Rapid diagnosis of respiratory distress syndrome by oral aspirate in premature newborns / Diagnóstico rápido da síndrome do desconforto respiratório por aspirado bucal em recém-nascidos prematuros

Abstract Objective: The stable microbubble test on gastric aspirate and on amniotic fluid has been used for the diagnosis of respiratory distress syndrome in the newborn. However, no study has performed this test on oral aspirates from premature infants. The objective of this study was to evaluate the performance of the stable microbubble test on oral aspirates from preterm newborns to predict respiratory distress syndrome. Method: This study included infants with gestational age <34 weeks. Oral fluids were obtained immediately after birth and gastric fluids were collected within the first 30 minutes of life. The samples were frozen and tested within 72 hours. Results: The sample was composed of paired aspirates from 64 newborns, who were divided into two groups: respiratory distress syndrome group (n = 21) and control group (n = 43). The median (interquartile range) of the stable microbubble count in the oral samples of infants with respiratory distress syndrome was significantly lower than that of infants who did not develop respiratory symptoms: respiratory distress syndrome group = 12 (8 -22) stable microbubbles/mm2; control group = 100 (48 -230) microbubbles/mm2 (p < 0.001). The correlation between microbubble count in gastric and oral aspirates was 0.90 (95% confidence interval = 0.85 -0.95; p < 0.001). Considering a cut-off point of 25 microbubbles/mm2, the sensitivity and the specificity of the stable microbubble test were 81.4% and 85.7%, respectively. Conclusion: The study suggests that the stable microbubble test performed on oral aspirate is a reliable alternative to that performed on gastric fluid for the prediction of respiratory distress syndrome in the newborn.

Resumo Objetivo: O teste das microbolhas estáveis no aspirado gástrico e no líquido amniótico foi usado no diagnóstico da síndrome do desconforto respiratório do recém-nascido. Contudo, nenhum estudo fez esse teste nos aspirados bucais de neonatos prematuros. O objetivo deste estudo foi avaliar o desempenho do teste das microbolhas estáveis em aspirados bucais de recém-nascidos prematuros para prever síndrome do desconforto respiratório. Método: Este estudo incluiu neonatos com idade gestacional < 34 semanas. Os fluidos orais foram obtidos imediatamente após o nascimento e os fluidos gástricos foram coletados nos primeiros 30 minutos de vida. As amostras foram congeladas e testadas em 72 horas. Resultados: A amostra foi composta de aspirados pareados de 64 recém-nascidos, divididos em dois grupos: grupo de síndrome do desconforto respiratório (n = 21) e grupo de controle (n = 43). A mediana (intervalo interquartil) da contagem das microbolhas estáveis nas amostras de fluido oral dos neonatos com síndrome do desconforto respiratório foi significativamente menor que a dos neonatos que não desenvolveram sintomas respiratórios: grupo de síndrome do desconforto respiratório = 12 (8-22) microbolhas estáveis/mm2; grupo de controle = 100 (48-230) microbolhas/mm2 (p < 0,001). A correlação entre a contagem das microbolhas nos aspirados gástricos e bucais foi 0,90 (intervalo de confiança de 95% = 0,85-0,95; p < 0,001). Considerando um ponto de corte de 25 microbolhas/mm2, a sensibilidade e a especificidade do teste das microbolhas estáveis foram 81,4% e 85,7%, respectivamente. Conclusão: O estudo sugere que o teste das microbolhas estáveis feito no aspirado bucal é uma opção confiável ao fluido gástrico para a predição da síndrome do desconforto respiratório do recém-nascido.

Rapid diagnosis of respiratory distress syndrome by oral aspirate in premature newborns.

OBJECTIVE: The stable microbubble test on gastric aspirate and on amniotic fluid has been used for the diagnosis of respiratory distress syndrome in the newborn. However, no study has performed this test on oral aspirates from premature infants. The objective of this study was to evaluate the performance of the stable microbubble test on oral aspirates from preterm newborns to predict respiratory distress syndrome. METHOD: This study included infants with gestational age <34 weeks. Oral fluids were obtained immediately after birth and gastric fluids were collected within the first 30 minutes of life. The samples were frozen and tested within 72 hours. RESULTS: The sample was composed of paired aspirates from 64 newborns, who were divided into two groups: respiratory distress syndrome group (n=21) and control group (n=43). The median (interquartile range) of the stable microbubble count in the oral samples of infants with respiratory distress syndrome was significantly lower than that of infants who did not develop respiratory symptoms: respiratory distress syndrome group=12 (8-22) stable microbubbles/mm2; control group=100 (48-230)microbubbles/mm2 (p<0.001). The correlation between microbubble count in gastric and oral aspirates was 0.90 (95% confidence interval=0.85-0.95; p<0.001). Considering a cut-off point of 25microbubbles/mm2, the sensitivity and the specificity of the stable microbubble test were 81.4% and 85.7%, respectively. CONCLUSION: The study suggests that the stable microbubble test performed on oral aspirate is a reliable alternative to that performed on gastric fluid for the prediction of respiratory distress syndrome in the newborn.

