ROX index as a predictor of failure of high-flow nasal cannula in infants with bronchiolitis.

High-flow nasal cannula (HFNC) is a relatively recent therapy that has been used to treat respiratory failure. Until now, the criterion for failure requiring escalation to other forms of ventilatory support has remained unclear. This study evaluated how the ROX index predicts the success or failure of HFNC in infants with bronchiolitis. A prospective, observational, multicenter study was conducted in 2 pediatric ICUs. The data were collected at 7 moments. Patients were categorized into failure and success groups according to HFNC. A total of 102 infants were included, 18(17.6%) of whom failed HFNC therapy. For the ROX index, significant differences were observed between the failure 5.8(95%CI 4.7-7.1) and success 7.7(95%CI 7.2-8.2) groups (p = 0.005) at the 12 h evaluation. According to the analysis of the performance of the ROX index, the AUC at 12 h was 0.716(95%CI 0.591-0.842; p = 0.016). The best cutoff range for the ROX index at 12 h was 6.50-7.18, with a sensitivity of 42% and a specificity of 66% at the cutoff of 6.50, and a sensitivity of 92% and a specificity of 54% at the cutoff of 7.18. We concluded that the ROX index could be effective at predicting the failure of HFNC therapy in infants with bronchiolitis beginning at 12 h after installation.

Quality improvement project to reduce unplanned extubations in a paediatric intensive care unit.

BACKGROUND: Unplanned extubations are recurrent adverse events in mechanically ventilated children and have been the focus of quality and safety improvement in paediatric intensive care units (ICUs). LOCAL PROBLEM: To reduce the rate of unplanned extubation in the paediatric ICU by 66% (from 2.02 to 0.7). METHODS: This is a quality improvement project that was conducted in a paediatric ICU of a private hospital at the quaternary level. All hospitalised patients who used invasive mechanical ventilation between October 2018 and August 2019 were included. INTERVENTIONS: The project was based on the Improvement Model methodology of the Institute for Healthcare Improvement to implement change strategies. The main ideas of change were innovation in the endotracheal tube fixation model, evaluation of the endotracheal tube positioning, good practices of physical restraint, sedation monitoring, family education and engagement and checklist for prevention of unplanned extubation, with Plan-Do-Study-Act, the tool chosen to test and implement ideas for change. RESULTS: The actions reduced the unplanned extubation rate to zero in our institution and sustained this result for a period of 2 years, totalling 743 days without any event. An estimate was made comparing cases with unplanned extubation and controls without the occurrence of this adverse event, which resulted in savings of R$955 096.65 (US$179 540.41) during the 2 years after the implementation of the improvement actions. CONCLUSION: The improvement project conducted in the 11-month period reduced the unplanned extubation rate to zero in our institution and sustained this result for a period of 743 days. Adherence to the new fixation model and the creation of a new restrictor model, which enabled the implementation of good practices of physical restraint were the ideas of change that had the greatest impact in achieving this result.

Effect of general anesthesia and controlled mechanical ventilation on pulmonary ventilation distribution assessed by electrical impedance tomography in healthy children.

INTRODUCTION: General anesthesia is associated with the development of atelectasis, which may affect lung ventilation. Electrical impedance tomography (EIT) is a noninvasive imaging tool that allows monitoring in real time the topographical changes in aeration and ventilation. OBJECTIVE: To evaluate the pattern of distribution of pulmonary ventilation through EIT before and after anesthesia induction in pediatric patients without lung disease undergoing nonthoracic surgery. METHODS: This was a prospective observational study including healthy children younger than 5 years who underwent nonthoracic surgery. Monitoring was performed continuously before and throughout the surgical period. Data analysis was divided into 5 periods: induction (spontaneous breathing, SB), ventilation-5min, ventilation-30min, ventilation-late and recovery-SB. In addition to demographic data, mechanical ventilation parameters were also collected. Ventilation impedance (Delta Z) and pulmonary ventilation distribution were analyzed cycle by cycle at the 5 periods. RESULTS: Twenty patients were included, and redistribution of ventilation from the posterior to the anterior region was observed with the beginning of mechanical ventilation: on average, the percentage ventilation distribution in the dorsal region decreased from 54%(IC95%:49-60%) to 49%(IC95%:44-54%). With the restoration of spontaneous breathing, ventilation in the posterior region was restored. CONCLUSION: There were significant pulmonary changes observed during anesthesia and controlled mechanical ventilation in children younger than 5 years, mirroring the findings previously described adults. Monitoring these changes may contribute to guiding the individualized settings of the mechanical ventilator with the goal to prevent postoperative complications.

Effect of flow rate on the end-expiratory lung volume in infants with bronchiolitis using high-flow nasal cannula evaluated through electrical impedance tomography.

