Noninvasive Respiratory Support or Intubation during Stabilization after Birth and Neonatal and Neurodevelopmental Outcomes in Infants Born Preterm at 23-25 Weeks of Gestation.

OBJECTIVE: To examine the association between noninvasive respiratory support (NRS) or tracheal intubation (TI) during stabilization in infants born at 23-25 weeks of gestation and severe brain injury (sBI) or death, and significant neurodevelopmental impairment (sNDI). STUDY DESIGN: A retrospective cohort study of infants born at 23°/7-256/7 weeks of gestation in Canada. We compared infants successfully managed with NRS or TI during 30 minutes after birth. The primary outcomes were sBI or death before discharge, and sNDI among survivors with follow-up data at 18-24 months corrected age. The associations between exposures and outcomes were assessed using logistic regression models, and propensity score-matched analyses. RESULTS: The mean (SD) of gestational age and birth weight were 24.6 (0.6), 24.3 (0.7) weeks [P < .01], and 757 (173), 705 (130) grams [P < .01] in the NRS, and tracheal intubation (TI) groups, respectively, and 77% of infants in the NRS group were intubated by 7 days of age. sBI or death occurred in 25% (283/1118), and 36% (722/2012) of infants in the NRS and TI groups, respectively (aOR and 95% CI 0.74 [0.60, 0.91]). Among survivors with follow-up data, sNDI occurred in 17% (96/551), and 23% (218/937) of infants in the NRS and TI groups, respectively (aOR [95% CI] 0.77 [0.60, 0.99]). In the propensity score-matched analyses (NRS vs TI), results were consistent for sBI or death (OR [95% CI] 0.72 [0.60, 0.86]), but not for sNDI (OR [95% CI] 0.78 [0.58, 1.05]). CONCLUSIONS: Infants born at 23-25 weeks who were successfully managed with NRS, compared with TI, in the first 30 minutes after birth had lower odds of sBI or death before discharge, but had no significant differences in neurodevelopmental outcomes among survivors.

Maternal vaccination against COVID-19 and neonatal outcomes during Omicron: INTERCOVID-2022 study.

BACKGROUND: In early 2023, when Omicron was the variant of concern, we showed that vaccinating pregnant women decreased the risk for severe COVID-19-related complications and maternal morbidity and mortality. OBJECTIVE: This study aimed to analyze the impact of COVID-19 during pregnancy on newborns and the effects of maternal COVID-19 vaccination on neonatal outcomes when Omicron was the variant of concern. STUDY DESIGN: INTERCOVID-2022 was a large, prospective, observational study, conducted in 40 hospitals across 18 countries, from November 27, 2021 (the day after the World Health Organization declared Omicron the variant of concern) to June 30, 2022, to assess the effect of COVID-19 in pregnancy on maternal and neonatal outcomes and to assess vaccine effectiveness. Women diagnosed with laboratory-confirmed COVID-19 during pregnancy were compared with 2 nondiagnosed, unmatched women recruited concomitantly and consecutively during pregnancy or at delivery. Mother-newborn dyads were followed until hospital discharge. The primary outcomes were a neonatal positive test for COVID-19, severe neonatal morbidity index, severe perinatal morbidity and mortality index, preterm birth, neonatal death, referral to neonatal intensive care unit, and diseases during the neonatal period. Vaccine effectiveness was estimated with adjustment for maternal risk profile. RESULTS: We enrolled 4707 neonates born to 1577 (33.5%) mothers diagnosed with COVID-19 and 3130 (66.5%) nondiagnosed mothers. Among the diagnosed mothers, 642 (40.7%) were not vaccinated, 147 (9.3%) were partially vaccinated, 551 (34.9%) were completely vaccinated, and 237 (15.0%) also had a booster vaccine. Neonates of booster-vaccinated mothers had less than half (relative risk, 0.46; 95% confidence interval, 0.23-0.91) the risk of being diagnosed with COVID-19 when compared with those of unvaccinated mothers; they also had the lowest rates of preterm birth, medically indicated preterm birth, respiratory distress syndrome, and number of days in the neonatal intensive care unit. Newborns of unvaccinated mothers had double the risk for neonatal death (relative risk, 2.06; 95% confidence interval, 1.06-4.00) when compared with those of nondiagnosed mothers. Vaccination was not associated with any congenital malformations. Although all vaccines provided protection against neonatal test positivity, newborns of booster-vaccinated mothers had the highest vaccine effectiveness (64%; 95% confidence interval, 10%-86%). Vaccine effectiveness was not as high for messenger RNA vaccines only. Vaccine effectiveness against moderate or severe neonatal outcomes was much lower, namely 13% in the booster-vaccinated group (all vaccines) and 25% and 28% in the completely and booster-vaccinated groups, respectively (messenger RNA vaccines only). Vaccines were fairly effective in protecting neonates when given to pregnant women ≤100 days (14 weeks) before birth; thereafter, the risk increased and was much higher after 200 days (29 weeks). Finally, none of the neonatal practices studied, including skin-to-skin contact and direct breastfeeding, increased the risk for infecting newborns. CONCLUSION: When Omicron was the variant of concern, newborns of unvaccinated mothers had an increased risk for neonatal death. Neonates of vaccinated mothers had a decreased risk for preterm birth and adverse neonatal outcomes. Because the protective effect of COVID-19 vaccination decreases with time, to ensure that newborns are maximally protected against COVID-19, mothers should receive a vaccine or booster dose no more than 14 weeks before the expected date of delivery.

