Caracterización de las infecciones en niños portadores de cánula de traqueotomía: revisión sistemática de la literatura / Characterization of infections in children with Tracheostomy Tube: A Systematic Review of the Literature

Resumen Introducción: actualmente los profesionales de la salud se enfrentan al manejo de las vías aéreas artificiales en grupos pediátricos, esto requiere de cuidados delicados y mucha atención para detectar, establecer y manejar situaciones apremiantes; por esta razón, existe un mayor riesgo de aparición de infecciones bacterianas traqueopulmonares. El objetivo del estudio fue analizar la caracterización de las infecciones en pacientes pediátricos portadores de cánula de traqueotomía en las diferentes publicaciones científicas. Materiales y métodos: se realizó una revisión sistemática mediante la búsqueda de la literatura existente entre los años 2015-2020 en las bases de datos Elsevier, PubMed, Google Académico y SciELO, teniendo en cuenta los criterios de inclusión artículos en idioma inglés, español y población de edad entre los 0-15 años con infección de cánula de traqueotomía en los años 2015-2020. Resultados: de 258 artículos distribuidos en las bases de datos, se seleccionaron 21 artículos que cumplían con los criterios de inclusión. Conclusiones: a pesar de que en la actualidad existan criterios clínicos, factores de riesgo y pruebas de laboratorio asociados a infecciones de la cánula postraqueotomía en pacientes pediátricos, se requiere mayor investigación para definir las guías clínicas de manejo en la toma de decisiones médicas. Asimismo, se consideró como limitación importante la cantidad de literatura existente con respecto al tema.

Abstract Introduction: Currently, health professionals face the management of artificial airways in pediatric groups, this requires delicate care and a lot of attention to detect, establish and manage pressing situations, which is why there is a greater risk of tracheo-pulmonary bacterial infections. The objective was to analyze the characterization of infections in pediatric patients with tracheostomy tubes in the different scientific publications. Method: A systematic review of the literature was carried out between the years 2015-2020 in Elsevier, PubMed, Google Academic and SciELO databases, taking into account the inclusion criteria of the population aged 0-15 years in the years 2015-2020. The amount of existing literature on the subject was considered an important limitation. Results: From 258 articles distributed in the databases, 21 articles were selected that met the inclusion criteria. Conclusions: Although there are currently clinical criteria, risk factors and laboratory tests associated with infections of the post-tracheotomy tube in pediatric patients, further research is required to define clinical guidelines for management in medical decision-making.

Antibiotic therapy in ventilator-associated tracheobronchitis: a literature review. / Terapêutica antibiótica na traqueobronquite associada à ventilação mecânica: uma revisão da literatura.

The concept of ventilator-associated tracheobronchitis is controversial; its definition is not unanimously accepted and often overlaps with ventilator-associated pneumonia. Ventilator-associated tracheobronchitis has an incidence similar to that of ventilator-associated pneumonia, with a high prevalence of isolated multiresistant agents, resulting in an increase in the time of mechanical ventilation and hospitalization but without an impact on mortality. The performance of quantitative cultures may allow better diagnostic definition of tracheobronchitis associated with mechanical ventilation, possibly avoiding the overdiagnosis of this condition. One of the major difficulties in differentiating between ventilator-associated tracheobronchitis and ventilator-associated pneumonia is the exclusion of a pulmonary infiltrate by chest radiography; thoracic computed tomography, thoracic ultrasonography, or invasive specimen collection may also be required. The institution of systemic antibiotic therapy does not improve the clinical impact of ventilator-associated tracheobronchitis, particularly in reducing time of mechanical ventilation, hospitalization or mortality, despite the possible reduced progression to ventilator-associated pneumonia. However, there are doubts regarding the methodology used. Thus, considering the high prevalence of tracheobronchitis associated with mechanical ventilation, routine treatment of this condition would result in high antibiotic usage without clear benefits. However, we suggest the institution of antibiotic therapy in patients with tracheobronchitis associated with mechanical ventilation and septic shock and/or worsening of oxygenation, and other auxiliary diagnostic tests should be simultaneously performed to exclude ventilator-associated pneumonia. This review provides a better understanding of the differentiation between tracheobronchitis associated with mechanical ventilation and pneumonia associated with mechanical ventilation, which can significantly decrease the use of antibiotics in critically ventilated patients.