Surfactant deficiency in full-term newborns with transient tachypnea delivered by elective C-section.

INTRODUCTION: Previous studies have suggested that full-term newborns delivered by elective cesarean section who develop transient tachypnea have low gastric microbubble counts. In the present study, microbubble concentrations in oral fluid samples were used to evaluate pulmonary maturity. OBJECTIVE: To evaluate lung maturity in full-term newborns delivered by elective caesarean section using the stable microbubble test in oral aspirates collected at birth. METHOD: The study involved newborns with gestational age >37 weeks delivered by elective cesarean section. Oral fluid samples were obtained in the delivery room immediately after birth, and gastric fluid was collected within the first hour of life. Samples were frozen and analyzed by two blinded researchers. RESULTS: The sample comprised 544 newborns. Twenty-two were diagnosed with transient tachypnea of the newborn by the assisting physician, and required admission to the Neonatal Intensive or Intermediate Care Unit. The median (interquartile range) of the number of microbubbles in the oral samples of these patients was 67.5 (45-150) microbubbles/mm(2) . The remaining 498 newborns without respiratory difficulties had a count of 350 (150-750) microbubbles/mm(2) -P < 0.001. Gastric fluid tests revealed a count of 150 (82.5-700) microbubbles/mm(2) for neonates with respiratory difficulties, and of 600 (216-1125) microbubbles/mm(2) -P < 0.05 for those without respiratory symptoms. CONCLUSION: The present results suggest that transient tachypnea of the newborn is associated with surfactant dysfunction. Pediatr Pulmonol. 2016;51:596-600. © 2015 Wiley Periodicals, Inc.

Surfactant with and without bronchoalveolar lavage in an experimental model of meconium aspiration syndrome.

OBJECTIVES: To assess the effect of surfactant administration, preceded or not by bronchoalveolar lavage (BAL) with dilute surfactant, on pulmonary function in experimental severe meconium aspiration syndrome. METHODS: Twenty-one newborn pigs received 20% meconium in saline intratracheally and were randomly allocated to one of three groups: I, control; II, surfactant only (poractant alfa, 200 mg/kg); or III, dilute surfactant BAL followed by 125 mg/kg surfactant. Arterial blood gases (ABGs), lung compliance, and resistance were assessed. RESULTS: Thirty minutes after treatment, mean PaO2 (mm Hg) increased to 72 in group I, to 106 in group II and to 172 in group III (P=0.01). After 3 h, mean PaO2 (mm Hg) was 70 in group I, 95 in group II and 198 in group III (P<0.01). After 6 h, it was 79 in group I, 110 in group II, and 217 in group III (P=0.01). From the 30-min point onward, there were significant differences among treatment groups in all other parameters and at every point of assessment, except for compliance and resistance 3 h after treatment. CONCLUSIONS: BAL with dilute surfactant, followed by an additional dose of surfactant, produced significant improvements in ABGs and pulmonary mechanics as compared with a single dose of surfactant.

Surfactant deficiency in infants with severe acute viral bronchiolitis.

OBJECTIVES: To evaluate surfactant content and function through the lamellar body count (LBC) and stable microbubble test (SMT) in mechanically ventilated infants with severe acute viral bronchiolitis. STUDY DESIGN: Controlled cross-sectional study of 32 infants receiving mechanical ventilation: 16 with a diagnosis of acute viral bronchiolitis and 16 with normal lungs. Tracheal fluid was collected and LBC was performed in an automated cell counter. Samples were kept frozen and thawed for testing. At the time of analysis, samples were diluted in a dithiothreitol solution, vortexed for 10 seconds, and aspirated by the cell counter. SMT was performed using the Pattle technique. RESULTS: In the bronchiolitis group, the median (IQR) LBC was significantly lower than in the control group: 130,000 (61,250-362,250) vs. 518,000 (180,250-896,000) lamellar bodies/µL; P = .003. Median (IQR) SMT values were also significantly lower in the bronchiolitis group: 10 (2-13) vs. 400 (261-615) microbubbles/mm2; P < .001. CONCLUSIONS: Infants with acute viral bronchiolitis have reduced surfactant content and function. We speculate that these simple tests may be useful to identify infants with bronchiolitis who would benefit from surfactant replacement therapy.