New and personalized ventilatory strategies in patients with COVID-19.

Coronavirus disease (COVID-19) is caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus and may lead to severe respiratory failure and the need for mechanical ventilation (MV). At hospital admission, patients can present with severe hypoxemia and dyspnea requiring increasingly aggressive MV strategies according to the clinical severity: noninvasive respiratory support (NRS), MV, and the use of rescue strategies such as extracorporeal membrane oxygenation (ECMO). Among NRS strategies, new tools have been adopted for critically ill patients, with advantages and disadvantages that need to be further elucidated. Advances in the field of lung imaging have allowed better understanding of the disease, not only the pathophysiology of COVID-19 but also the consequences of ventilatory strategies. In cases of refractory hypoxemia, the use of ECMO has been advocated and knowledge on handling and how to personalize strategies have increased during the pandemic. The aims of the present review are to: (1) discuss the evidence on different devices and strategies under NRS; (2) discuss new and personalized management under MV based on the pathophysiology of COVID-19; and (3) contextualize the use of rescue strategies such as ECMO in critically ill patients with COVID-19.

Analysis of predictors of response to high-flow oxygen nasal cannula therapy in a pediatric intensive care unit.

BACKGROUND: Bronchiolitis is one of the most frequent reasons for admission to pediatric intensive care units. Medical treatment is primarily supportive. The usefulness of high-flow oxygen (HFO) nasal cannula in these patients has been described. This study evaluated the clinical and analytical variables of patients admitted to our Pediatric Intensive Care Unit (PICU) for initiation or continuation of HFO for respiratory distress and to identify any variable that may be a predictor of success or failure of this technique. METHODS: We conducted a retrospective observational study that included infants aged < 24 months admitted to our PICU due to bronchiolitis between January 2015 and March 2019 for HFO. RESULTS: We analyzed the characteristics between responders (n = 112) and non-responders (n = 37). No statistically significant differences were observed between groups regarding sex, age, weight, comorbidities, nasopharyngeal aspirate result, hours of evolution, and respiratory and heart rate. However, a pCO2 ≥ 75 mmHg (p = 0.043) and a SCORE of bronchiolitis severity (p = 0.032) were predictors of HFNC failure. CONCLUSIONS: The pCO2 level and SCORE of bronchiolitis severity are predictors of this respiratory support modality.

INTRODUCCIÓN: La bronquiolitis es uno de los motivos más frecuentes de ingreso en las Unidades de Cuidados Intensivos Pediátricos (UCIP); el tratamiento médico es básicamente de soporte. Se ha descrito la utilidad de la oxigenoterapia de alto flujo (OAF) en estos pacientes. El objetivo de este estudio fue evaluar algunas variables clínicas y analíticas de los pacientes que ingresan en nuestra UCIP para inicio o continuación de OAF ante cuadros de dificultad respiratoria e identificar cualquier variable que pueda ser factor predictor del éxito o fracaso de esta técnica. MÉTODOS: Se realizó un estudio retrospectivo observacional, incluyendo lactantes menores de 24 meses ingresados en la UCIP entre enero de 2015 y marzo de 2019 para OAF ante cuadros de bronquiolitis. RESULTADOS: Se analizaron las características entre el grupo de respondedores (n = 112) y no respondedores (n = 37). No se observaron diferencias estadísticamente significativas en cuanto al sexo, edad, peso, comorbilidades, resultado del aspirado naso-faríngeo, horas de evolución, frecuencia respiratoria, frecuencia cardiaca entre ambos grupos. Sin embargo, una pCO2 ≥75 mmHg (p = 0.043) y un SCORE de gravedad de la bronquiolitis mayor (p = 0.032) fueron factores predictores de fracaso de la OAF. CONCLUSIONES: El nivel de pCO2 y el SCORE de gravedad de la bronquiolitis son factores predictores de esta modalidad de soporte respiratorio.

