Factors Associated With Accidental Decannulation in Tracheostomized Children.

BACKGROUND: Tracheostomy has many benefits for pediatric patients in the ICU, but it is also associated with complications. Accidental decannulation (AD) is a frequent complication and cause of mortality in this population. Our study aimed to determine the factors associated with AD in tracheostomized pediatric subjects. METHODS: This was a case-control study with 1:2 allocation ratio. Participants were tracheostomized children hospitalized in a prolonged mechanical ventilation hospital between 2013-2018. Each child who experienced decannulation during the study period was included as a case at the time of the event. Controls were obtained from the same population and were defined as subjects without an AD event during the same period. RESULTS: One hundred forty patients were hospitalized at Josefina Martinez Hospital at the time, of whom 41 were selected as cases and 82 as controls. Median (interquartile range) age was 20 (12-36) months, being 60% male. The median time from tracheostomy placement to AD event was 364 (167-731) d. Eighty-four percent of subjects were mechanically ventilated. AD mainly occurred by self-decannulation (53.7%). The risk of AD was higher in children who reached the midline in a sitting position (odds ratio 9.5 [95% CI 1.59-53.90]), inner diameter (ID) tracheostomy tube size ≤ 4.0 mm (odds ratio 5.18 [95% CI 1.41-19.06]), and who had been hospitalized in hospital rooms with a low ratio of nursing staff for each subject (1 nurse to 4 subjects) (odds ratio 4.48 [95% CI 1.19-16.80]). CONCLUSIONS: Factors associated with a higher risk of AD in tracheostomized children included the ability to reach the midline in a sitting position, the use of a smaller tracheostomy tube (≤ 4.0 mm ID), and lower supervision from staff.

[Reference values for the 6-minutes walking test in healthy Chilean children]. / Valores de referencia del test de marcha de seis minutos en niños sanos.

BACKGROUND: The 6-minutes walking test (6WT) is the ideal submaximal test for the evaluation and follow-up of patients with chronic respiratory diseases. There are no reference values (RV) for Chilean children using the American Thoracic Society guidelines. AIM: To generate 6WT reference values for Chilean children aged 6 to 14 years. MATERIAL AND METHODS: 6MW was evaluated in 192 healthy children (100 women) aged between 6 and 14 years. The test was carried out in a 30 m long indoor flat surface. Children also answered a survey about health problems and their weight and height were recorded. RESULTS: The distance walked by women and men was 596.5 ± 57 and 625 ± 59.7 m respectively (p < 0.05). There was a significant correlation between the distance walked and height (r = 0.58), age (r = 0.56), weight (r = 0.54) and reserve heart rate (r = 0.21). CONCLUSIONS: These results can be used as reference values for the 6WT in Chilean children aged 6 to 14 years. They are similar to those reported abroad.

Reliability and validity of the revised impact on family scale (RIOFS) in the hospital context.

BACKGROUND: The lack of formal instruments to measure Burden in primary caregivers of Children in a hospital context is limited because mostly of published instruments are related to cancer survivors, ambulatory environment or general context for children with chronic conditions, but none of them adapted property to prolonged hospitalization context. This leaves the rising population of hospitalized chronic children's caregivers without a proper assessment. The aim of this study was to develop a version of the Revised Impact on Family Scale adapted to primary caregivers of chronic hospitalized children. A cross-sectional study with two main stages was conducted. The first one describes the linguistic and contextual adaptation process of the instrument, and the second refers to the psychometric testing and analysis.. RESULTS: Less than 15% of the participants expressed problems with some adapted items in the scale. Eighty-six caregivers were evaluated at Josefina Martinez Hospital, mostly female (34.2 ± 11.6 years old). Majority of participants were graduated from high school, salaried employee and mothers of the chronic child. The scale exhibits a high level of internal consistency (Cronbach's alpha 0.73), excellent intra-observer reliability (Intraclass Correlation Coefficient 0.9), acceptable empirical evaluation of content validity and low and negative construct validity (Pearson's correlation coefficient - 0.23). CONCLUSIONS: This adapted version of the Revised Impact on Family Scale to the hospital context is a reliable, valid, self-administered and simple instrument to implement in order to assess the burden of primary caregivers with chronic hospitalized children.

