Selective left mainstem bronchial intubation in the neonatal intensive care unit / Intubação seletiva do brônquio principal esquerdo em unidade de terapia intensiva neonatal

Abstract Background: Selective neonatal left mainstem bronchial intubation to treat right lung disease is typically achieved with elaborate maneuvers, instrumentation and devices. This is often attributed to bronchial geometry which favors right mainstem entry of an endotracheal tube deliberately advanced beyond the carina. Case summary: A neonate with severe bullous emphysema affecting the right lung required urgent non-ventilation of that lung. We achieved left mainstem bronchial intubation by turning the endotracheal tube 180° such that the Murphy's eye faced the left instead of the right, and simulated a left-handed intubation by slightly orientating the endotracheal tube such that its concavity faced the left instead of the right as in a conventional right-handed intubation. Conclusion: Urgent intubation of the left mainstem bronchus with an endotracheal tube can be easily achieved by recognizing that it is the position of the endotracheal tube tip and the direction of its concavity that are the chief determinants of which bronchus an endotracheal tube goes when advanced. This is important in critically ill neonates as the margin of safety and time window are small, and the absence of double-lumen tubes. Use of fiberoptic bronchoscope and blockers should be reserved as backup plans.

Resumo Justificativa: A intubação seletiva neonatal do brônquio principal esquerdo para tratar a doença pulmonar direita é tipicamente feita com elaboradas manobras, instrumentação e dispositivos. Isso é frequentemente atribuído à geometria brônquica que favorece a entrada principal direita de um tubo endotraqueal (TET) deliberadamente avançado para além da carina. Resumo do caso: Recém-nascido com enfisema bolhoso grave que afetava o pulmão direito e precisou com urgência da não ventilação desse pulmão. Para conseguir a intubação brônquica esquerda fizemos uma rotação de 180° do TET, de forma que o olho de Murphy ficasse voltado para a esquerda, e não para a direita, e para simular uma intubação à esquerda orientamos ligeiramente o TET, de modo que sua concavidade virasse para a esquerda em vez de para a direita, como em uma intubação convencional à direita. Conclusão: A intubação urgente do brônquio principal esquerdo com um TET pode ser facilmente obtida se reconhecermos que é a posição da ponta do TET e a direção de sua concavidade que determinam para qual brônquio o TET irá quando avançado. Isso é importante em neonatos criticamente doentes diante da margem de segurança e janela de tempo pequenas e na ausência de tubos de duplo lúmen. O uso de broncofibroscópio e bloqueadores deve ser considerado como planos de segurança.

[Selective left mainstem bronchial intubation in the neonatal intensive care unit]. / Intubação seletiva do brônquio principal esquerdo em unidade de terapia intensiva neonatal.

BACKGROUND: Selective neonatal left mainstem bronchial intubation to treat right lung disease is typically achieved with elaborate maneuvers, instrumentation and devices. This is often attributed to bronchial geometry which favors right mainstem entry of an endotracheal tube deliberately advanced beyond the carina. CASE SUMMARY: A neonate with severe bullous emphysema affecting the right lung required urgent non-ventilation of that lung. We achieved left mainstem bronchial intubation by turning the endotracheal tube 180° such that the Murphy's eye faced the left instead of the right, and simulated a left-handed intubation by slightly orientating the endotracheal tube such that its concavity faced the left instead of the right as in a conventional right-handed intubation. CONCLUSION: Urgent intubation of the left mainstem bronchus with an endotracheal tube can be easily achieved by recognizing that it is the position of the endotracheal tube tip and the direction of its concavity that are the chief determinants of which bronchus an endotracheal tube goes when advanced. This is important in critically ill neonates as the margin of safety and time window are small, and the absence of double-lumen tubes. Use of fiberoptic bronchoscope and blockers should be reserved as backup plans.

Hypoglycemia in unmonitored full-term newborns-a surveillance study.