Analysis of predictors of response to high-flow oxygen nasal cannula therapy in a pediatric intensive care unit / Análisis de factores predictores de respuesta a la oxigenoterapia de alto flujo en una unidad de cuidados intensivos pediátricos

Abstract Background: Bronchiolitis is one of the most frequent reasons for admission to pediatric intensive care units. Medical treatment is primarily supportive. The usefulness of high-flow oxygen (HFO) nasal cannula in these patients has been described. This study evaluated the clinical and analytical variables of patients admitted to our Pediatric Intensive Care Unit (PICU) for initiation or continuation of HFO for respiratory distress and to identify any variable that may be a predictor of success or failure of this technique. Methods: We conducted a retrospective observational study that included infants aged < 24 months admitted to our PICU due to bronchiolitis between January 2015 and March 2019 for HFO. Results: We analyzed the characteristics between responders (n = 112) and non-responders (n = 37). No statistically significant differences were observed between groups regarding sex, age, weight, comorbidities, nasopharyngeal aspirate result, hours of evolution, and respiratory and heart rate. However, a pCO2 ≥ 75 mmHg (p = 0.043) and a SCORE of bronchiolitis severity (p = 0.032) were predictors of HFNC failure. Conclusions: The pCO2 level and SCORE of bronchiolitis severity are predictors of this respiratory support modality.

Resumen Introducción: La bronquiolitis es uno de los motivos más frecuentes de ingreso en las Unidades de Cuidados Intensivos Pediátricos (UCIP); el tratamiento médico es básicamente de soporte. Se ha descrito la utilidad de la oxigenoterapia de alto flujo (OAF) en estos pacientes. El objetivo de este estudio fue evaluar algunas variables clínicas y analíticas de los pacientes que ingresan en nuestra UCIP para inicio o continuación de OAF ante cuadros de dificultad respiratoria e identificar cualquier variable que pueda ser factor predictor del éxito o fracaso de esta técnica. Métodos: Se realizó un estudio retrospectivo observacional, incluyendo lactantes menores de 24 meses ingresados en la UCIP entre enero de 2015 y marzo de 2019 para OAF ante cuadros de bronquiolitis. Resultados: Se analizaron las características entre el grupo de respondedores (n = 112) y no respondedores (n = 37). No se observaron diferencias estadísticamente significativas en cuanto al sexo, edad, peso, comorbilidades, resultado del aspirado naso-faríngeo, horas de evolución, frecuencia respiratoria, frecuencia cardiaca entre ambos grupos. Sin embargo, una pCO2 ≥75 mmHg (p = 0.043) y un SCORE de gravedad de la bronquiolitis mayor (p = 0.032) fueron factores predictores de fracaso de la OAF. Conclusiones: El nivel de pCO2 y el SCORE de gravedad de la bronquiolitis son factores predictores de esta modalidad de soporte respiratorio.

Evaluation of Trends in Bronchopulmonary Dysplasia and Respiratory Support Practice for Very Low Birth Weight Infants: A Population-Based Cohort Study.

OBJECTIVES: To characterize the incidence of bronchopulmonary dysplasia (BPD) over time and to test the association of multilevel factors, including respiratory support, with the diagnosis of BPD. STUDY DESIGN: This population-based cohort study included 40 268 infants born between 22 and 32 weeks of gestation at hospitals in California between 2008 and 2017. The diagnosis of BPD was based on respiratory support at 36 weeks postmenstrual age. Tests for linear trend and multivariable logistic regression analyses were performed. RESULTS: The rate of BPD was consistent year to year, and the mortality rate declined. The incidence of BPD was 23.5% for the overall cohort, 44.9% for infants born at <28 weeks of gestational age, and 45.2% for extremely low birth weight infants. For infants born at >26 weeks of gestational age, the incidence of BPD was significantly decreased in the most recent 3-year period compared with the earlier 3 years (OR, 0.91). Invasive ventilation during delivery room resuscitation (OR, 2.64) and after leaving the delivery room (OR, 10.02) conferred the highest risk of BPD compared with oxygen or no respiratory support. Noninvasive ventilation as maximum respiratory support at 36 weeks increased by 20% over time. CONCLUSIONS: Marked changes in noninvasive support care have occurred without an overall decline in BPD rate. Further research, quality improvement, and strategies, along with noninvasive respiratory support, are needed for a reduction in the incidence of BPD.

Severe hepatopulmonary syndrome with hypoxemia refractory to liver transplant: Recovery after 67 days of ECMO support.

