Albert Bousso

The impact of daily evaluation and spontaneous breathing test on the duration of pediatric mechanical ventilation: a randomized controlled trial.

Objectives:To assess whether the combination of daily evaluation and use of a spontaneous breathing test could shorten the duration of mechanical ventilation as compared with weaning based on our standard of care. Secondary outcome measures included extubation failure rate and the need for noninvasive ventilation. Design:A prospective, randomized controlled trial. Setting:Two pediatric intensive care units at university hospitals in Brazil. Patients:The trial involved children between 28 days and 15 yrs of age who were receiving mechanical ventilation for at least 24 hrs. Interventions:Patients were randomly assigned to one of two weaning protocols. In the test group, the children underwent a daily evaluation to check readiness for weaning with a spontaneous breathing test with 10 cm H2O pressure support and a positive end-expiratory pressure of 5 cm H2O for 2 hrs. The spontaneous breathing test was repeated the next day for children who failed it. In the control group, weaning was performed according to standard care procedures. Measurements and Main Results:A total of 294 eligible children were randomized, with 155 to the test group and 139 to the control group. The time to extubation was shorter in the test group, where the median mechanical ventilation duration was 3.5 days (95% confidence interval, 3.0 to 4.0) as compared to 4.7 days (95% confidence interval, 4.1 to 5.3) in the control group (p = .0127). This significant reduction in the mechanical ventilation duration for the intervention group was not associated with increased rates of extubation failure or noninvasive ventilation. It represents a 30% reduction in the risk of remaining on mechanical ventilation (hazard ratio: 0.70). Conclusions:A daily evaluation to check readiness for weaning combined with a spontaneous breathing test reduced the mechanical ventilation duration for children on mechanical ventilation for >24 hrs, without increasing the extubation failure rate or the need for noninvasive ventilation.

End-of-life practices in seven Brazilian pediatric intensive care units.

Objective: To evaluate the incidence of life support limitation and medical practices in the last 48 hrs of life of children in seven Brazilian pediatric intensive care units (PICUs). Design: Cross-sectional multicenter retrospective study based on medical chart review. Setting: Seven PICUs belonging to university and tertiary hospitals located in three Brazilian regions: two in Porto Alegre (southern region), two in São Paulo (southeastern region), and three in Salvador (northeastern region). Patients: Medical records of all children who died in seven PICUs from January 2003 to December 2004. Deaths in the first 24 hrs of admission to the PICU and brain death were excluded. Interventions: Two pediatric intensive care residents from each PICU were trained to fill out a standard protocol (&kgr; = 0.9) to record demographic data and all medical management provided in the last 48 hrs of life (inotropes, sedatives, mechanical ventilation, full resuscitation maneuvers or not). Students t-test, analysis of variance, chi-square test, and relative risk were used for comparison of data. Measurements and Main Results: Five hundred and sixty-one deaths were identified; 97 records were excluded (61 because of brain death and 36 due to <24 hrs in the PICU). Thirty-six medical charts could not be found. Cardiopulmonary resuscitation was performed in 242 children (57%) with a significant difference between the southeastern and northeastern regions (p = .0003). Older age (p = .025) and longer PICU stay (p = .001) were associated with do-not-resuscitate orders. In just 52.5% of the patients with life support limitation, the decision was clearly recorded in the medical chart. No ventilatory support was provided in 14 cases. Inotropic drug infusions were maintained or increased in 66% of patients with do-not-resuscitate orders. Conclusions: The incidence of life support limitation has increased among Brazilian PICUs but with significant regional differences. Do-not-resuscitate orders are still the most common practice, with scarce initiatives for withdrawing or withholding life support measures.