Terapêutica antibiótica na traqueobronquite associada à ventilação mecânica: uma revisão da literatura / Antibiotic therapy in ventilator-associated tracheobronchitis: a literature review

RESUMO O conceito de traqueobronquite associada à ventilação mecânica é controverso, e sua definição não é unanimemente aceita, sobrepondo-se, muitas vezes, à da pneumonia associada à ventilação mecânica. A traqueobronquite associada à ventilação mecânica tem incidência semelhante à da pneumonia associada à ventilação mecânica, com elevada prevalência de agentes multirresistentes isolados, condicionando um aumento do tempo de ventilação mecânica e de internação, ainda que sem impacto na mortalidade. A realização de culturas quantitativas pode permitir melhor definição diagnóstica da traqueobronquite associada à ventilação mecânica, possivelmente evitando o sobrediagnóstico desta entidade. Uma das maiores dificuldades na diferenciação entre traqueobronquite associada à ventilação mecânica e pneumonia associada à ventilação mecânica reside na exclusão de um infiltrado pulmonar por meio da radiografia do tórax; também podem ser necessárias a tomografia computadorizada torácica, a ultrassonografia torácica ou ainda a colheita de amostras invasivas. A instituição de terapêutica antibiótica sistêmica não demonstrou melhorar o impacto clínico da traqueobronquite associada à ventilação mecânica, nomeadamente na redução do tempo de ventilação mecânica, de internação ou mortalidade, apesar da eventual menor progressão para pneumonia associada à ventilação mecânica, ainda que existam dúvidas relativas à metodologia utilizada. Deste modo, considerando a elevada prevalência da traqueobronquite associada à ventilação mecânica, o tratamento desta entidade, por rotina, resultaria em elevada prescrição antibiótica sem benefícios claros. No entanto, sugerimos a instituição de terapêutica antibiótica em doentes com traqueobronquite associada à ventilação mecânica e choque séptico e/ou agravamento da oxigenação, devendo ser realizados simultaneamente outros exames auxiliares de diagnóstico para exclusão da pneumonia associada à ventilação mecânica. Após esta revisão da literatura, entendemos que uma melhor diferenciação entre traqueobronquite associada à ventilação mecânica e pneumonia associada à ventilação mecânica pode diminuir, de forma significativa, a utilização de antibióticos em doentes críticos ventilados.

ABSTRACT The concept of ventilator-associated tracheobronchitis is controversial; its definition is not unanimously accepted and often overlaps with ventilator-associated pneumonia. Ventilator-associated tracheobronchitis has an incidence similar to that of ventilator-associated pneumonia, with a high prevalence of isolated multiresistant agents, resulting in an increase in the time of mechanical ventilation and hospitalization but without an impact on mortality. The performance of quantitative cultures may allow better diagnostic definition of tracheobronchitis associated with mechanical ventilation, possibly avoiding the overdiagnosis of this condition. One of the major difficulties in differentiating between ventilator-associated tracheobronchitis and ventilator-associated pneumonia is the exclusion of a pulmonary infiltrate by chest radiography; thoracic computed tomography, thoracic ultrasonography, or invasive specimen collection may also be required. The institution of systemic antibiotic therapy does not improve the clinical impact of ventilator-associated tracheobronchitis, particularly in reducing time of mechanical ventilation, hospitalization or mortality, despite the possible reduced progression to ventilator-associated pneumonia. However, there are doubts regarding the methodology used. Thus, considering the high prevalence of tracheobronchitis associated with mechanical ventilation, routine treatment of this condition would result in high antibiotic usage without clear benefits. However, we suggest the institution of antibiotic therapy in patients with tracheobronchitis associated with mechanical ventilation and septic shock and/or worsening of oxygenation, and other auxiliary diagnostic tests should be simultaneously performed to exclude ventilator-associated pneumonia. This review provides a better understanding of the differentiation between tracheobronchitis associated with mechanical ventilation and pneumonia associated with mechanical ventilation, which can significantly decrease the use of antibiotics in critically ventilated patients.