Hepatopulmonary syndrome (HPS) is a complication of end stage liver disease (ESLD) and is manifested by severe hypoxemia, which usually responds to liver transplantation (LT). As compared to patients undergoing LT for other etiologies, patients with HPS present an increased risk of postoperative morbidity and mortality. There is no effective treatment for patients whose hypoxemia does not respond to LT. This subset of patients is at a highly increased risk of death. There are very few reports on the use of extracorporeal membrane oxygenation (ECMO) in this setting with rapid response. However, there is no prior report of ECMO utilization for longer than 4 weeks. We present the case of a 17 year-old male patient who underwent LT for ESLD secondary to chronic portal vein thrombosis and HPS. He received a liver from a deceased donor and presented with severe HPS after LT, requiring ECMO support for 67 days. The patient was discharged home and is breathing in ambient air. He is currently asymptomatic and has a normal liver function.

Evolving changes in mortality of 13,301 critically ill adult patients with COVID-19 over 8 months.

PURPOSE: Clinical characteristics and management of COVID-19 patients have evolved during the pandemic, potentially changing their outcomes. We analyzed the associations of changes in mortality rates with clinical profiles and respiratory support strategies in COVID-19 critically ill patients. METHODS: A multicenter cohort of RT-PCR-confirmed COVID-19 patients admitted at 126 Brazilian intensive care units between February 27th and October 28th, 2020. Assessing temporal changes in deaths, we identified distinct time periods. We evaluated the association of characteristics and respiratory support strategies with 60-day in-hospital mortality using random-effects multivariable Cox regression with inverse probability weighting. RESULTS: Among the 13,301 confirmed-COVID-19 patients, 60-day in-hospital mortality was 13%. Across four time periods identified, younger patients were progressively more common, non-invasive respiratory support was increasingly used, and the 60-day in-hospital mortality decreased in the last two periods. 4188 patients received advanced respiratory support (non-invasive or invasive), from which 42% underwent only invasive mechanical ventilation, 37% only non-invasive respiratory support and 21% failed non-invasive support and were intubated. After adjusting for organ dysfunction scores and premorbid conditions, we found that younger age, absence of frailty and the use of non-invasive respiratory support (NIRS) as first support strategy were independently associated with improved survival (hazard ratio for NIRS first [95% confidence interval], 0.59 [0.54-0.65], p < 0.001). CONCLUSION: Age and mortality rates have declined over the first 8 months of the pandemic. The use of NIRS as the first respiratory support measure was associated with survival, but causal inference is limited by the observational nature of our data.

Liver injury predicts overall mortality in severe COVID-19: a prospective multicenter study in Brazil.

BACKGROUND/PURPOSE: The relationship between liver injury and mortality remains unclear in patients with COVID-19. We aimed to evaluate the prognostic value of aminotransferases levels at hospital admission to predict mortality in patients with COVID-19. METHODS AND RESULTS: This prospective study included 406 patients [57% male, aged 56 years] with COVID-19 hospitalized in 26 centers in Brazil. Overall, 36.7% (95% CI 32.1-41.5) presented at admission with severe disease requiring respiratory support. The prevalence of elevated ALT and AST levels at admission [> 2 × ULN] was 14.0% (95% CI 11.0-17.8) and 12.9% (95% CI 10.0-16.6), respectively. Sixty-two patients [15.3% (95% CI 12.1-19.1)] died during hospitalization and the overall mortality rate was 13.4 (10.5-17.2) deaths per 1000 persons-years. The 15-day-overall survival (95% CI) was significantly lower in patients with ALT levels ≥ 2 × ULN compared to those with ALT < 2 × ULN [67.1% (48.4-80.2) vs 83.4% (76.1-88.6), p = 0.001] and in those with AST levels ≥ 2 × ULN compared to those with AST < 2 × ULN [61.5% (44.7-74.6) vs 84.2% (76.5-89.5), p < 0.001]. The presence of elevated aminotransferases levels at hospital admission significantly increased the risk of in-hospital all-cause mortality adjusted for age-and-sex. Those findings were present in the subgroup of critically ill patients already admitted in need of respiratory support (n = 149), but not in patients without that requirement at admission (n = 257). CONCLUSIONS: Elevated aminotransferases at hospital admission predicted in-hospital all-cause mortality in patients with COVID-19, especially in those with severe disease. Measurement of transaminases levels at hospital admission should be integrated to the care of patients with COVID-19 as an auxiliary strategy to identify patients at higher death risk.

Sugammadex Neuromuscular Blockade Reversal Associated With Lower Postoperative Arterial Carbon Dioxide Levels After Congenital Cardiac Surgery.

