency, and reduced bronchopulmonary dysplasia. However, studies in children are limited. Additional investigation is warranted on this matter, and its clinical application evidence. A literature review was conducted based on textbooks and MEDLINE, Pubmed, Cochrane library, SciELO, and Ovid databases, from 1998 to 2009, both in Portuguese and English. Publications on alveolar recruitment maneuver both in adults and children, review articles, experimental and clinical trials were included using the key words: protective ventilatory strategy, alveolar recruitment maneuver, pediatrics and mechanic ventilation.

Alveolar recruitment maneuver in mechanic ventilation pediatric intensive care unit children. / A manobra de recrutamento alveolar em crianças submetidas à ventilação mecânica em unidade de terapia intensiva pediátrica.

Recent changes were introduced in acute hypoxemic respiratory failure children ventilation methods. There are evidences that less aggressive ventilation strategies can improve severe pulmonary injury survival. Experimental trials evidenced a relationship between inappropriate ventilatory measures and delayed acute pulmonary injury improvement, or even worsening. From this, a protective ventilatory measure arises in combination with alveolar recruitment maneuver. This association is believed in clinical practice to determine importantly reduced morbidity and mortality as well as reduced mechanic ventilation-induced injuries. It is indicated for acute lung injury patients, generally from pneumonia or sepsis, with severe hypoxemia. Its main contraindications are homodynamic instability, pneumothorax and intracranial hypertension. Experimental trials showed beneficial maneuver effects on both oxygenation and alveolar collapse. Adult studies showed improved pulmonary function with hypoxemia reversion. In children, the maneuver lead to significant inspired oxygen fraction and alveolar collapse reductions, less oxygen dependency, improved pulmonary complacency, and reduced bronchopulmonary dysplasia. However, studies in children are limited. Additional investigation is warranted on this matter, and its clinical application evidence. A literature review was conducted based on textbooks and MEDLINE, Pubmed, Cochrane library, SciELO, and Ovid databases, from 1998 to 2009, both in Portuguese and English. Publications on alveolar recruitment maneuver both in adults and children, review articles, experimental and clinical trials were included using the key words: protective ventilatory strategy, alveolar recruitment maneuver, pediatrics and mechanic ventilation.