Incidence and prognosis of ventilator-associated tracheobronchitis (TAVeM): a multicentre, prospective, observational study.

BACKGROUND: Ventilator-associated tracheobronchitis has been suggested as an intermediate process between tracheobronchial colonisation and ventilator-associated pneumonia in patients receiving mechanical ventilation. We aimed to establish the incidence and effect of ventilator-associated tracheobronchitis in a large, international patient cohort. METHODS: We did a multicentre, prospective, observational study in 114 intensive care units (ICU) in Spain, France, Portugal, Brazil, Argentina, Ecuador, Bolivia, and Colombia over a preplanned time of 10 months. All patients older than 18 years admitted to an ICU who received invasive mechanical ventilation for more than 48 h were eligible. We prospectively obtained data for incidence of ventilator-associated lower respiratory tract infections, defined as ventilator-associated tracheobronchitis or ventilator-associated pneumonia. We grouped patients according to the presence or absence of such infections, and obtained data for the effect of appropriate antibiotics on progression of tracheobronchitis to pneumonia. Patients were followed up until death or discharge from hospital. To account for centre effects with a binary outcome, we fitted a generalised estimating equation model with a logit link, exchangeable correlation structure, and non-robust standard errors. This trial is registered with ClinicalTrials.gov, number NCT01791530. FINDINGS: Between Sept 1, 2013, and July 31, 2014, we obtained data for 2960 eligible patients, of whom 689 (23%) developed ventilator-associated lower respiratory tract infections. The incidence of ventilator-associated tracheobronchitis and that of ventilator-associated pneumonia at baseline were similar (320 [11%; 10·2 of 1000 mechanically ventilated days] vs 369 [12%; 8·8 of 1000 mechanically ventilated days], p=0·48). Of the 320 patients with tracheobronchitis, 250 received appropriate antibiotic treatment and 70 received inappropriate antibiotics. 39 patients with tracheobronchitis progressed to pneumonia; however, the use of appropriate antibiotic therapy for tracheobronchitis was associated with significantly lower progression to pneumonia than was inappropriate treatment (19 [8%] of 250 vs 20 [29%] of 70, p<0·0001; crude odds ratio 0·21 [95% CI 0·11-0·41]). Significantly more patients with ventilator-associated pneumonia died (146 [40%] of 369) than those with tracheobronchitis (93 [29%] of 320) or absence of ventilator-associated lower respiratory tract infections (673 [30%] of 2271, p<0·0001). Median time to discharge from the ICU for survivors was significantly longer in the tracheobronchitis (21 days [IQR 15-34]) and pneumonia (22 [13-36]) groups than in the group with no ventilator-associated lower respiratory tract infections (12 [8-20]; hazard ratio 1·65 [95% CI 1·38-1·97], p<0·0001). INTERPRETATION: This large database study emphasises that ventilator-associated tracheobronchitis is a major health problem worldwide, associated with high resources consumption in all countries. Our findings also show improved outcomes with use of appropriate antibiotic treatment for both ventilator-associated tracheobronchitis and ventilator-associated pneumonia, underlining the importance of treating both infections, since inappropriate treatment of tracheobronchitis was associated with a higher risk of progression to pneumonia. FUNDING: None.

Comparison of polymyxin B with other antimicrobials in the treatment of ventilator-associated pneumonia and tracheobronchitis caused by Pseudomonas aeruginosa or Acinetobacter baumannii.

PURPOSE: This study was designed to compare the efficacy of polymyxin B with other antimicrobials in the treatment of ventilator-associated pneumonia (VAP) and tracheobronchitis (VAT) by Pseudomonas aeruginosa or Acinetobacter baumannii. METHODS: A prospective cohort study was performed. Patients >18 years of age with the diagnosis of VAP or VAT who received appropriate therapy for >48 h were analyzed. The primary outcome was 30-day mortality. Clinical covariates were assessed and compared between the groups. RESULTS: A total of 67 episodes were analyzed: 45 (67 %) treated with polymyxin B and 22 (33 %) with comparators. The crude 30-day mortality was 53 % (24 of 45) in the polymyxin B group and 27 % (6 of 22) in the comparator group (P = 0.08). Multivariable analysis using Cox regression models indicated that polymyxin B treatment was independently associated with increased mortality. CONCLUSIONS: Polymyxin B treatment in the currently recommended dosage may be inferior to other drugs in the treatment of VAP and VAT caused by organisms tested as susceptible in vitro to this agent.