Impact of a Noninvasive Ventilation Protocol in Hospitalized Children With Acute Respiratory Failure.

BACKGROUND: Noninvasive ventilation (NIV) has proven to be useful in the management of children with acute respiratory failure as a result of acute lower respiratory infection. Despite this, evidence addressing the initiation and/or discontinuation criteria of NIV in children remains limited. The objective of this study was to evaluate the usefulness and clinical impact of an NIV protocol in hospitalized children with acute respiratory failure because of acute lower respiratory infection. METHODS: A randomized controlled clinical trial was carried out among subjects admitted during the winter season at Hospital Josefina Martinez between May and October of 2013. Inclusion criteria were age 3 months to 2 y, diagnosis of acute lower respiratory infection and requiring NIV according to a Modified Wood Scale score of ≥ 4 points. Subjects were randomized to NIV management according to medical criteria (control group) or to protocolized management of NIV (protocol group). Hours of NIV, hospital stay, and supplemental oxygen use after discontinuation of NIV, severity changes after NIV initiation, respiratory symptoms, and proportion of intubations were considered as events of interest. RESULTS: A total of 23 subjects were analyzed in the control group and 24 were analyzed in the protocol group. Hours of hospital stay, NIV, and supplemental oxygen post-NIV were not significantly different between groups (P = .70, .69, and .68, respectively). There were also no differences in intubation rate (3 of 29 for the control group and 2 of 31 for the protocol group). For the total sample there was a statistically significant decrease in the Modified Wood Scale score after 1 h of NIV (P < .001). A similar result was observed when performing a stratified intragroup analysis. CONCLUSIONS: We observed that the implementation of an NIV management protocol that integrates initiation and discontinuation criteria for NIV is feasible. However, its use showed no advantages over a non-protocolized strategy.

Razonamiento clínico en kinesiología mediante aprendizaje basado en casos / Clinical reasoning in kinesiology by case-based learning

Introducción: En cursos clínicos con gran número de estudiantes, las experiencias clínicas con pacientes reales son limitadas, dificul-tando el logro de objetivos de aprendizaje. La didáctica aprendizaje basado en casos (ABC) promueve el pensamiento crítico y trabajo coolaborativo, aspectos esenciales para desarrollar competencias profesionales. El objetivo de este estudio fue reportar si la incorpo-ración de la metodología ABC en una asignatura clínica curricular promueve el razonamiento clínico en la formación en kinesiología. Metodología: En la asignatura curricular "evaluación cardiorrespiratoria en kinesiología", 10 grupos de 7 estudiantes desarrollaron casos clínicos de temas disciplinares seleccionados bajo criterio de jueces por expertos del área, y lo presentaron al resto de sus compañeros. Un académico guió la reflexión del tema tratado en el ABC, fomentando la discusión entre los estudiantes. Al finalizar la asignatura se evaluó la percepción de la didáctica educativa mediante encuesta y logro de objetivos de aprendizaje con indicadores académicos. Resultados: Los estudiantes reportaron gran satisfacción con la metodología, mayor preparación para actividades de campo clínico y mejoras en sus habilidades comunicacionales. El promedio obtenido en las interrogaciones y en las actividades clínicas fue superior a versiones previas de la asignatura, aumentando el porcentaje de aprobación y satisfacción con el curso. Conclusión: La incorporación de la didáctica de ABC fomentó el razonamiento clínico, reflexión y habilidades comunicacionales mejorando el rendimiento académico y promoviendo competencias profesionales. Como producto final se elaboró un libro de descarga libre con los temas tratados en los ABC, titulado: "Identificando problemas kinesiológicos: aprendizaje basado en casos".