Pulmonary surfactant in respiratory syncytial virus bronchiolitis: The role in pathogenesis and clinical implications

Respiratory syncytial virus (RSV) bronchiolitis is the leading cause of lower respiratory tract infection, and the most frequent reason for hospitalization among infants throughout the world. In addition to the acute consequences of the disease, RSV bronchiolitis in early childhood is related to further development of recurrent wheezing and asthma. Despite the medical and economic burden of the disease, therapeutic options are limited to supportive measures, and mechanical ventilation in severe cases. Growing evidence suggests an important role of changes in pulmonary surfactant content and composition in the pathogenesis of severe RSV bronchiolitis. Besides the well‐known importance of pulmonary surfactant in maintenance of pulmonary homeostasis and lung mechanics, the surfactant proteins SP‐A and SP‐D are essential components of the pulmonary innate immune system. Deficiencies of such proteins, which develop in severe RSV bronchiolitis, may be related to impairment in viral clearance, and exacerbated inflammatory response. A comprehensive understanding of the role of the pulmonary surfactant in the pathogenesis of the disease may help the development of new treatment strategies. We conducted a review of the literature to analyze the evidences of pulmonary surfactant changes in the pathogenesis of severe RSV bronchiolitis, its relation to the inflammatory and immune response, and the possible role of pulmonary surfactant replacement in the treatment of the disease. Pediatr. Pulmonol. 2011; 46:415–420.

Brain death: medical management in seven Brazilian pediatric intensive care units

OBJECTIVE To assess the incidence of brain death (BD) and its medical management and adopted protocols after its diagnosis in seven pediatric intensive care units (PICUs) located in three Brazilian regions. METHODS A cross-sectional and multicenter study was conducted, based on the retrospective review of medical records regarding all deaths that occurred between January 2003 and December 2004 in seven Brazilian PICUs of tertiary hospitals located in Porto Alegre (two), São Paulo (two) and Salvador (three). Two pediatric intensive care residents from each hospital were previously trained and filled out a standard protocol for the investigation of demographic data, cause of death, diagnosis of BD, related protocols and subsequent medical management. RESULTS A total of 525 death patients were identified and 61 (11.6%) were defined as BD. The incidence of BD was different (p = 0.015) across the seven PICUs, but with no difference across the three regions. Intracranial hemorrhage was the most frequent cause of BD (31.1%). In 80% of the cases the diagnosis of BD was confirmed by complementary exams (south = 100%, southeast = 68% and northeast = 72%; p = 0.02). The interval between the diagnosis of BD and the withdrawal of life support was different (p < 0.01) across the three regions, being faster (p = 0.04) in the south (1.8+/-1.9 h) than in the southeast (28.6+/-43.2 h) and than in the northeast (15.5+/-17.1 h). Only six (9.8%) children with BD were organ donors. CONCLUSION Although a Brazilian law defining the criteria for the determination of BD has been in place since 1997, we verified that it is not followed as strictly as it should be. Consequently, unnecessary life support is offered to deceased individuals, and there is a discrete involvement of PICUs in organ donation.

Incidência e características endoscópicas de lesões das vias aéreas associadas à intubação traqueal em crianças

OBJECTIVES: describe the incidence and endoscopic characteristics of airway injuries in children submitted to intubation. METHODS: during a two-year period (october/1999-october/2001) we conducted a prospective study in which all patients that required intubation, excluding those who deceased before extubation and newborns (NB) weighing less than 1.250g, were submitted to airway endoscopy at extubation. The endoscopic findings were classified as minor, moderate or severe. Descriptions were made through proportions and medians, comparisons were done through chi-square for proportions. RESULTS: we studied 61 NB and 154 children. In 89.8%, 55 NB and 138 children (P=0.89), it was detected at least one lesion in a total of 507. Patients with minor lesions were 54.8% (IC95%:48.1-61.5), those with moderate were 24.2% (IC95%:18.5-30.0) and severe injury occurred in 10.7% (IC95%:6.6-14.8). Lesions at the glottis (48.1% of lesions) and subglottis (35.1%) presented the highest incidence. Erosions had the highest incidence in both age groups (P=0.88). Vocal folds edema was the main moderate lesion in both groups (P=0.96), followed by ulcerations (P=0.92). Fibrous nodules at vocal folds and adhesions were the main severe injuries in both groups (P=0.12). Subglottic stenosis was detected in 2.8% of the patients without difference between groups (P=0.35). CONCLUSIONS: we observed a high incidence of airway injury, without statistical significant difference between age groups in regard to the incidence and characteristics of the injuries. Minor injury was detected in the majority of the population. Lesions were mainly noticed at the glottis and were characterized by erosions, edema and ulcerations.