Inhaled 1,8-cineole reduces inflammatory parameters in airways of ovalbumin-challenged Guinea pigs.

Eucalyptol, also known as 1,8-cineole, is a monoterpene traditionally used to treat respiratory disorders due to its secretolytic properties. In addition to its myorelaxant effects, it also has anti-inflammatory actions in vitro. In this study, we aimed to evaluate the efficacy of acute treatment with 1,8-cineole on reducing airway inflammatory parameters. Ovalbumin (OVA)-sensitized guinea pigs were submitted to antigenic challenge (OVA) with or without pre-treatment with a single dose of 1,8-cineole administered by inhalation. Airway inflammatory parameters were reduced or absent in 1,8-cineole-treated animals as compared with untreated guinea pigs. Acute treatment with 1,8-cineole impaired the development of airway hyperresponsiveness to carbachol in isolated tracheal rings. Levels of the pro-inflammatory cytokines TNFα and IL-1ß was lower in bronchoalveolar lavage fluid (BALF) of 1,8-cineol-treated guinea pigs than in untreated animals. 1,8-Cineole impaired the OVA-induced increase of the myeloperoxidase activity in BALF. 1,8-Cineole also prevented the reduction of the mucociliary clearance induced by the antigen presentation. The present investigation provides evidence that inhaled 1,8-cineole prevents hyperresponsiveness and inhibits inflammation in airways of ovalbumin-challenged guinea pigs.

Segurança de nebulização com 3 a 5 ml de adrenalina (1:1000) em crianças: uma revisão baseada em evidência / The safety of nebulization with 3 to 5 ml of adrenaline (1:1000) in children: an evidence based review

OBJETIVO: Apresentar evidências sobre a segurança da nebulização com 3 a 5 ml de adrenalina (1:1000) no tratamento das crianças com obstrução inflamatória aguda das vias aéreas. FONTES DE DADOS: Uma busca eletrônica foi feita, utilizando-se, principalmente, o banco de dados do MEDLINE (janeiro de 1949 a julho de 2004). Os critérios de inclusão do estudo para esta revisão foram: 1) ensaio clínico randomizado; 2) pacientes (até 12 anos) com diagnós tico de bronquiolite ou laringotraqueobronquite; 3) uso de adrenalina (1:1000) através de nebulização. Os principais dados extraídos dos ensaios dizem respeito a doses de adrenalina e seus efeitos sobre a freqüência cardíaca e a pressão arterial sistêmica, bem como outros efeitos colaterais. SíNTESE DOS DADOS: Sete ensaios clínicos, com um total de 238 pacientes, foram incluídos para esta revisão. Dos cinco ensaios clínicos nos quais a maior dose (> 3 ml) de adrenalina foi usada, dois demonstraram aumento significativo de freqüência cardíaca. O aumento médio de freqüência cardíaca variou de sete a 21 batimentos por minuto, até 60 minutos após o tratamento. A maior incidência de palidez foi observada em um ensaio clínico com 21 crianças tratadas com 3 ml de adrenalina através de nebulização (47,6 por cento no grupo de adrenalina versus 14,3 por cento no grupo de salbutamol, 30 minutos após o tratamento). Não foram observados, em dois ensaios clínicos, efeitos significativos em nebulização com adrenalina (4 e 5 ml) na pressão arterial sistêmica. CONCLUSAO: As evidências mostram que nebulização com 3 a 5 ml de adrenalina (1:1000) é uma terapia segura, com poucos efeitos colaterais, em crianças com obstrução inflamatória aguda das vias aéreas.