Introduction: In clinical courses with a large number of students, clinical experiences with real patients are limited, difficult to achieve the learning objectives. The 'Case-Based Learning' (CBL), like educational methodology, promotes critical thinking and improve collaborative work, which are essential aspects of the development of professional skills. The objective of this study was to report how the incorporation of the CBL methodology in a clinical course promoted the clinical reasoning in kinesiology students. Methodology: In the curriculum subject ten groups of seven students analyzed different clinical cases and presented them to their classmates. The CBL topics were selected by academic experts, who also guided and encouraged the discussion among the students. An online survey at the end of the course assessed perceptions students participated in this methodology. The final academic indicators assessed the learning objectives of the course achieved by students that participated with this methodology. Results: The students reported high satisfaction with the CBL methodology. They showed better preparation for clinical experiences and an improvement in their communication skills. The final marks obtained in the interrogations and the clinical practice activities were higher than in previous years. There was an increase in academic approval and student satisfaction with the course. Conclusion: The incorporation of the CBL methodology enhanced clinical reasoning, reflection, and communication skills, improving academic performance, and promoting professional skills. The topics covered in the CBLs conformed a free download book, entitled: «Identifying kinesiology problems: case-based learning.

Evaluación del trabajo respiratorio mediante oxigenación muscular / Assessment of work of breathing using muscle oxygenation

RESUMEN El aumento del trabajo respiratorio (work of breathing, WOB) es uno de los problemas kinesiológicos frecuentes en el quehacer clínico. Un desafío profesional es contar con valores de variables fisiológicas que permitan objetivar el WOB facilitando así su interpretación entre los diferentes profesionales de la salud. El uso de dispositivos portátiles que registran la longitud de onda cercana al rango infrarrojo (680- 820 nm, Near Infrared Spectroscopy (NIRS)) en músculos superficiales permite obtener valores de hemoglobina total unida a oxígeno (tHb) y oxigenación muscular local (SmO2), variables relacionadas al trabajo muscular pues reportan el flujo sanguíneo en la microcirculación y consumo de oxígeno local, respectivamente. Estos dispositivos situados en musculatura intercostal nos informan el WOB asociado a la respiración. Para evaluar esto, se analizó el comportamiento de tHb y SmO2 en m. intercostal en 20 corredores de maratón durante la valoración de consumo de oxígeno máximo (VO2- max), instancia que implica aumento sostenido e incremental de la ventilación pulmonar (��E), y por tanto de la actividad muscular respiratoria. El aumento de V E en 128,4 L·min-1 ( ��E (máximo-reposo)) implicó una disminución en SmO2- m.intercostal del 34% ( SmO2 (reposo-máximo)), sin cambios en tHb (p=0,805). La tuvo una correlación inversa con SmO2-m.intercostal (rho=-0.565; p=0,001). Se concluye que la valoración de SmO2-m.intercostal es una forma novedosa de objetivar el WOB en sujetos sanos. Conocer la aplicabilidad clínica requiere de otros estudios que evalúen esta herramienta en pacientes con disfunciones cardiorrespiratorias, lo que permitiría incorporar su uso en nuestro desarrollo clínico profesional.

The work of breathing (WOB) increased is a commonkinesiological problems at the clinical practice. A professional challenge is to have values of physiological variables that allows to objective the WOB, thus facilitating its interpretation among different health professionals. The use of portable devices that measure by spectroscopy the near-infrared wavelength (680-820 nm) atsuperficial muscles allows to obtain values of total hemoglobin linked to oxygen (tHb) and local muscle oxygenation (SmO2), variables related to muscle work because give information of the blood flow at the microcirculation and local oxygen consumption, respectively. These devices located at the m.intercostal could give information about the WOB associated to breathing. To evaluate this, the tHb and SmO2 of the m.intercostal in 20 marathon runners were analyzed while they doing the maximum oxygen consumption test (VO2-max), an exercise that increase the pulmonary ventilation and the respiratory muscle activity. The increase of V E (128,4 L·min-1((max-rest)) implied a decrease in SmO2- m.intercostal (34% ( SmO2 (max-rest)), without changes in tHb (p=0.805). The showedan negative correlation to SmO2-m.intercostal (rho= -0.565; p=0.001). It is concluded that the assessment of SmO2-m.intercostal is a novel way to measure the WOB in healthy subjects. Their clinical applicability requires more studies that applied this tool in patients with cardiorespiratory dysfunctions, facilitating their incorporation in the professional clinical practice.