OBJECTIVE: To compare postoperative arterial blood gas samples and requirement for respiratory support between patients who received sugammadex versus neostigmine reversal before extubation after congenital cardiac surgery. DESIGN: Retrospective, cross-sectional study. SETTING: Single-center, university-based, tertiary care hospital. PARTICIPANTS: Patients with congenital heart disease undergoing surgery with cardiopulmonary bypass. INTERVENTIONS: Chart review. MEASUREMENTS AND MAIN RESULTS: The first postoperative arterial blood gas measurements were abstracted from electronic medical records, and reintubation or use of positive- pressure respiratory support within the first 24 postoperative hours was documented. Of the 237 charts reviewed, 111 (47%) patients received sugammadex reversal and 126 (53%) received neostigmine. Multivariate models showed that patients with 2-ventricle congenital heart disease who received sugammadex had lower postoperative arterial carbon dioxide partial pressure (PaCO2) values (coefficient -3.1, 95% confidence interval [CI] -5.9 to -0.4; p = 0.026) and required less- noninvasive positive- pressure ventilation (odds ratio 0.3, 95% CI 0.1-0.8; p = 0.021). Single-ventricle congenital heart disease patients who received sugammadex had higher postoperative pH values (coefficient 0.04, 95% CI 0.01-0.06; p = 0.01) and lower PaCO2 values (coefficient -5.2, 95% CI -9.6 to -0.8; p = 0.021). CONCLUSION: Sugammadex reversal was associated with lower postoperative PaCO2 values. In addition, sugammadex reversal was associated with less need for noninvasive positive- pressure ventilation in 2-ventricle patients. The magnitude of the effect appears modest, therefore the clinical significance remains unclear. Additional studies focused on investigating particular patient populations, such as infants, single-ventricle congenital heart disease, or patients with pulmonary hypertension, are needed to identify whether these patients appreciate a greater benefit from sugammadex reversal.

Recomendaciones para la implementación de soporte respiratorio pediátrico en COVID-19. Kinesiología Intensiva y Terapia Respiratoria Pediátrica de Chile / Recommendations for the implementation of pediatric respiratory support in COVID-19. Intensive Kinesiology and Respiratory Therapy Chilean

Resumen: De acuerdo a la información disponible, los pacientes pediátricos con COVID-19 tendrían una me nor frecuencia, se presentarían en su mayoría con un cuadro clínico de leve a moderado, y con una baja tasa de morbimortalidad asociada5. Sin embargo, es incierto el comportamiento real que tendrá el SARS-CoV-2 en Chile, así como tampoco sabemos el impacto que tendrá su interacción con otros virus respiratorios en el desenlace clínico. Asumiendo que los pacientes pediátricos que requieran hospitalización por sospecha o confirmación de COVID-19 necesitarán de diferentes niveles de so porte respiratorio, hemos elaborado recomendaciones transversales fundamentadas en el óptimo manejo del apoyo respiratorio pediátrico, basados en los principios de calidad y eficiencia en la en trega del soporte, en parámetros de bioseguridad y en el uso apropiado de recursos6. Estos elementos que se encuentran relacionados al armado y filtrado de los aerosoles producidos por algunos equipos de soporte ventilatorio, son recomendados en esta guía con el fin de unificar criterios técnicos que permitan entregar un apoyo óptimo al paciente pediátrico, manteniendo la mayor bioseguridad po sible para el paciente y el equipo de salud.

Abstract: According to the available information, pediatric cases of COVID-19 would present less frequently, most of them with mild to moderate clinical picture, and low associated morbidity and mortality5. However, we do not know the actual behavior that SARS-CoV-2 will have in Chile, nor the impact that its interaction with other respiratory viruses will have on the clinical outcome. On the assump tion that pediatric patients requiring hospitalization due to suspicion or confirmation of COVID-19 will need different levels of respiratory support, we have developed wide-range recommendations based on the optimal management of pediatric respiratory support according to the principles of quality and efficiency in the delivery of support, biosafety parameters, and appropriate use of resou rces6. These elements, which are related to assembling and filtering the aerosols produced by some respiratory support equipment, are recommended in this guide in order to unify technical criteria that allow optimal support for the pediatric patient while maintaining the highest possible biosafety for the patient and the health team.

Oxygenation Instability Assessed by Oxygen Saturation Histograms during Supine vs Prone Position in Very Low Birthweight Infants Receiving Noninvasive Respiratory Support.