OBJECTIVES: To evaluate the effects of four flow rates on the functional residual capacity (FRC) and pulmonary ventilation distribution while using a high-flow nasal cannula (HFNC). WORKING HYPOTHESIS: Our hypothesis is that flow rates below 1.5 L·kg-1 ·min-1 lead to FRC loss and respiratory distress. STUDY DESIGN: A single-center, prospective clinical study. PATIENT SELECTION: Infants diagnosed with acute viral bronchiolitis were given HFNC. METHODOLOGY: Through a prospective clinical study, the effects of four different flow rates, 2.0, 1.5, 1.0, and 0.5 L·kg-1 ·min-1 , on FRC and the pulmonary ventilation pattern were evaluated using electrical impedance tomography. The impedance variation (delta Z), end-expiratory lung volume (EELZ), respiratory rate, heart rate, respiratory distress score, and saturation/fraction of inspired oxygen ratio (SpO2 /FI O2 ), were also evaluated at each flow rate. RESULTS: Among the 11 infants included, There was a decrease in respiratory distress score at a flow rate of 1.5 L·kg-1 ·min-1 (*p = 0.021), and at a flow rate of 2.0 L·kg-1 ·min-1 (**p = 0.003) compared to 0.5 L·kg-1 ·min-1 . There was also a small but significant increase in SpO2 /FiO2 at flow rates of 1.5 (*p = 0.023), and 2.0 L·kg-1 ·min-1 (**p = 0.008) compared to 0.5 L·kg-1 ·min-1 . There were no other significant changes in the clinical parameters. In the global EELZ measurements, there was a significant increase under a flow rate of 2.0 L·kg-1 ·min-1 as compared to 0.5 L·kg-1 ·min-1 (p = 0.03). In delta Z values, there were no significant variations between the different flow rates. CONCLUSION: The ∆EELZ increases at the highest flow rates were accompanied by decreased distress scores and improved oxygenation.

Electrical impedance tomography in pediatric patients with COVID-19, the first reports.

INTRODUCTION: Electrical impedance tomography (EIT) is a noninvasive, radiation-free, bedside tool to monitor ventilation distribution in real time. OBJECTIVE: To evaluate, in pediatric COVID-19 patients, the ventilation distribution using EIT and compare it to thoracic computed tomography (TCT) or chest radiograph results obtained in these patients. METHODS: This was a prospective, observational clinical study including pediatric patients admitted to the intensive care unit of a private hospital. The patients monitored with EIT tested positive for COVID-19 and were submitted to the previously mentioned radiation exams. EIT monitoring lasted 15 min and no sedation was used. RESULTS: Six patients were included in this study. The main differences observed in the EIT were in the right-left distribution and were compatible with the morphological changes found in the TCT or radiograph images due to COVID-19 infection. CONCLUSION: We conclude that EIT is ready to investigate the ventilatory profile present at different lung diseases, including COVID-19, and might postpone or mitigate the need of repeated ionizing radiation exams in the pediatric population, although larger pediatric cohorts comparing to standard radiological imaging are needed.

Impact of social isolation due to COVID-19 on the seasonality of pediatric respiratory diseases.

INTRODUCTION: Respiratory tract diseases are the major cause of morbidity and mortality in children under the age of 5 years, constituting the highest rate of hospitalization in this age group. OBJECTIVES: To determine the prevalence of hospitalizations for respiratory diseases in childhood in the last 5 years and to assess the impact of social isolation due to COVID-19 on the seasonal behavior of these diseases. METHODS: A cross-sectional clinical study was carried out, with a survey of all patients aged 0 to 17 years who were admitted with a diagnosis of respiratory diseases between January 2015 and July 2020. The database was delivered to the researchers anonymized. The variables used for analysis were date of admission, date of discharge, length of stay, age, sex and diagnosis. In order to make the analysis possible, the diagnoses were grouped into upper respiratory infection (URI), asthma / bronchitis, bronchiolitis and pneumonia. RESULTS: 2236 admissions were included in the study. Children under 5 years old account for 81% of hospitalizations for respiratory disease in our population. In the adjusted model, an average reduction of 38 hospitalizations was observed in the period of social isolation (coefficient: -37.66; 95% CI (- 68.17; -7.15); p = 0.016). CONCLUSION: The social isolation measures adopted during the COVID-19 pandemic dramatically interfered with the seasonality of childhood respiratory diseases. This was reflected in the unexpected reduction in the number of hospitalizations in the pediatric population during this period.

Nasogastric tube, a warning sign for high-flow nasal cannula failure in infants with bronchiolitis.