Guí­as de rehabilitación respiratoria en niños con enfermedades respiratorias crónicas: actualización 2016 / Pulmonary rehabilitation guidelines in children with chronic respiratory diseases: 2016 update

Pulmonary rehabilitation (PR) is an essential tool in the management of chronic respiratory diseases in childhood. PR improve symptoms, physical performance, quality of life and social integration in children who have limitations in their daily activities. Health professionals have a key role in identifying those children who are candidates for pulmonary rehabilitation programs, in the initial evaluation and in the implementation of therapeutic strategies for training and education. This document is intended as a reference guide for all those professionals who are dedicated to the care of children with chronic respiratory diseases.

La rehabilitación respiratoria (RR) es un componente esencial en el manejo de las enfermedades respiratorias crónicas en la infancia. La RR ha demostrado mejorar los síntomas, el rendimiento físico, la calidad de vida y su participación social en aquellos niños que tienen limitaciones en el desarrollo de sus actividades de la vida diaria. Los profesionales de la salud tienen un rol fundamental en identificar aquellos niños que son candidatos para los programas de rehabilitación respiratoria, en la evaluación inicial y en la implementación de estrategias terapéuticas de entrenamiento y de educación. Este documento pretende ser una guía de consulta para todos aquellos profesionales que se dedican a la atención de niños con enfermedades respiratorias crónicas.

Valores de referencia del test de marcha de seis minutos en niños sanos / Reference values for the 6-minutes walking test in healthy Chilean children

Background: The 6-minutes walking test (6WT) is the ideal submaximal test for the evaluation and follow-up of patients with chronic respiratory diseases. There are no reference values (RV) for Chilean children using the American Thoracic Society guidelines. Aim: To generate 6WT reference values for Chilean children aged 6 to 14 years. Material and Methods: 6MW was evaluated in 192 healthy children (100 women) aged between 6 and 14 years. The test was carried out in a 30 m long indoor flat surface. Children also answered a survey about health problems and their weight and height were recorded. Results: The distance walked by women and men was 596.5 ± 57 and 625 ± 59.7 m respectively (p < 0.05). There was a significant correlation between the distance walked and height (r = 0.58), age (r = 0.56), weight (r = 0.54) and reserve heart rate (r = 0.21). Conclusions: These results can be used as reference values for the 6WT in Chilean children aged 6 to 14 years. They are similar to those reported abroad.

Guía clínica para el diagnóstico y cuidado de niños/adolescentes con bronquiolitis obliterante post-infecciosa, 2009 / Clinical guidelines for the diagnosis and care of children and adolescents with post-infectious bronchiolitis obliterans, 2009

La bronquiolitis obliterante (BO) es un síndrome clínico poco frecuente en niños, caracterizado por la obstrucción crónica al flujo de aire asociado a cambios inflamatorios y distintos grados de fibrosis en la vía aérea pequeña. Si bien existen muchas etiologías, la causa mas frecuente se asocia a infeccionesrespiratorias virales, principalmente adenovirus. No existe un consenso para establecer su diagnóstico; sin embargo, se considera un espectro de síntomas persistentes asociados a un patrón en mosaico, bronquiectasias y atelectasias persistentes. El rol de la biopsia pulmonar ha sido cuestionado por subajo rendimiento, invasividad y complicaciones. No existe un tratamiento específico por lo que elmanejo es soporte. Probablemente la mejor estrategia constituya el empleo de antibióticos en forma agresiva, soporte kinésico y nutricional constante y una precoz rehabilitación pulmonar. Estas guías clínicas representan un esfuerzo multidisciplinario, basado en evidencias actuales para brindarherramientas prácticas para el diagnóstico y cuidado de niños y adolescentes con BO post infecciosa.

Asistencia mecánica de la tos: dispositivo de tos asistida, in-exsufflator / In-exsufflator assisted cough devices

Este capitulo describe los fundamentos e indicaciones del equipo electromecánico de tos asistida, “in-exsufflator”, en pacientes con enfermedades neuromusculares u otras condiciones que comprometen la eficacia en la remoción de las secreciones traqueobronquiales relacionadas a mecanismos de tos ineficiente. Se señalan los criterios de selección para la entrega de esta terapia kinésica y el funcionamiento básico de este dispositivo. Además se propone un protocolo complementario de manejo kinésico para pacientes neuromusculares usuarios de asistencia ventilatoria no invasiva e invasiva.