OBJECTIVE: To evaluate the effect of prone vs supine position on the oxygenation instability among very low birth weight (VLBW) infants receiving noninvasive respiratory support, as assessed by the average oxygen saturation (SpO2) histograms. STUDY DESIGN: Sixty-nine histograms from 23 VLBW infants were studied prospectively. Each infant was studied during 3 consecutive 3-hour periods of alternating positions; 12 infants started the study while prone and 11 infants started supine, by random order. Histogram classification system was used to quantify oxygenation stability and time spent in different SpO2 ranges. RESULTS: The fraction of inspired oxygen values were similar in both positions. Unstable histograms were more common in supine vs prone position (20/34 [59%] vs 10/35 [29%]; P = .02, respectively). Analyzing oxygenation stability as per position change revealed that a change from prone to supine increased oxygenation instability, and supine to prone decreased instability (P = .02). In the supine vs prone position, percent of time spent in SpO2 ≤80% and <90% was higher (5.0 ± 4.2 vs 2.4 ± 3.4 [P < .001] and 24.1 ± 13.7 vs 13.2 ± 10.0 [P < .001], respectively), and percent of time in SpO2 >94% was lower (39.7 ± 26.0 vs 52.4 ± 23.4 [P = .04]). CONCLUSIONS: Prone positioning decreased oxygenation instability and resulted in higher oxygenation among VLBW premature infants on noninvasive respiratory support. SpO2 histograms allow easy bedside assessment of oxygenation instability, and quantification of the time spent at different SpO2 ranges.

Heated Humidifier versus Heat-and-Moisture Exchanger During Positive Pressure Ventilation With a T-Piece Resuscitator in Rabbits.

BACKGROUND: There are many proven benefits of the use of conditioned gases in mechanically ventilated patients. In spite of this, its use in the delivery room is limited, perhaps because of known difficulties with heated humidifiers (HH); moreover, there is no evidence regarding the use of heat-and-moisture exchangers (HME) in a delivery room setting. We sought to asess the airway's absolute humidity level using three diferents strategies: HH, HME and unconditioned gases. METHODS: We conducted an experimental study in 12 intubated rabbits ventilated with a T-piece resuscitator. Absolute humidity levels in inspired gases were measured at baseline and at 5, 10, 15, and 20 min while using HH, HME, or no conditioning method (ie, unconditioned). The animals were initially randomized to one of the 3 interventions, and each animal underwent the other methods with at least 24 h between each test. RESULTS: There were no differences in vital signs at baseline or at the end of the procedures. Mean absolute humidity at the end of the tests was 38.2 ± 1.7 g/m3 for HH, 28.9 ± 4.7 g/m3 for HME, and 13.9 ± 5.1 g/m3 for unconditioned gas (P = .003). CONCLUSIONS: During ventilation with a T-piece resuscitator, the absolute humidity was the highest with HH. The absolute humidity with HME was lower, but it was still significantly more than that with unconditioned gas. Therefore, the use of a T-piece resuscitator with HME could be a good alternative to HH given that positive-pressure ventilation is used ideally for short periods of time in the delivery room.

Update on the diagnosis and management of COVID-19 in pediatric patients

Coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), became a pandemic in March 2020, affecting millions of people worldwide. However, COVID-19 in pediatric patients represents 1-5% of all cases, and the risk for developing severe disease and critical illness is much lower in children with COVID-19 than in adults. Multisystem inflammatory syndrome in children (MIS-C), a possible complication of COVID-19, has been described as a hyperinflammatory condition with multiorgan involvement similar to that in Kawasaki disease or toxic shock syndrome in children with evidence of SARS-CoV-2 infection. This review presents an update on the diagnostic methods for COVID-19, including reverse-transcriptase polymerase chain reaction (RT-PCR) tests, serology tests, and imaging, and summarizes the current recommendations for the management of the disease. Particular emphasis is placed on respiratory support, which includes noninvasive ventilation and invasive mechanical ventilation strategies according to lung compliance and pattern of lung injury. Pharmacological treatment, including pathogen-targeted drugs and host-directed therapies, has been addressed. The diagnostic criteria and management of MIS-C are also summarized.

Optimal Target Range of Closed-Loop Inspired Oxygen Support in Preterm Infants: A Randomized Cross-Over Study.

OBJECTIVE: To investigate the effect of different pulse oximetry (SpO2) target range settings during automated fraction of inspired oxygen control (A-FiO2) on time spent within a clinically set SpO2 alarm range in oxygen-dependent infants on noninvasive respiratory support. STUDY DESIGN: Forty-one preterm infants (gestational age [median] 26 weeks, age [median] 21 days) on FiO2 >0.21 receiving noninvasive respiratory support were subjected to A-FiO2 using 3 SpO2 target ranges (86%-94%, 88%-92%, or 89%-91%) in random order for 24 hours each. Before switching to the next target range, SpO2 was manually controlled for 24 hours (washout period). The primary outcome was the time spent within the clinically set alarm limits of 86%-94%. RESULTS: The percent time within the 86%-94% SpO2 alarm range was similar for all 3 A-FiO2 target ranges (74%). Time spent in hyperoxemia was not significantly different between target ranges. However, the time spent in severe hypoxemia (SpO2 <80%) was significantly reduced during the narrowed target ranges of A-FiO2 (88%-92%; 1.9%, 89%-91%; 1.7%) compared with the wide target range (86%-94%; 3.4%, P < .001). There were no differences between the 88%-92% and 89-91% target range. CONCLUSIONS: Narrowing the target range of A-FiO2 to the desired median ±2% is effective in reducing the time spent in hypoxemia, without increasing the risk of hyperoxemia. TRIAL REGISTRATION: www.trialregister.nl: NTR4368.