Cervical necrotizing fasciitis in an infant caused by Haemophilus non influenzae

We describe a rare case of cervical necrotizing fasciitis caused by Haemophilus non influenzae in a 5-month-old infant who was concomitantly affected by bacteremia, pneumonia and meningitis. The patient had a satisfactory evolution after treatment with antibiotics, intensive clinical support, and five surgical debridements of the lesion. A previously healthy 5-month-old boy was brought to the Emergency Room with fever and enlargement of the neck associated with vomiting and irritability during the 3 previous days. There was no history of previous trauma nor significant infections. The immunization schedule had not included a vaccine against Haemophilus. The infant was found to be febrile, irritable, pale and dehydrated, with signs of respiratory distress and upper airway obstruction. Examination of the oral cavity revealed the presence of a purulent secretion covering the pharynx. The skin in the cervical region appeared stretched and erythematous, and there were dark purple spots in the right submandibular area. The tissues had a hard consistency without fluctuation points. Lung auscultation showed bilateral rales and inspiratory stridor. X-rays of the cervical area showed a hyperextended cervical lordosis and a diffuse radiolucent area in the retropharyngeai region. Ultrasonographic and computerised tomography (CT) of the neck and skull revealed extensive swelling of the soft cervical tissues. The chest scan disclosed condensations in the lower two thirds of the right lung and in the left pulmonary base, which were barely visible in the X-ray. The infant was admitted to the Intensive Care Unit where laboratory tests conducted showed some abnormal blood results: anaemia, leukopenia withneutrophil ia, increased prothrombin and activated partial thromboplastin time, and analysis of the arterial gases revealed hypoxemia. The cerebrospinal fluid yielded an elevated cellularity mostly of polymorphonuclear cells, as well as high protein and low glucose content. CSF bacterioscopy presented intraand extra-cellular gram-negative pleomorphic bacilli, but the culture was found to be negative. Three blood cultures in brain heart infusion (BHI) medium were performed and subsequently replicated in chocolate agar incubated in carbon dioxide [1]. Samples for culture in tryptic soy broth (TSB) with polianetol sodium sulphonate in anaerobiosis were also collected. The clinical laboratory picture led to a diagnosis of necrotizing fasciitis of the cervical region with meningitis and bilateral bronchopneumonia. Due to his respiratory insufficiency, the infant was submitted to orotracheal intubation and mechanical ventilation. Parenteral antimicrobial therapy was started with clindamycin and ceftriaxone. Surgical intervention was subsequently performed to decompress the airways and remove necrotic tissues. Bacterioscopic examination of the secretion showed the presence of gram-negative coccobacilli which, however, did not grow either in BHI subcultured in chocolate agar under CO 2 or in TSB under anaerobiosis. The patient s initial outcome was unfavourable. Another CT scan disclosed the presence of gas in the soft tissues of the cervical region. The blood cultures allowed the identification of Haemophilus sp. non influenzae, resistant to the antibiotics in use but susceptible to chloramphenicol [2]. After the therapeutic change to chloramphenicol, the infant showed overall improvement. However, the cervical lesion continued to show new necrotic areas and four other debridements were performed. The patient was discharged on day 34 and was followed up by the outpatient clinic team for I year, showing no functional impairment or relevant infections. Immunologic evaluation tests remained normal throughout this period. Our literature review revealed that this is the first documented case of necrotizing fasciitis caused by Haemophilus non influenzae in children, although other previous cases may have not been recognized [3, 4]. There are two reports of necrofizing fasciitis in infants caused by Haemophihts influenzae [5, 6]. The first is similar to the one described here in its pharyngeal onset and cervical involvement: however, three other pathogens including two anaerobic bacteria were also involved [5]. In the other case, the bacteria caused an isolated infection in a 13-month-old infants leg where there might have been a previous trauma [6]. In a recent literature review, only Haemophihts influenzae is mentioned among the various bacteria potentially causing necrotizing fasciitis in children, whereas this aetiology is recognized in adults [7, 8]. The most frequent causal agents of necrotizing fasciitis are group A beta-hemolytic streptococci and Staphylococcus aureus which may act separately, in conjunction with, or associated with other pathogens. For the other aerobic and anaerobic bacteria, a synergistic action is considered essential to the occurrence of necrosis of the fascia and other deep soft tissues, but this was not observed in the present case [5, 10]. In our infant, only Haemophihts sp. was isolated from the blood and observed in the material collected from the cervical lesion and the spinal fluid [111 . The hypothesis of a simultaneous occurrence of infection caused by strictly anaerobic bacteria was considered, given the high fiequency of these agents in deep infections of the neck and the local presence of gas revealed by the CT scan [5]. The fact that these agents were neither observed at the microscopy nor isolated from the specific culture led us to the conclusion that these bacteria are probably not involved. It is possible that the tissue gas was produced by Haemophilus non influenzae which can act as a gas-producing facultative anaerobic bacterium [3]. The occasional pathogenicity of Haemophilus non influenzae in various severe diseases in.children as well as its frequent presence in the upper airways are recognized [3]. The high virulence of~the strain involved in the case reported here could be indirectly inferred through observation of multiple infectious sites caused in this immunocompetent infant. Unfortunately, the loss of viability of the strain in culture did not permit a conclusive identification of the species of this Haernophilus non influenzae. There is, however, indirect evidence of the species involved. The bacterial growth was found to be dependent only on factor X