Experimental model of atelectasis in newborn piglets.

BACKGROUND: There are few studies using animal models in chest physical therapy. However, there are no models to assess these effects in newborns. This study aimed to develop a model of obstructive atelectasis induced by artificial mucus injection in the lungs of newborn piglets, for the study of neonatal physiotherapy. METHODS: Thirteen newborn piglets received artificial mucus injection via the endotracheal tube. X-rays and blood gas analysis confirmed the atelectasis. RESULTS: The model showed consistent results between oxygenation parameters and radiological findings. Ten (76.9%) of the 13 piglets responded to the intervention. This did not significantly differ from the expected percentage of 50% by the binomial test (95% CI 46.2-95%, P = .09). CONCLUSIONS: Our model of atelectasis in newborn piglets is both feasible and appropriate to evaluate the impact of physical therapies on atelectasis in newborns.

Surfactant deficiency in transient tachypnea of the newborn.

OBJECTIVE: To evaluate surfactant production and function in term neonates with transient tachypnea of the newborn (TTN). STUDY DESIGN: Samples of gastric aspirates collected within 30 minutes of birth from 42 term newborns with gestational age ≥ 37 weeks (21 patients with TTN and 21 control subjects), delivered via elective cesarean delivery, were analyzed with lamellar body count and stable microbubble test. RESULTS: Results of lamellar body counts and stable microbubble tests were significantly lower in the TTN group than in control subjects (P = .004 and .013, respectively). Lamellar body counts were significantly lower in infants with TTN requiring oxygen for ≥ 24 hours after birth than in infants requiring oxygen for < 24 hours (P = .029). When the cutoff point was 48 hours, the stable microbubble count was significantly lower in the group requiring oxygen for ≥ 48 hours than in the group requiring oxygen for < 48 hours (P = .047). CONCLUSIONS: Term infants with TTN had low lamellar body counts associated with decreased surfactant function, suggesting that prolonged disease is associated with surfactant abnormalities.

O uso de suinos como modelo experimental de fisioterapia respiratória em recém-nascidos / The use of piglets as experimental model of chest physiotherapy innewborn babies

Aims: The purpose of the present study was to investigate the viability of the use of piglets as experimental model of newborn chest physiotherapy.Methods: Five piglets (1-2 days old) were studied. The animals received anesthesia and analgesia and were ventilated with positive pressure, on 100% oxygen. All piglets received chest physiotherapy protocol of manual vibration.Results: All five animals presented stable physiological parameters during the preparation phase and the physiotherapy protocol application.Conclusions: We conclude that piglets are a viable model for studies of chest physiotherapy in mechanically ventilated newborns.

Objetivos: o objetivo do presente estudo foi investigar a viabilidade do uso de suínos como modelo experimental de fisioterapia respiratória em recém-nascidos.Métodos: foram estudados cinco suínos recém-nascidos (1-2 dias de idade). Os animais receberam anestesia e analgesia e foram ventilados com pressão positiva, com oxigênio a 100%. Todos os animais receberam o protocolo de fisioterapia respiratória de vibração manual.Resultados: todos os cinco animais apresentaram estabilidade dos parâmetros fisiológicos durante a fase de preparação e aplicação do protocolo de fisioterapia.Conclusões: concluímos que os suínos representam um modelo viável para estudos de fisioterapia respiratória em recém-nascidos em ventilação mecânica.

Prospective operationalization and feasibility of a glycemic control protocol in critically ill children.