A Randomized Trial of Conditioned or Unconditioned Gases for Stabilizing Preterm Infants at Birth.

OBJECTIVE: To determine whether the use of heated-humidified gases for respiratory support during the stabilization of infants <30 weeks of gestational age (GA) in the delivery room reduces rates of hypothermia on admission to the neonatal intensive care unit (NICU). STUDY DESIGN: A multicenter, unblinded, randomized trial was conducted in Melbourne, Australia, between February 2013 and June 2015. Infants <30 weeks of GA were randomly assigned to receive either heated-humidified gases or unconditioned gases during stabilization in the delivery room and during transport to NICU. Infants born to mothers with pyrexia >38°C were excluded. Primary outcome was rate of hypothermia on NICU admission (rectal temperature <36.5°C). RESULTS: A total of 273 infants were enrolled. Fewer infants in the heated-humidified group were hypothermic on admission to NICU (36/132 [27%]) compared with controls (61/141 [43%], P < .01). There was no difference in rates of hyperthermia (>37.5°C); 20% (27/132) in the heated-humidified group compared with 16% (22/141) in the controls (P = .30). There were no differences in mortality or respiratory outcomes. CONCLUSIONS: The use of heated-humidified gases in the delivery room significantly reduces hypothermia on admission to NICU in preterm infants, without increased risk of hyperthermia. CLINICAL TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Register (www.anzctr.org.au) ACTRN12613000093785.

Morbilidad respiratoria en prematuros tardíos y término tempranos / Respiratory morbidity in late preterm and early term infant

INTRODUCCIÓN: Los Recién Nacidos prematuros tardíos (RNPTT) y los Recién Nacidos de Término Temprano (RNTt) son considerados una población de riesgo, con altos índices de ingreso hospitalario y morbimortalidad, mayor cantidad de días de internación y altas tasas de reingreso hospitalario en comparación a los Recién Nacidos de Término Tardío (RNTT). El Síndrome de distrés respiratorio es uno de los principales diagnósticos al ingreso, requiriendo distintos modos de soporte respiratorio, por lo tanto, requieren de cuidados especiales en unidades de media o alta complejidad, significando así un importante costo en salud. OBJETIVOS: Comparar la frecuencia en que se presenta la morbilidad respiratoria (MR) entre RNPTT y en RNTt Vs Recién Nacido a Termino Tardío (RNTT). Establecer factores asociados a MR. Describir los distintos modos de soporte respiratorio utilizados. PACIENTES Y MÉTODOS: Se incluyeron a todos los RNPTT (34 a 36 SEG), y RNTt (37 a 38 SEG) y se compararon con todos los pacientes RNTT (39 a 41 SEG) durante los años 2011 a 2015. Se excluyó a pacientes con malformación o síndrome genético, o derivados de otro centro médico. Análisis estadístico: La frecuencia de MR se consignó en porcentajes. La misma se comparó en ambos grupos utilizando la prueba de Chicuadrado y se realizó el cálculo de Odss Ratio. Las variables maternas o neonatales asociadas a MR se compararon entre los pacientes con o sin MR utilizando prueba U de Mann-Whitney para las variables continuas y Chi-cuadrado para variables categóricas. Las variables con un valor de P ≤ 0.1 en el análisis univariado se incluyeron en un modelo multivariado de regresión logística. El soporte terapéutico utilizado fue descripto en porcentajes y comparados mediante prueba de Chicuadrado y evaluados mediante odss ratio. RESULTADOS: Durante el periodo evaluado se analizaron los datos de 10512 pacientes de los cuales 766 (7,8%) fueron RNPTT, 3654 (92,6%) RNTt y 6087 (57,90%) RNTT. La frecuencia de MR en los RNPTT fue de 202 (26,4%), en los RNTt fue de 115 (3,15%) Vs 46 (0,76%) en los RNTT. El Odss ratio para MR entre RNPTT y RNTt comparado con RNTT respectivamente fue: OR 47.03, IC95% 33.7 a 65.53, P 0.0001, OR 4.26, IC95% 3.02 a 6.02, P 0.0001. (Siendo los RNTT el grupo control. Ver tabla). En el análisis multivariado se observaron factores de riesgo asociados a MR: Patología asociada al embarazo (OR 4,248, IC95% 2,918 a 6,184, P 0.0001), el Apgar menor a 7 a los 5 min (OR 15,09, IC95% 4,64 a 49,03, P 0.0001), el nacimiento por cesárea (OR 2,96 IC95% 2,32 a 3,78, P 0.0001), sexo masculino (OR 1,5 IC95% 1,21 a 2,01, 0,001). En la evaluación en toda la población general se observó al Retardo de Crecimiento Intrauterino (RCIU) como factor protector de MR, (OR 0.51, IC95% 0,29 a 0,92, P 0.029). Los datos en relación al soporte de oxígeno se muestran en la Tabla1. CONCLUSION: Los recién nacidos prematuros tardíos y los recién nacido termino temprano presentaron mayor morbilidad respiratoria comparado con los recién nacidos termino tardío. Los factores de riesgo más preponderantes para MR fueron la prematurez, el nacimiento por cesárea, nacer con Apgar menor a 7 a los 5 min y la existencia de patología materna asociada al embarazo. Los RNPTT y RNTT son una población de riesgo (mayor requerimiento de internación, más días de internación, mayor morbilidad respiratoria y mayor soporte de oxigeno), por lo que se deben de adoptar medidas preventivas para lograr disminuir los factores de riesgo que generan el nacimiento prematuro tardío y término temprano y así lograr disminuir los índices de morbi mortalidad y costos en salud que estos implican. (AU)