Evaluation of the dead space to tidal volume ratio as a predictor of extubation failure.

OBJECTIVE The objective of this study was to evaluate the ratio of dead space to tidal volume (VD/VT) as a predictor of extubation failure of children from mechanical ventilation. METHODS From September 2001 to January 2003 we studied a cohort consisting of all children (1 day-15 years) submitted to mechanical ventilation at a pediatric intensive care unit who were extubated and for whom pre-extubation ventilometry data were available, including the VD/VT ratio. Extubation success was defined as no need for any type of ventilatory support, invasive or otherwise, within 48 hours. Patients who tolerated extubation, with or without noninvasive support, were defined as success-R and compared with those who were reintubated. Statistic analysis was based on a VD/VT cutoff point of 0.65. RESULTS During the study period 250 children received mechanical ventilation at the pediatric intensive care unit. Eighty-six of these children comprised the study sample. Twenty-one children (24.4%) met the criteria for extubation failure, with 11 (12.8%) of these requiring non-invasive support and 10 (11.6%) reintubation. Their mean age was 16.8 (+/-30.1) months (median = 5.5 months). The mean VD/VT ratio for all cases was 0.62 (+/-0.18). Mean VD/VT ratios for patients with successful and failed extubations were 0.62 (+/-0.17) and 0.65 (+/-0.21) (p = 0.472), respectively. Logistic regression failed to reveal any statistically significant correlation between VD/VT ratio and success or failure of extubation (p = 0.8458), even for patients who were reintubated (p = 0.5576). CONCLUSIONS In a pediatric population receiving mechanical ventilation due to a variety of etiologies, the VD/VT ratio was unable to predict the populations at risk of extubation failure or of reintubation.