BACKGROUND AND OBJECTIVES: Hypoglycemia monitoring is not recommended for most full-term newborns. We wished to determine the incidence, presentation and case characteristics of hypoglycemia in low-risk newborns. METHODS: With the assistance of the Canadian Paediatric Surveillance Program, we conducted a national study of severe hypoglycemia in apparently low-risk full-term newborns. Paediatricians who reported a case were sent a detailed questionnaire and the data were analyzed. RESULTS: All 93 confirmed cases were singletons, 56% were first-borns and 65% were male. An 8% rate of First Nations cases was twofold the population rate. Maternal hypertension rate was 23%, fourfold the general pregnancy rate. Maternal obesity was double the general pregnancy rate at 23%. Concerning signs or feeding issues were noted in 98% at the time of diagnosis. Median time to diagnosis was 4.1 hours. Mean blood glucose at intravenous (IV) start was 1.4 ± 0.5 hours (SD). Seventy-eight per cent had at least one of four potential stress indicators and were more likely to have early diagnosis (P=0.03). Major signs were present in 20%. Those cases presented later and had lower glucose levels (median=0.8 mmol/L versus 1.6 mmol/L, [P<0.001). Twenty-five per cent of cases had birth weight less than the 10th centile. Neurodevelopmental concern was reported in 20%. Of the 13 cases which had brain magnetic resonance imaging, 11 were abnormal. CONCLUSION: Hypoglycemia in unmonitored newborns is uncommon but is associated with significant morbidity. We provide a range of clues to help identify these newborns soon after birth. Widespread adoption of norm-based standards to identify small-for-gestational age infants is supported.

Esophageal Atresia/Tracheoesophageal Fistula Repair Complicated by Tracheomalacia: A Case Report of Successful Management of Respiratory Distress Using Caudal Morphine.

We report a case of severe respiratory distress in a neonate who was not endotracheally intubated soon after esophageal atresia/tracheoesophageal fistula (EA/TEF) repair. In this serious situation, any form of emergency respiratory support or definitive airway management may compromise the esophageal anastomosis and fistula repair. The cause of respiratory distress in the early postoperative period after EA/TEF is multifactorial, and in this case, included symptomatic tracheomalacia, which is commonly associated with EA/TEF.

Effect of Picture Archiving and Communication System Image Manipulation on the Agreement of Chest Radiograph Interpretation in the Neonatal Intensive Care Unit.

OBJECTIVE: Variability in image interpretation has been attributed to differences in the interpreters' knowledge base, experience level, and access to the clinical scenario. Picture archiving and communication system (PACS) has allowed the user to manipulate the images while developing their impression of the radiograph. The aim of this study was to determine the agreement of chest radiograph (CXR) impressions among radiologists and neonatologists and help determine the effect of image manipulation with PACS on report impression. MATERIALS AND METHODS: Prospective cohort study included 60 patients from the Neonatal Intensive Care Unit undergoing CXRs. Three radiologists and three neonatologists reviewed two consecutive frontal CXRs of each patient. Each physician was allowed manipulation of images as needed to provide a decision of "improved," "unchanged," or "disease progression" lung disease for each patient. Each physician repeated the process once more; this time, they were not allowed to individually manipulate the images, but an independent radiologist presets the image brightness and contrast to best optimize the CXR appearance. Percent agreement and opposing reporting views were calculated between all six physicians for each of the two methods (allowing and not allowing image manipulation). RESULTS: One hundred percent agreement in image impression between all six observers was only seen in 5% of cases when allowing image manipulation; 100% agreement was seen in 13% of the cases when there was no manipulation of the images. CONCLUSION: Agreement in CXR interpretation is poor; the ability to manipulate the images on PACS results in a decrease in agreement in the interpretation of these studies. New methods to standardize image appearance and allow improved comparison with previous studies should be sought to improve clinician agreement in interpretation consistency and advance patient care.

Novel Method to Improve Radiologist Agreement in Interpretation of Serial Chest Radiographs in the ICU.