OBJECTIVE: To evaluate the feasibility and safe operationalization of a pediatric glycemic control protocol in the setting of a general pediatric intensive care unit in a developing country. DESIGN: Prospective, observational cohort study carried out over 12 months. SETTING: Fourteen-bed pediatric intensive care unit in Brazil. PATIENTS: Children requiring mechanical ventilation with at least one organ system dysfunction were included. INTERVENTIONS: Glucose was monitored and insulin used for persistent hyperglycemia (glucose >140 mg/dL [7.8 mmol/L] for at least two observations separated by at least a 1-hr interval), with a target glucose during insulin use of 60-140 mg/dL (3.3-7.8 mmol/L). RESULTS: Out of 410 admissions, 144 children met the criteria for applying the protocol. One hundred fourteen of 144 (79%) children had at least one peak glucose level that was hyperglycemic, but only 44 (31%) children required insulin. Insulin infusion was most frequently started on day 1 (61%), with a glucose level at the time of 229 ± 79 mg/dL (12.7 ± 4.4 mmol/L). The mean glucose level after 6 hrs of insulin was 172 ± 87 mg/dL (9.6 ± 4.8 mmol/L), and the time to achieve the target glucose range was 9.5 (2-20) hrs (median [interquartile range]). The overall duration of insulin was 24.5 (10-48) hrs, and the average dose required was 0.06 ± 0.03 U/kg/hr. In the whole series, the peak glucose level was 202 ± 93 mg/dL (11.2 ± 5.2 mmol/L), with no difference between survivors and nonsurvivors. There was no difference in mortality when different glucose bands were considered and no association between glucose level and mortality. The overall rate of hypoglycemia (glucose <40 mg/dL [2.2 mmol/L]) was 8.3%, and it was more common in those receiving insulin (20% vs. 3%, p < .05). CONCLUSIONS: Hyperglycemia is frequent in critically ill children managed in a pediatric intensive care unit in a developing country. Using a glycemic control protocol, one-third of these children required insulin, but attendants should be aware of a significant risk of hypoglycemia in this setting. Based on these data, a trial to detect a 20% relative reduction in mortality (power 90%, p = .05) associated with insulin in a similar population would need to screen >10,000 patients.

Lamellar body count and stable microbubble test on gastric aspirates from preterm infants for the diagnosis of respiratory distress syndrome.

BACKGROUND: Lamellar body count (LBC) in amniotic fluid is being used to identify infants at risk of respiratory distress syndrome (RDS) who would benefit from surfactant prophylaxis or very early therapy. The test in gastric aspirates of newborns has not been properly explored. OBJECTIVE: The main objective of this research was to evaluate the performance of LBC alone or in combination with the stable microbubble test (SMT), done on gastric aspirates from preterm babies to predict RDS. METHODS: A total of 34 preterm infants with RDS and 29 without RDS, with a gestational age between 24 and 34 weeks, were included in the study. Gastric fluid was collected in the delivery room. A diluent (dithiothreitol) allowed all samples to be processed, even the thickest and non-homogeneous ones, without centrifugation. The SMT was done for comparison. RESULTS: The best cut-off value was <42,000 lamellar bodies/microl to predict RDS, with a sensitivity of 92% (95% CI 73-100%) and specificity of 86% (95% CI 77-95%). The area under the receiver-operating characteristic curve was 0.928 (95% CI 0.86-0.99). SMT showed similar results. LBC and SMT together in series (positive result if both tests were positive) showed a sensitivity of 100% and a specificity of 86%. CONCLUSION: LBC on gastric aspirates diluted in a solution of dithiothreitol can be rapidly and easily performed, and may be used alone or in combination with SMT as a predictor of RDS, allowing selective prophylaxis or very early treatment only in surfactant-deficient newborns.

Screening for Toxoplasma gondii antibodies in 2, 513 consecutive parturient women and evaluation of newborn infants at risk for congenital toxoplasmosis / Triagem para anticorposanti-Toxoplasma gondii em 2. 513 parturientes consecutivas e avaliação dos recém-nascidos comrisco de toxoplasmose congênita

Aims: To determine the prevalence of seropositivity for toxoplasmosis in pregnant women, to assess the outcome and the prevalence of congenital toxoplasmosis, and to evaluate the usefulness of routine screening for Toxoplasma gondii antibodies in parturient women.Methods: Prospective cross-sectional study of consecutive mothers and their liveborn infants within the first 12 months of the implementation in a maternity ward of a routine consisting in screening for toxoplasmosis at delivery.Results: Serologic status for toxoplasmosis were assessed in 2,477 (98.5%) of 2,513 mothers of liveborn infants throughout the study period. Of the 2,477 mothers, 810 (32.7%; 95%CI 30.9-34.6%) were susceptible and 1,667 (67.3%; 95%CI 65.4-69.1%) were immune. Three newborn infants with congenital toxoplasmosis were identified because of the maternal serum tests at delivery, and all of them had The prevalence of congenital toxoplasmosis was 12/10,000 (CI 95%: 6/10,000-21/10,000).Conclusions: Maternal serologic screening at delivery was useful for the early detection of cases of congenital toxoplasmosis that would have otherwise gone undetected in the neonatal period, and allowed for earlier treatment of newborns with retinochoroiditis. The high prevalence of Toxoplasma gondii antibodies in pregnant women and of congenital toxoplasmosis justify a prenatal screening program in this population.The prevalence of congenital toxoplasmosis was 12/10,000 (CI 95%: 6/10,000-21/10,000).Conclusions: Maternal serologic screening at delivery was useful for the early detection of cases of congenital toxoplasmosis that would have otherwise gone undetected in the neonatal period, and allowed for earlier treatment of newborns with retinochoroiditis. The high prevalence of Toxoplasma gondii antibodies in pregnant women and of congenital toxoplasmosis justify a prenatal screening program in this population.