INTRODUCTION: Late Preterm Newborns (LPN) and Early Term newborns (ETN) are considered to be at risk, because they have high rates of hospital admission, morbidity and mortality, more days of hospitalization, and high rates of hospital readmission compared To Late term Newborns (LTN). Respiratory distress syndrome is one of the major diagnoses on admission, requiring different modes of respiratory support, therefore, require special care in medium or high complexity neonatal units, meaning a significant health cost. OBJETIVES: Compare the frequency of respiratory morbidity (RM) between late preterm and early term infants Vs complete or late term newborns. Establish factors associated with RM. Describe the different modes of oxigen respiratory support used. PATIENTS AND METHODS: All LPN (34-36 SEGs) and ETN (37-38 SEGs) were included and compared to all LTN (39-41 SEGs) during the years 2011 to 2015. Were excluded patients With malformation or genetic syndrome, or derived from another medical center. Statistical analysis: The frequency of RM was recorded in percentages. The same was compared in both groups using the Chi-square test and the Odss Ratio calculation was performed. Maternal or neonatal variables associated with RM were compared between patients with or without RM using Mann-Whitney U test for continuous variables and Chisquare for categorical variables. Variables with a value of P ≤ 0.1 in the univariate analysis were included in a multivariate logistic regression model. The therapeutic support used was described in percentages and compared by chi-square test and evaluated by odss ratio. RESULTS: Data from 10512 patients were analyzed in the evaluation periode, of which 766 (7.8%) were LPN, 3654 (92.6%) ETN and 6087 (57.90%) LTN. The frequency of RM in the LPN was 202 (26.4%), in the ETN it was 115 (3.15%) vs 46 (0.76%) in the LTN, the odss ratio for RM comparing LPN and ETN with LTN respectively was: OR 47.03, 95% CI 33.7 to 65.53, P 0.0001, OR 4.26, IC95% 3.02 to 6.02, P 0.0001 (LTN being the control group. See table). In the multivariate analysis it was observed the risk factors asociated with RM: the pathology associated with pregnancy (OR 4.248, 95% CI 2.918 to 6.184, P 0.0001), Apgar less than 7 at 5 min (OR 15.09, 95% CI 4.64 to 49.03, P 0.0001). Cesarean birth (OR 2.96, IC95% 2.32 a 3.78, P 0.0001) and Male sex (OR 1,5 IC95% 1,21 a 2,01 P 0,001). In the evaluation in the general population, the Intrauterine Growth Retardation (IUGR) was observed as a protective factor of MR, (OR 0.51, 95% CI 0.29 to 0.92, P 0.029). The data in relation to the oxygen support are shown in Table 1. CONCLUSION: Late preterm infants and early term infants presented higher respiratory morbidity compared to late term newborns. The most important risk factors for RM were prematurity, cesarean birth, birth with Apgar less than 7 at 5 minutes and the existence of maternal pathology associated with pregnancy. The LPN and ETN are a population at risk (greater requirement of hospitalization, more days of hospitalization, greater respiratory morbidity and greater support of oxygen), so that preventive actions must be taken to reduce the risk factors who give late preterm and early term birth and thus reduce morbidity rates and health costs that these imply. (AU)