OBJECTIVES: To determine whether a novel method and device, called a variable attenuation plate (VAP), which equalizes chest radiographic appearance and allows for synchronization of manual image windowing with comparison studies, would improve consistency in interpretation. MATERIALS AND METHODS: Research ethics board approved the prospective cohort pilot study, which included 50 patients in the intensive care unit (ICU) undergoing two serial chest radiographs with a VAP placed on each one of them. The VAP allowed for equalization of density and contrast between the patients' serial chest radiographs. Three radiologists interpreted all the studies with and without the use of VAP. Kappa and percent agreement was used to calculate agreement between radiologists' interpretations with and without the plate. RESULTS: Radiologist agreement was substantially higher with the VAP method, as compared to that with the non-VAP method. Kappa values between Radiologists A and B, A and C, and B and C were 46%, 55%, and 51%, respectively, which improved to 73%, 81%, and 66%, respectively, with the use of VAP. Discrepant report impressions (i.e., one radiologist's impression of unchanged versus one or both of the other radiologists stating improved or worsened in their impression) ranged from 24 to 28.6% without the use of VAP and from 10 to 16% with the use of VAP (χ (2) = 7.454, P < 0.01). Opposing views (i.e., one radiologist's impression of improved and one of the others stating disease progression or vice versa) were reported in 7 (12%) cases in the non-VAP group and 4 (7%) cases in the VAP group (χ (2) = 0.85, P = 0.54). CONCLUSION: Numerous factors play a role in image acquisition and image quality, which can contribute to poor consistency and reliability of portable chest radiographic interpretations. Radiologists' agreement of image interpretation can be improved by use of a novel method consisting of a VAP and associated software and has the potential to improve patient care.

The association between the interpregnancy interval and autism spectrum disorder in a Canadian cohort.

OBJECTIVES: Two studies reported an increased risk of autistic disorder in children conceived less than 12 months after a previous birth. Our objective was to examine the association between the interpregnancy interval (IPI) and autism spectrum disorder (ASD) in a Canadian cohort. METHODS: Using administrative datasets housed at the Manitoba Centre for Health Policy, we identified pairs of first- and second-born singleton siblings born between 1988 and 2005. Diagnoses of ASD were ascertained by searching physician billing claims, hospital discharge abstracts, education data, and a database containing information on individuals identified for a 2002-2007 ASD surveillance program in Manitoba. Logistic regression models were fit to examine the association between the IPI and ASD in 41,050 second-born siblings where the first-borns did not have ASD, using IPIs of ≥ 36 months as the reference category and specifying three case groups. Case Group 1 included individuals with at least one ASD code (n = 490); Case Group 2 included those with two or more ASD codes (n = 375); and Case Group 3 comprised individuals with a record in the ASD surveillance program database (n = 141). RESULTS: The adjusted odds ratios (ORs) for IPIs shorter than 12 months ranged from 1.22 (95% CI: 0.91-1.63) for Case Group 1 to 1.72 (95% CI: 0.96-3.06) for Case Group 3. When the case groups were restricted to individuals with more severe ASD, the ORs increased and were significant for Case Groups 1 and 2. CONCLUSION: Our findings also support an association between short IPIs and more severe ASD.

Canadian paediatric asthma action plans and their correlation with current consensus guidelines.

BACKGROUND: While written action plans are standard in the treatment and management of asthma, significant variability exists in the content and format among plans. This variability results in inconsistent educational messages that lend themselves to patient confusion and suboptimal health outcomes. OBJECTIVES: To assess the content of Canadian paediatric written action plans for consistency in format, layout, zone-defining symptoms, suggested treatment options and adherence to current Canadian asthma care guidelines. METHODS: Written action plans were sought from Canadian paediatric hospitals, major teaching hospitals associated with academic centres and three national organizations, for a total of 17 plans. An analysis was performed to assess the similarities and differences among plans. RESULTS: Of all the Canadian paediatric written action plans, 76% were found to consist of three zones and 82% incorporated a traffic light-style design. The plans were divided between symptom-based (59%) and combined symptom- and peak-flow rate approaches (41%). Nominal concordance with the 2012 Canadian Thoracic Society guidelines existed with respect to inhaled corticosteroid and oral corticosteroid therapy. Considerable variability existed among the symptom descriptors that defined each zone. Greater consistency existed among treatment strategies, although the suggested treatment was often difficult to ascertain from the plan templates. CONCLUSION: Canadian written action plans would be improved by nationally clarifying the symptom descriptors for each zone, adding asthma trigger information to the plans, increasing the emphasis of the common cold as a potential harbinger of worsening asthma symptoms and further incorporating national guideline recommendations.