Objetivos: Avaliar a prevalência de soropositividade para toxoplasmose em gestantes, investigar os desfechos clínicos e a prevalência da toxoplasmose congênita e verificar a utilidade da triagem de rotina para Toxoplasma gondii em parturientes.Métodos: Estudo prospectivo incluindo todas as mães e seus respectivos recém-nascidos vivos, durante os 12 primeiros meses de implantação, em uma maternidade, de uma rotina de triagem para toxoplasmose em parturientes.Resultados: Foi avaliado o estado imunológico para toxoplasmose em 2.477 (98,5%) entre as 2.513 mães de recém-nascidos vivos durante o período do estudo. Destas, 810 (32,7%; IC 95% 30,9-34,6%) eram suscetíveis e 1.667 (67.3%; IC 95% 65,4-69,1%) eram imunes. Foram diagnosticados três casos de toxoplasmose congênita apenas pela sorologia materna na hora do parto, sendo que os três pacientes apresentavam lesões ativas de retinocoroidite toxoplásmica A prevalência de toxoplasmose congênita foi de 12/10.000 (IC 95%: 6/10.000-21/10.000).Conclusões: A sorologia materna no momento do parto foi útil na identificação precoce de casos de toxoplasmose congênita que teriam passado despercebidos no período neonatal, permitindo o tratamento precoce de bebês com retinocoroidite. Nesta população, a elevada prevalência encontrada, tanto de anticorpos anti-Toxoplasma gondii nas gestantes, quanto de toxoplasmose congênita, justificam um programa de triagem pré-natal.

Situação sobre a prevenção de intoxicações exógenas em Ambulatório de Pediatria na década de 90 / Diagnosis of exogenous intoxication prevention in Pediatric Outpatient Clinic in the 1990's

Objetivos: avaliar o conhecimento dos pais de crianças de 0 a 7 anos, que consultaram no Ambulatório de Pediatria do Hospital São Lucas da PUCRS, sobre prevenção de intoxicações exógenas no ambiente domiciliar, identificando se os pais estavam sendo orientados quanto à prevenção das intoxicações durante a consulta médica.Métodos: os pais foram selecionados e entrevistados quando traziam as crianças à consulta ambulatorial pediátrica, previamente agendada, durante o primeiro semestre de 1996. Para a coleta de dados foi utilizada amostragem aleatória sistemática, com realização de entrevista com questionário estruturado. Os dados foram processados com os programas Epi Info 6.0 e SPSS 7.5. Para as comparações, foram utilizados o teste qui-quadrado e o exato de Fisher. Foi calculado o risco relativo com intervalo de confiança de 95%.Resultados: foram entrevistadas 309 famílias, sendo que em 175 (56,6%) a criança era do sexo masculino. A mediana da idade das crianças foi de 13 meses. A idade média dos pais foi de 30,2 anos, e a das mães de 26,7 anos. A maioria (53,3%) dos pais e mães tinha primeiro grau incompleto. Verificou-se que 184 (59,5%) dos entrevistados armazenavam os produtos de limpeza doméstica e 113 (36,6%) os remédios de uso da família em locais potencialmente perigosos. Apesar de 82,2% dos entrevistados referirem saber que as plantas podem intoxicar, 48,3% possuíam pelo menos uma planta tóxica em sua casa. A maioria dos entrevistados 224 ? 72,5%) recorreria à emergência de algum hospital no caso de uma intoxicação e nenhum fez referência ao Centro de Informações Toxicológicas. Duzentos e noventa e cinco (95,3%) entrevistados referiram que nenhum profissional da saúde havia conversado sobre intoxicações, sendo que 76,4% haviam levado seu filho à consulta pediátrica nos últimos três meses. Com relação às orientações sobre a prevenção das intoxicações no Ambulatório de Pediatria do Hospital São Lucas da PUCRS, dos 211 que haviam consulta...