Avaliaçåo terapêutica do penetro inalante em pacientes portadores de afecçöes das vias aéreas / Therapeutic evaluation of Penetro Inalante in patients with affection in the Respiratory Tract

Vinte e sete pacientes com afecçöes das vias aéreas foram tratados com Penetro inalante em um estudo aberto, nåo comparativo, no estado do Rio de Janeiro visando avaliar sua eficácia terapêutica e tolerabilidade, utilizando a posologia de duas a três inalaçöes ao dia, durante sete a 15 dias. Penetro inalante, composto por Eucaliptol, terpinol, mentol e ácido benzóico, demonstrou-se estatisticamente eficaz, com tolerância excelente e boa em 100 por cento dos casos

Traqueítis bacteriana

La traqueítis bacteriana es una entidad potencialmente fatal que ha reaparecido en la última década con inusitado auge. A propósito de su detección en nuestro servicio decidimos realizar un estudio retrospectivo en el Hospital Universitario de la Misericordia de Santa Fe de Bogotá entre enero de 1990 y julio de 1994. Se revisaron 88 historias de pacientes con diagnósticos clínico sugestivo de traqueítis bacteriana pero sólo 13 pacientes cumplieron con el requisito de confirmación endoscópica del diagnóstico para ser considerados en el presente trabajo. La edad osciló entre 1 y 7 años, predominando el sexo masculino. Existió antecedente de infección respiratoria previa en el 54 por ciento, los síntomas más frecuentes fueron fiebre, tos perruna y dificultad respiratoria; los hemogramas mostraron leucocitosis, neutrofilia y aumento de la VSG. En la endoscopia se observó exudado traqueal, membranas purunlentas y úlceras; en solo cultivo se aisló Staphylococcus aureus. El 62 por ciento requirió permeabilizar la vía aérea, 3 con traqueostomía y 5 con tubo orotraqueal. El 46 por ciento se manejó con oxacilina y todos evolucionaron satisfactoriamente.

Utilidad clínica de la azitromicina en infecciones de vía respiratoria superior / Clinical usefulness of azthromuycin in upper respiratory tract infections

La azitromicina pertenece al grupo de los azálidos y tiene una mayor penetración tisular, así como una vida media más prolongada que la eritromicina. Es activa contra patógenos intracelulares debido a su captación y acumulación en células fagocíticas y fibroblastos. Ha mostrado mayor actividad in vitro contra H. influenzae, N. gonorrhoeae, M. hominis y Citrobacter diversus que la eritromicina. Se estudiaron 20 pacientes adultos ambulatorios (12 mujeres y ocho varones), con diagnóstico de infección aguda de vía respiratoria superior, quienes recibieron 500 mg de azitromicina por vía oral, en dosis única durante tres días. Se evaluaron antes del tratamiento, 48 h y siete días postratamiento. Los diagnósticos establecidos fueron: faringoamigdalitis aguda (8), sinusitis aguda (4), amigdalitis aguda (4), faringitis aguda (1), faringolaringotraqueitis aguda (1), laringitis aguda (1) y exacerbación de sinusitis crónica (1). Las bacterias encontradas en el pretratamiento fueron: S. aureus (5), M. catarrhalis (2), H. influenzae (2), estreptococo grupo D (1), estreptococo spp (1), K. oxytoca (1), Acinetobacter spp (1), E. coli (1) y Klebsiella spp (1). Todas las bacterias resultaron susceptibles a azitromicina, excepto K. oxytoca y estreptococo grupo D. Desde el punto de vista bacteriológico, la respuesta a las 48 h postratamiento se obtuvo curación en 14, mejoría en dos, y falla en cuatro, mientras que a los siete días postratamiento se obtuvo curación en 16 y falla en cuatro. Desde el punto de vista bacteriológico, la respuesta a las 48 h postratamiento fue: erradicación en 13, persistencia en cuatro y superinfección en uno, y a los siete días fue: erradicación en 13 y no evaluable en siete. Las cuatro bacterias persistentes fueron: S. aureus, estreptococo grupo D, K. oxytoca y H. influenzae, K. pneumoniae fue responsable de la superinfección. No se observaron efectos indeseables.