Avaliação da relação entre espaço morto e volume corrente como índice preditivo de falha de extubação

OBJETIVO: O objetivo do estudo foi avaliar a relacao entre espaco morto e volume corrente (VD/VT) como preditivo de falha na extubacao de criancas sob ventilacao mecânica. METODOS: Entre setembro de 2001 e janeiro de 2003, realizamos uma coorte, na qual foram incluidas todas as criancas (1 dia-15 anos) submetidas a ventilacao mecânica na unidade de terapia intensiva pediatrica em que foi possivel realizar a extubacao e a ventilometria pre-extubacao com a medida do indice VD/VT. Considerou-se falha na extubacao a necessidade de reinstituicao de algum tipo de assistencia ventilatoria, invasiva ou nao, em um periodo de 48 horas. Para a analise dos pacientes que foram reintubados, definiu-se como sucesso-R a nao reintubacao. Para as analises estatisticas, utilizou-se um corte do VD/VT de 0,65. RESULTADOS: No periodo estudado, 250 criancas receberam ventilacao mecânica na unidade de terapia intensiva pediatrica. Destas, 86 compuseram a amostra estudada. Vinte e uma criancas (24,4%) preencheram o criterio de falha de extubacao, com 11 (12,8%) utilizando suporte nao-invasivo e 10 (11,6%) reintubadas. A idade media foi de 16,8 (±30,1) meses, e a mediana, de 5,5 meses. A media do indice VD/VT de todos os casos foi de 0,62 (±0,18). As medias do indice VD/VT para os pacientes que tiveram a extubacao bem sucedida e para os que falharam foram, respectivamente, 0,62 (±0,17) e 0,65 (±0,21) (p = 0,472). Na regressao logistica, o indice VD/VT nao apresentou correlacao estatisticamente significativa com o sucesso ou nao da extubacao (p = 0,8458), nem para aqueles que foram reintubados (p = 0,5576). CONCLUSOES: Em uma populacao pediatrica submetida a ventilacao mecânica, por etiologias variadas, o indice VD/VT nao possibilitou predizer qual a populacao de risco para falha de extubacao ou reintubacao.

Septic Shock, Necrotizing Pneumonitis, and Meningoencephalitis Caused by Mycoplasma pneumoniae in a Child: A Case Report

Mycoplasma pneumoniae is an important causative agent of respiratory infection in childhood. Although the infection caused by M. pneumoniae is classically described as benign, severe and life-threatening pulmonary and extrapulmonary complications can occur. This study describes the first case of septic shock related to M. pneumoniae in a child with necrotizing pneumonitis, severe encephalitis, and multiple organs involvement, with a favorable outcome after lobectomy and systemic corticosteroids

Epidemiology of Sepsis in Children Admitted to Picus in South America

Objectives: To report the prevalence of sepsis within the first 24 hours at admission and the PICU sepsis-related mortality among critically ill children admitted to PICU in South America. Design: A prospective multicenter cohort study. Setting: Twenty-one PICU, located in five South America countries. Patients: All children from 29 days to 17 years old admitted to the participating PICU between June 2011 and September 2011. Clinical, demographic, and laboratory data were registered within the first 24 hours at admission. Outcomes were registered upon PICU discharge or death. Interventions: None. Measurements and Main Results: Of the 1,090 patients included in this study, 464 had sepsis. The prevalence of sepsis, severe sepsis, and septic shock were 42.6%, 25.9%, and 19.8%, respectively. The median age of sepsis patients was 11.6 months (interquartile range, 3.2–48.7) and 43% had one or more prior chronic condition. The prevalence of sepsis was higher in infants (50.4%) and lower in adolescents (1.9%). Sepsis-related mortality was 14.2% and was consistently higher with increased disease severity: 4.4% for sepsis, 12.3% for severe sepsis, and 23.1% for septic shock. Twenty-five percent of deaths occurred within the first 24 hours at PICU admission. Multivariate analysis showed that higher Pediatric Risk of Mortality and Pediatric Logistic Organ Dysfunction scores, the presence of two or more chronic conditions, and admission from pediatric wards were independently associated with death. Conclusions: We observed high prevalence of sepsis and sepsis-related mortality among this sample of children admitted to PICU in South America. Mortality was associated with greater severity of illness at admission and potentially associated with late PICU referral.