Aims: To evaluate the knowledge of parents of children from 0 to 7 years old who had an appointment at the outpatient clinic of Hospital São Lucas da PUCRS about prevention of exogenous poisoning at home environment, identifying if parents were receiving preventive orientation about intoxication during the consultation. Methods: Parents were selected and interviewed when they brought their children to the pediatric outpatient clinic appointment, previously scheduled, during the first semester of 1996. The method used for collecting data was systematic sampling, with interviews through a structured questionary. The data was processed with the Epi Info Program 6.0 and SPSS 7.5. For comparisons chi-square test and the Fisher’s exact test were used. Relative risk with the confidence intervals of 95% was also used. Results: A total of 309 families were interviewed, and in 175 (56.6%) the child was a boy. The median age of children was 13 months. Mean age of fathers and mothers were 30.2 years and 26.7 years, respectively. Most of the parents (53,3%) had incomplete elementary school. We have found that 184 (59.5%) of the interviewed subjects stored their home cleaning products in potentially dangerous places and 113 (36.6%) of them stored the drugs used by the family in unsafe places. Although 82,2% of the subjects interviewed were aware that some ornamental domestic plants could be poisonous, 48.3% of them had at least one toxic plant at home. The majority of subjects interviewed (224 – 72,5%) would look for an emergency service of any hospital in case of an intoxication. No subjects mentioned Toxicological Information Center as a place to call in emergency. Two hundred twenty four (95,3%) subjects mentioned that any health professional had ever spoken to them about intoxication. From the total subjects studied, 76.4% had taken their children to pediatric consultation in the last three months. In regards to orientation for the prevention of pois...

Tadalafil improves oxygenation in a model of newborn pulmonary hypertension.

OBJECTIVES: Sildenafil, a phosphodiesterase-5 inhibitor, significantly improves oxygenation when used in animal models and patients with pulmonary hypertension. Tadalafil is a new and clinically available phosphodiesterase-5 inhibitor that, aside from causing pulmonary vasodilation, has been shown to increase cardiac output in pulmonary hypertensive adults. Its hemodynamic effects on the newborn, however, have not been tested. The objective was to evaluate the effect of tadalafil on central hemodynamics and arterial oxygenation in a piglet model of acute pulmonary hypertension. DESIGN: Laboratory experiment. SETTING: University laboratory. SUBJECTS: Seven anesthetized and mechanically ventilated newborn piglets. INTERVENTIONS: Pulmonary hypertension was induced and maintained in seven anesthetized and mechanically ventilated newborn piglets following acute exposure to 11% oxygen. The experimental animals received orla tadalafil (1 mg/kg), whereas the control animals were given an equal volume of normal saline. Systemic and pulmonary hemodynamic variables were measured, and the cardiac output and ejection fraction were obtained from two-dimensional echocardiogram and Doppler measurements in all animals. Serial arterial blood gases were also obtained, and the alveolar-arterial oxygen gradient was calculated. MEASUREMENTS AND MAIN RESULTS: In contrast with the control animals, in which no significant changes were noted, in the experimental animals pulmonary arterial pressure decreased on average by 54% and cardiac output increased by 88% following tadalafil administration (p < .05). Tadalafil increased the PaO2 by 48% +/- 21% (p < .01), likely as a result of a 74% +/- 13% reduction in the alveolar-arterial oxygen gradient (p < .01). CONCLUSIONS: In a newborn animal model of acute pulmonary hypertension, oral tadalafil administration reduces pulmonary vascular resistance and increases arterial oxygenation by increasing cardiac output and reducing the lung shunt fraction. This previously untested compound deserves additional investigation in laboratory models of persistent pulmonary hypertension of the newborn.

Bronchoalveolar lavage plus surfactant in a piglet model of meconium aspiration syndrome.