Tratamento de processos inflamatórios das vias aéreas superiores e ouvido, sem componente infeccioso, com AINH: estudo randomizado comparando o nimesulide ao diclofenato potássico / The treatment of upper respiratory tract and ear inflammatory non-infectious conditions with NSAID: a comparative randomized trial with nimesulide and potassium diclofenac

Através de um estudo randomizado, foram comparados os efeitos do nimesulide, um novo antiinflamatório não-hormonal, e do diclofenato potássico em 36 pacientes de ambos os sexos (27 femininos e nove masculinos) e com mais de 12 anos de idade, portadores de processos inflamatórios do trato respiratotio superior e/ou do ouvido. Dezessete pacientes receberam o nimesulide (1 comprimido a cada 12 horas) e 19 o diclofenaco (1 drágea três vezes ao dia), durante sete dias. Com o diclofenaco, os resultados foram excelentes ou bons em 36,5 por cento dos casos e regulares em 26,3 por cento. O nimesulide proporcionou 94,1 por cento de resultados excelentes ou bons e 5,9 por cento regfulares, sem falha terapêutica. A tolerância foi boa em 100 por cento dos pacientes que receberam o nimesulide e em 89,5 por cento dos tratados com o diclofenaco potássico, que apresentou 10,5 por cento de efeitos adversos (enjôo, tonturas, azia). O nimesulide não induziu qualquer reação indesejável, destacando-se pela eficácia, rápido início de ação e segurança

Antibiotic activity in sputum.

Pulmonary infection in cystic fibrosis (CF) is primarily a purulent tracheobronchitis. Antibiotics are available that are active in vitro against bacteria isolated from sputum from patients with CF. Despite efficacious antibiotic concentrations in serum, however, the results of treatment are frequently suboptimal. A widely accepted explanation for this limited efficacy is poor penetration of orally or intravenously administered antibiotics into respiratory secretions. The bioactivity of antibiotics in respiratory secretions is not identical to that found in vitro. Laboratory conditions are standardized and selected to approximate serum. Deviations from these conditions can markedly influence the results. Differences in composition between sputum and laboratory culture media, as well as variation in growth and metabolism of the pathogen in respiratory secretions, must be considered when predicting in vivo activity in sputum. Thus, when defining criteria for antibiotic susceptibility or resistance in the treatment of pulmonary infection in patients with CF, the concentrations achievable in bronchial secretions as well as the bioactivity in this environment should be considered.

Tratamiento de laringotraqueítis grave con adrenalina racémica en respirador de presión positiva intermitente / Treatment of the severe laryngotracheitis with racemic adrenaline in intermittent positive pressure respirator

La laringotraqueítis es una enfermedad de pronóstico benigno. Algunos casos pueden ser graves debido a la obstrucción laríngea que obliga al médico a la intubación endotraqueal o traqueostomía para permitir la ventilación. Como un método alterno, la administración de adrenalina racémica, aplicada por presión positiva intermitente, ha demostrado ser benéfica y evita los inconvenientes de otros procedimientos. Según la anterior, se realizó un estudio prospectivo en 979 niños

[Evaluation of racemic epinephrine with intermittent positive pressure in the treatment of acute infections laryngotracheitis]. / Evaluación de la epinefrina racémica con presión positiva intermitente en el tratamiento de la laringotraqueítis infecciosa aguda.

Fourteen children admitted to the Hospital de Pediatría of the C.M.N. of the I.M.S.S. with the diagnosis of acute infectious laryngotracheobronchitis were divided into two groups with similar conditions for their study. The benefit derived from the application of recemic epinephrine with intermittent positive pressure was confirmed 15 and 30 minutes later by means of a double blind study; the improvement was swift and spectacular, but temporary; therefore, such treatment must be given only in hospitals, since relapses may show up two to four hours later, making in dangerous to send the patients home or to apply to ambulatory cases. The use of racemic epinephrine is proposed for hospitals having equipment and personnel trained in its management and the convenience of further studies is set forth to determine the period of effectiveness of racemic epinephrine and the advantage of giving repeated doses.