HISTORIQUE: Les plans d'action écrits sont la norme pour traiter et prendre en charge l'asthme, mais leur contenu et leur présentation varient énormément. Cette variabilité s'associe à des messages d'éducation non uniformes qui favorisent la confusion des patients et des résultats de santé sous-optimaux. OBJECTIFS: Évaluer le contenu des plans d'action canadiens écrits en pédiatrie pour vérifier l'uniformité de la présentation, de la disposition, des symptômes définissant la zone, des possibilités thérapeutiques suggérées et de l'adhérence aux lignes directrices canadiennes à jour sur l'asthme. MÉTHODOLOGIE: Les chercheurs ont obtenu les plans d'action écrits des hôpitaux pédiatriques canadiens, des grands hôpitaux d'enseignement associés à des centres universitaires et de trois organisations internationales, pour un total de 17 plans. Ils ont effectué une analyse pour évaluer les similarités et les différences entre les plans. RÉSULTATS: Il a été établi que 76 % des plans d'action canadiens écrits en pédiatrie se divisaient en trois zones et que 82 % étaient structurés selon le principe des feux de signalisation. Ils étaient répartis entre une approche fondée sur les symptômes (59 %) et une approche combinant les symptômes et le débit de pointe (41 %). Ils présentaient une concordance nominale avec les lignes directrices de la Société canadienne de thoracologie de 2012 à l'égard des corticoïdes inhalés et des corticoïdes oraux. On constatait une importante variabilité quant aux descripteurs des symptômes qui définissaient chaque zone. Les stratégies thérapeutiques étaient plus uniformes, même si le traitement proposé était souvent difficile à déterminer d'après les modèles du plan. CONCLUSION: On améliorerait les plans d'action canadiens écrits si, sur la scène nationale, on clarifiait les descripteurs des symptômes dans chaque zone, on y ajoutait l'information sur les déclencheurs de l'asthme, on insistait davantage sur le rhume banal comme prédicteur potentiel d'aggravation des symptômes de l'asthme et on intégrait davantage les recommandations sur les lignes directrices nationales.

Effect of inhaled hypertonic saline on hospital admission rate in children with viral bronchiolitis: a randomized trial.

OBJECTIVE: We sought to determine whether inhaled 3% hypertonic saline (HS) reduces admission to hospital in ambulatory children with moderately severe viral bronchiolitis. Secondary objectives compared changes in respiratory scores before and after treatment and assessed the need for unscheduled medical intervention within 7 days. METHODS: Children under the age of 2 years presenting with moderately severe viral bronchiolitis to the emergency department of 4 general hospitals from November 2008 to March 2009 were randomly assigned to receive 3 consecutive 4-mL doses of nebulized 3% HS (treatment group) or 0.9% normal saline (NS; control group) in a double blind fashion, each coadministered with 1 mg salbutamol. Outcome measures included the difference in hospital admission rate and changes in respiratory distress scores. RESULTS: A total of 81 children (mean age 8.9 mo, range 0.7-22 mo) were assessed over 88 visits on an intention-to-treat basis. No statistically significant differences were found between treatment groups. Children in the HS group had a nonsignificant trend toward greater improvement compared with NS controls with a same-day admission rate of 18% (95% confidence interval [CI] 9%-32%) versus 27% (95% CI 16%-42%), respectively. Respiratory Assessment Change Scores (RACS) favoured the HS group over NS controls (mean RACS 4.7 [95% CI 3.6-5.8] v. 3.7 [95% CI 2.5-4.9], respectively), although the CIs overlap and these differences were not statistically significant. CONCLUSION: The short-term use of nebulized 3% HS did not result in any statistically significant benefits, although a nonsignificant trend toward a decrease in admission rate and improvement in respiratory distress was found. A larger study would be required to determine whether these trends arise from a clinically relevant treatment effect.

Hyperthermia amplifies brain cytokine and reactive oxygen species response in a model of perinatal inflammation.

Chorioamnionitis, a perinatal infection of the fetal membranes, and maternal fever, which often accompanies infection are both risk factors for cerebral palsy (CP). Inflammation is a typical reaction to infection. Thus the aim of this study was to determine if hyperthermia alters newborn rat brain inflammatory response and oxidant stress after a maternal rat lipopolysaccaharide (LPS) injection. Since chorioamnionitis can predispose the fetus to perinatal hypoxia, we also explored the interaction with postnatal hypoxia. Exposure of newborn pups to brief hypoxia alone significantly increased brain tumor necrosis factor-alpha (TNF-alpha) and slightly increased levels of nitrite/nitrate. When maternal LPS was combined with postnatal hypoxia, the levels of TNF-alpha in were further increased when compared with hypoxia alone. Exposure of newborn pups to hyperthermia at 39 degrees C following maternal LPS and hypoxia caused yet more significant increases in brain TNF-alpha, nitrite/nitrate, and MDA/4-HAD compared to that under normal temperature conditions. This study supports the hypothesis that fever is a significant modifier of brain inflammatory response in developing brain particularly in a setting of hypoxia.