INTRODUCTION: Meconium aspiration produces airway obstruction and surfactant inhibition. Bronchoalveolar lavage (BAL) and surfactant replacement have been proposed as treatments for the syndrome. OBJECTIVE: To evaluate the effect of BAL with normal saline followed by a supplementary dose of surfactant in a piglet model of meconium aspiration syndrome. METHODS: 15 newborn piglets were used in the study. The animals were ventilated with fixed settings. After inhalation of 4 ml/kg of diluted meconium, the piglets were randomized into three groups: group I (n = 5) - tracheal aspiration without BAL; group II (n = 5) - BAL with normal saline (15 ml/kg), and group III (n = 5) - BAL with normal saline (15 ml/kg) followed by a supplementary dose of surfactant (Curosurf(R) 100 mg/kg). Arterial blood gas samples were obtained 30 min and 6 h after the inhalation of meconium. RESULTS: A significant increase of PaO(2 )values at 6 h after treatment was only observed in group III (from 51 +/- 13 to 189 +/- 115 mm Hg; p = 0.04). At this time, PaO(2) in group III was significantly higher compared to group II (189 +/- 115 and 37 +/- 11 mm Hg, respectively; p = 0.023) and showed a borderline significance when compared to group I (p = 0.066). CONCLUSION: BAL with normal saline followed by a supplementary dose of surfactant may improve oxygenation in an experimental piglet model of meconium aspiration syndrome.

Determinação da pressão arterial em recém-nascidos / Determination of blood pressure in newborns

Objetivo: descrever as recomendações para a determinação da pressão arterial em recém-nascidos, os métodos e instrumentos utilizados. Fonte de Dados: Revisão de artigosmédicos sobre pressão arterial em recém-nascidos publicados nos últimos vinte anos (base de dados: Medline, Pubmed) e artigos originais sobre o método do "flush". Síntese de Dados: Vários fatores dificultam as medidas e interpretação em neonatos, como tamanho variável do braço, dificuldade de obtenção em recém-nascidos chorosos e variação na pressão arterial deve ser realizada preferencialmente no braço direito, com a largura do manguito correspondendo a 40%a 100% da respectiva extremidade. Atualmente, os métodos de monitoriazação não-invasiva da pressão arterial estão bem difundidos, especialmente o uso da oscilometria automática. Além disso, o antigo método do "flush" e a técnica da oximetria de pulsotêm sido citados na literatura. Como limitação mais importante encontra-se a ausência de validação dos equipamentos neonatologia, especialente dos monitores oscilométricos.

Novas opções terapêuticas na síndrome de aspiração de mecônio / New therapeutic options in meconium aspiration syndrome

OBJETIVOS: revisar a literatura sobre a síndrome de aspiração de mecônio (SAM), enfocando aspectos clínicos, fisiopatológicos e abordagem terapêutica, com destaque ao uso do surfactante e lavado broncoalveolar. MÉTODOS: revisão baseada em artigos publicados na MEDLINE, SCIELO e resumos de congressos internacionais de 1988 a 2004, incluindo ensaios randomizados ou quasi-randomizados, estudos caso-controle e metanálises. RESULTADOS: devido à comprovação da inibição do surfactante na SAM, houve modificações em sua abordagem terapêutica. O manejo atual consiste na aspiração das vias aéreas na sala de parto, seguida de suporte ventilatório necessário para manter a oxigenação arterial adequada, e tratamento das complicações. Tendo em vista a obstrução mecânica do mecônio e seu efeito inibitório sobre o surfactante, a reposição e lavado broncoalveolar com surfactante estão sendo estudados atualmente. CONCLUSÕES: estudos em animais e em recém-nascidos apresentam resultados controversos quanto aos benefícios do uso de surfactante e lavado broncoalveolar na SAM. Torna-se importante a realização de mais estudos para avaliar novas estratégias ventilatórias e se existem vantagens no uso do surfactante e lavado broncoalveolar com surfactante na SAM.

OBJECTIVES: to review the literature on meconium aspiration syndrome (MAS) focusing on clinical aspects, pathophysiology, and treatment with emphasis on surfactant and bronchoalveolar lavage. METHODS: review including articles from MEDLINE, SCIELO and abstracts published in the national and international literature, from 1988 to 2004 using the keywords meconium aspiration syndrome, surfactant and bronchoalveolar lavage. Randomized and quasi-randomized trials, case control studies, meta-analyses and recently published reviews were selected. Other articles were included for their valuable contribution to the subject. RESULTS: the discovery of new pathophysiological mechanisms ensued new therapeutic options availability. MAS management is initiated with airway aspiration in the delivery room, followed by the ventilatory management required to maintain optimal arterial oxygenation, as well as complications treatment. Considering evidences showing that meconium mechanical airway obstruction and its inhibitory effect on the surfactant system, the use of surfactant replacement and bronchoalveolar lavage with surfactant suspension are under study. CONCLUSIONS: experimental studies and studies focused on newborn using different surfactant suspensions have demonstrated controversial results. Therefore, it is very important to identify new ventilatory strategies and evaluate whether there are advantages in using surfactant and bronchoalveolar lavage with surfactant suspension in MAS.