High-flow nasal cannula (HFNC) therapy is routinely used in the treatment of infants with bronchiolitis. This study sought to identify markers associated with failure of HFNC therapy that serve as warnings for early staging of other ventilatory support products. A retrospective study of infants with a diagnosis of bronchiolitis, receiving HFNC and admitted to the pediatric intensive care unit from January 2016 to June 2017, was conducted. The subjects were divided into two study groups according to the success or failure of HFNC therapy. Risk factors were assessed using the following variables: age, time between hospital admission and start of HFNC, equipment model, and the need for a nasogastric tube. Eighty-one infants were studied, and 18 (21.7%) of them exhibited therapy failure. The results of the logistic models showed that the chances of failure for patients requiring a nasogastric tube during HFNC use were more likely than those for patients with oral nutrition (OR = 8.17; 95% CI 2.30-28.99; p = 0.001). The HFNC failure was not associated with the device used (OR = 1.56; 95% CI 0.54-4.52; p = 0.41), time between hospital admission and HFNC installation (OR = 1.01; 95% CI 0.98-1.03; p = 0.73), or age (OR = 0.98; 95% CI 0.82-1.17; p = 0.82). Among late outcomes evaluated, the patients with therapy failure had longer total durations of O2 use (p < 0.001) and longer hospital stays (p < 0.001). The need to use a nasogastric tube during HFNC use was associated with HFNC therapy failure and can be considered as a marker of severity in children with bronchiolitis.

Type 1 diabetes does not impair the physical capacity of non-sedentary adolescents.

BACKGROUND: Type 1 diabetes patients have a higher risk of developing hypoglycemia or hyperglycemia during physical activity, which may compromise their safety during exercise but results regarding the exercise capacity of patients with type 1 DM when compared to control subjects have been contradictory. AIM: To evaluate if type 1 diabetes affects the capacity of adolescents to exercise. METHODS: The study enrolled 37 adolescents in stage 2-4 of the Tanner scale, aged from 10 to 14 years, 21 with type 1 diabetes and 16 without any chronic diseases. All subjects performed an incremental submaximal exercise test in a cycle ergometer. At the end of every test stage, glycemia and blood lactate levels were measured. During the test, heart rate was monitored and the Borg rating of perceived exertion (RPE) was used to assess fatigue. RESULTS: The two groups displayed no significant differences in anthropometric variables. The response to exercise, as evaluated by Borg RPE (p = 0.829), maximum oxygen uptake (VO2max) (p = 0.977), heart rate (p = 0.998), maximum load (p = 0.977), absolute load at lactate threshold (p = 0.377) and relative load at lactate threshold (p = 0.282), was also similar between the control and the type 1 diabetes group. Finally, there were no significant correlations between HbA1c levels, VO2max, duration of disease and pre-test glycemia levels. CONCLUSIONS: We detected no significant differences in lactate threshold, VO2max and heart rate during exercise between healthy adolescents and non-sedentary adolescents with type I diabetes, indicating that both groups had similar physical fitness and, therefore, that type 1 diabetes is not an obstacle for physical activity. This study was approved by the ethical committee of the Hospital Israelita Albert Einstein (Ethical Committee Number: 53638416.9.0000.0071) and free and informed consent was obtained from all participants and their legal representatives.

Manual Ventilation and Sustained Lung Inflation in an Experimental Model: Influence of Equipment Type and Operator's Training.

AIM: To compare the influence of devices for manual ventilation and individual experience on the applied respiratory mechanics and sustained lung inflation. METHODS: A total of 114 instructors and non-instructors from the Neonatal Resuscitation Program of the Brazilian Society of Pediatrics participated in this study. Participants ventilated an intubated manikin. To evaluate respiratory mechanics and sustained lung inflation parameters, a direct comparison was made between the self-inflating bag and the T-shaped resuscitator (T-piece), followed by an analysis of the effectiveness of the equipment according to the participants' education and training. RESULTS: A difference between equipment types was observed for the tidal volume, with a median (interquartile range) of 28.5 mL (12.6) for the self-inflating bag and 20.1 mL (8.4) for the T-piece in the instructor group and 31.6 mL (14) for the self-inflating bag and 22.3 mL (8.8) for the T-piece in the non-instructor group. Higher inspiratory time values were observed with the T-piece in both groups of professionals, with no significant difference between them. The operator's ability to maintain the target pressure over the 10 seconds of sustained lung inflation was evaluated using the area under the pressure-time curve and was 1.7-fold higher with the use of the T-piece. Inspiratory pressure and mean airway pressure applied during sustained lung inflation were greater with the self-inflating bag, as evaluated between the beginning and the end of the procedure. CONCLUSION: The T-piece resulted in lower tidal volume and higher inspiratory time values, irrespective of the operator's experience, and increased the ease of performing the sustained lung inflation maneuver, as demonstrated by the maintenance of target pressure for the desired period and a higher mean airway pressure than that obtained using the self-inflating bag.