Nebulized hypertonic saline in the treatment of viral bronchiolitis in infants.

OBJECTIVE: To investigate the use of nebulized 3% hypertonic saline (HS) for treating viral bronchiolitis in moderately ill hospitalized infants by a prospective, randomized, double-blinded, controlled, multicenter trial. STUDY DESIGN: A total of 96 infants (mean age, 4.7 months; range, 0.3 to 18 months) admitted to the hospital for treatment of viral bronchiolitis were recruited from 3 regional pediatric centers over 3 bronchiolitis seasons (December 2003 to May 2006). Patients were randomized to receive, in a double-blind fashion, repeated doses of nebulized 3% HS (treatment group) or 0.9% normal saline (NS; control group), in addition to routine therapy ordered by the attending physician. The principal outcome measure was hospital length of stay (LOS). RESULTS: On an intention-to-treat basis, the infants in the HS group had a clinically relevant 26% reduction in LOS to 2.6 +/- 1.9 days, compared with 3.5 +/- 2.9 days in the NS group (P = .05). The treatment was well tolerated, with no adverse effects attributable to the use of HS. CONCLUSIONS: The use of nebulized 3% HS is a safe, inexpensive, and effective treatment for infants hospitalized with moderately severe viral bronchiolitis.

Stages of development and injury patterns in the early years: a population-based analysis.

BACKGROUND: In Canada, there are many formal public health programs under development that aim to prevent injuries in the early years (e.g. 0-6). There are paradoxically no population-based studies that have examined patterns of injury by developmental stage among these young children. This represents a gap in the Canadian biomedical literature. The current population-based analysis explores external causes and consequences of injuries experienced by young children who present to the emergency department for assessment and treatment. This provides objective evidence about prevention priorities to be considered in anticipatory counseling and public health planning. METHODS: Four complete years of data (1999-2002; n = 5876 cases) were reviewed from the Kingston sites of the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP), an ongoing injury surveillance initiative. Epidemiological analyses were used to characterize injury patterns within and across age groups (0-6 years) that corresponded to normative developmental stages. RESULTS: The average annual rate of emergency department-attended childhood injury was 107 per 1000 (95% CI 91-123), with boys experiencing higher annual rates of injury than girls (122 vs. 91 per 1000; p < 0.05). External causes of injury changed substantially by developmental stage. This lead to the identification of four prevention priorities surrounding 1) the optimization of supervision; 2) limiting access to hazards; 3) protection from heights; and 4) anticipation of risks. CONCLUSION: This population-based injury surveillance analysis provides a strong evidence-base to inform and enhance anticipatory counseling and other public health efforts aimed at the prevention of childhood injury during the early years.

A comparison of high and standard blood transfusion volumes in premature infants.

UNLABELLED: We compared high volume (20 ml/kg) with standard volume (15 ml/kg) packed red blood cell (PRBC) transfusions in a randomized trial. Ten high volume babies received a mean of 2.8 transfusions, while 10 standard volume babies received a mean of 3.4 (p=0.58). No adverse events were attributed to the use of the high volume transfusions. CONCLUSION: Higher transfusion volumes appear to be well tolerated. The data can be used in the planning of larger controlled trials in VLBW infants.

Temporal profile of tissue plasminogen activator (tPA) and inhibitor expression after transient focal cerebral ischemia.

Altered tPA expression may influence the fate of neurons after cerebral ischemia. We determined the changes in tPA and plasminogen activator inhibitor (PAI-1) expression in adult rat brain after transient middle cerebral artery (MCA) occlusion. Immunohistology revealed tPA staining in ipsilateral but not contralateral cortex and striatum 6 h after occlusion. This pattern was maintained at 24 h. Staining data was supported by Western blot data which showed no tPA protein in contralateral cortex at 3 h but abundant protein in ipsilateral cortex which increased further at 6 h and 24 h. In contrast there was prominent PAI-1 immunostaining and protein expression in control tissue after MCA occlusion but it diminished progressively at 3, 6 and 24 h in the lesioned cortex.