Stable microbubble test on tracheal aspirate for the diagnosis of respiratory distress syndrome.

BACKGROUND: Exogenous surfactant should be used as early as possible in the presence of respiratory distress syndrome (RDS), but diagnosis may only become clear late in the course of the disease. The stable microbubble test (SMT) in the tracheal aspirates could help in the decision to give early surfactant to preterm babies with respiratory distress. OBJECTIVES: The objective of this study was to evaluate the accuracy of the SMT on tracheal aspirate for the diagnosis of RDS in newborns requiring mechanical ventilation. METHODS: The test was performed on specimens obtained from 74 infants requiring mechanical ventilation, through routine suctioning. RESULTS: Patients with RDS and meconium aspiration syndrome (MAS) had a significantly lower stable microbubble count than non-RDS and non-MAS patients. Preterm infants without RDS had a significantly higher microbubble count than preterm babies with RDS and a similar count to that of term babies. Considering a cutoff point of 120 microbubbles/mm(2) for the diagnosis of RDS, the sensitivity of the microbubble test was 96.3% (95% CI: 79.1-99.8) and the specificity 97.6% (95% CI: 85.9-99.9). CONCLUSIONS: The SMT on tracheal aspirates is accurate for RDS diagnosis and may be useful to support the decision to give surfactant to newborns on mechanical ventilation.

Módulo de ensino fototerapia / Modulus of teaching phototherapy

A icterícia é um dos achados de exame físico mais comuns em recém-nascidos (RNs) saudáveis ou enfermos. Estima-se que aproximadamente 60% dos RNs desenvolvem níveis séricos de bilirrubina superiores a 5 mg%, ou seja, detectáveis no exame clínico. As causas são diversas, e o tipo de tratamento dependerá do nível sérico de bilirrubina, presença de incompatibilidade sangüínea, peso, idade cronológica e comorbidades associadas. Uma história perinatal completa é essencial para o entendimento da causa da icterícia. O uso materno de medicações como o diazepam e a ocitocina aumenta o risco de hiperbilirrubinemia. Um parto traumático (pélvico, fórceps), com céfalo-hematoma ou outros sangramentos, aumenta de bilirrubina. A presença de policitemia, incompatibilidade sangüínea, teste de Coombs direto (no recém-nascido) ou indireto (na mãe) positivos são outros fatores que norteiam a necessidade de tratamento da hiperbilirrubinemia. O principal do tratamento da hiperbilirrubinemia é a prevenção da impregnação cerebral pelo pigmento amarelo e suas complicações neurológicas graves, como o Kernicterus. A fototerapia constitui-se na modalidade terapêutica mais utilizada mundialmente no tratamento da hiperbilirrubinemia neonatal causada pelo aumento dos níveis de bilirrubina indireta (lipossolúvel, não conjugada). A eficácia da fototerapia é dependente da absroção de fótons de luz pelas moléculas de bilirrubina. Nas últimas décadas houve um aprimoramento das técnicas de fototerapia, aumentando muito sua eficácia e reduzindo o número de indicações de exsangüineotransfusão.

Prevenção de infecção em UTI Neonatal e alojamento conjunto / Infection prevention in ICU Neonatal and rooming-in care

Os avanços tecnológicos nos cuidados aplicados aos recém-nascidos de alto risco promoveram um aumento da sobrevida destes, mas levou também a um aumento da incidência de infecções hospitalares nas unidades de cuidados intensivos. A infecção hospitalar em recém-nascidos é considerada um problema de natureza médica, social e institucional, visto que a sua elevada freqüência resulta em um aumento da morbidade e mortalidade neonatais, bem como em hospitalizações prolongadas dos recém-nascidos sobreviventes, acarretando custos sociais e econômicos elevados. A definição da origem comunitária ou hospitalar das infecções em recém-nascidos está baseadas em aspectos epidemiológicos, relacionados à origem da aquisição dos microorganismos; se foram adquiridas antes do parto, durante o parto ou após o parto. No período neonatal, pelas dificuldades de distinção entre infecção adquirida da mãe ou do hospital, o CDC (Center for Disease Control) considera que infecção hospitalar no recém-nascido é qualquer infecção adquirida durante ou após o nascimento e que se manifesta nos primeiros 28 dias de vida. São consideradas comunitárias as infecções cuja aquisição é por via transplacentária (toxoplasmose, rubéola, sífilis, AIDS, etc.) ou aquelas associadas à bolsa rota num período maior de 18 a 24 horas e a pneumonia congênita.