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.

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.

[Anemia and iron deficiency in children with chronic respiratory diseases]. / Anemia y déficit de hierro en niños con enfermedades respiratorias crónicas.

INTRODUCTION: Children with chronic respiratory disease (CRD) are at increased risk of iron deficiency and anemia, which is under-diagnosed. AIM: To describe the iron (Fe) status in children with CRD and to evaluate the effects of its prophylactic indication. METHOD: Prospective study of children with CRD and adequate Fe intake in the diet. At baseline we measured hemogram, C-reactive protein and Fe profile. Subsequently, those with normal plasma hemoglobin (Hb) were not supplemented with Fe (Group A) and those with iron deficiency anemia or at risk of developing it (group B) were supplemented. We evaluated them 3 months later and, after supplementing all, at 4th month. RESULTS: Of 40 patients, median 30 months old (0.5 to 178), 60% were male, 80% eutrophic. Ventilation or oxygen were required in 45%. Diagnoses: 50% Chronic Lung Damage, 17.5% airway diseases, 10% Bronchopulmonary Dysplasia, 7.5% Cystic Fibrosis and 13.5% other. At baseline 20% were anemic (mostly ferropenic) and 12.5% had an abnormal iron profile. At all, 25 children completed the study: in group A, serum ferritin decreased to 3(th) month (-22.9 ± 30) and incremented to 4(th)month (+12.8 ± 26) µg/L (p = 0.013), without difference in Hb. Group B had a rise in Hb (91 ± 12 to 102 ± 12% of the mean for age, p = 0.04). CONCLUSION: Anemia and ferropenia are frequent in children with CRD. Decrease of their iron reserves can be prevented if they are supplemented. We suggest monitoring properly and treating early or supplement them prophylactically.

Introducción: Los niños con enfermedades respiratorias crónicas (ERC) tienen mayor riesgo de desarrollar anemia ferropriva, sin embargo, la ferropenia está infradiagnosticada. Objetivos: Describir el status de hierro (Fe) en niños con ERC y evaluar la respuesta a su suplementación profiláctica. Método: Estudio prospectivo de niños con ERC y adecuada ingesta de Fe en la dieta: se realizó hemograma, velocidad de eritro-sedimentación, proteína Creactiva y perfil de Fe. Posteriormente, aquellos con hemoglobina plasmática (Hb) normal no se suplementaron con Fe (Grupo A) y los que presentaban anemia ferropriva o factores de riesgo sí lo fueron (grupo B). Se evaluaron al 3º mes, después se suplementaron todos y se re-evaluaron al 4ºmes. Resultados: De 40 pacientes, con mediana de edad 30 meses (0,5 a 178), 60% eran hombres, 80% eutróficos. Requerían ventilación prolongada u oxigenoterapia 45%. Diagnósticos: 50% Bronquiolitis Obliterante post-infecciosa, 17,5% enfermedades de la vía aérea, 10% Displasia Broncopulmonar, 7,5% Fibrosis Quística y 15% otros. Basalmente 12,5% tuvo bajos depósitos de Fe y 20% anemia (la mayoría ferropriva). Completaron el estudio 25 niños: el grupo A disminuyó la ferritina sérica al 3ºmes (- 22,9 ± 30) y aumentó al 4ºmes (+12,8 ± 26) µg/L, (p = 0,013), sin cambio en la Hb. El grupo B tuvo ascenso de la Hb (91 ± 12 a 102 ± 12% del promedio para la edad, p = 0,04). Conclusión: La anemia ferropriva y la ferropenia son frecuentes en niños con ERC, quienes deterioran reversiblemente sus depósitos si no son suplementados. Sugerimos monitorizar con perfil de Fe y tratar precozmente, o suplementarlos en forma profiláctica.

Anemia y déficit de hierro en niños con enfermedades respiratorias crónicas / Anemia and iron deficiency in children with chronic respiratory diseases

Introducción: Los niños con enfermedades respiratorias crónicas (ERC) tienen mayor riesgo de desarrollar anemia ferropriva, sin embargo, la ferropenia está infradiagnosticada. Objetivos: Describir el status de hierro (Fe) en niños con ERC y evaluar la respuesta a su suplementación profiláctica. Método: Estudio prospectivo de niños con ERC y adecuada ingesta de Fe en la dieta: se realizó hemograma, velocidad de eritro-sedimentación, proteína Creactiva y perfil de Fe. Posteriormente, aquellos con hemoglobina plasmática (Hb) normal no se suplementaron con Fe (Grupo A) y los que presentaban anemia ferropriva o factores de riesgo sí lo fueron (grupo B). Se evaluaron al 3º mes, después se suplementaron todos y se re-evaluaron al 4ºmes. Resultados: De 40 pacientes, con mediana de edad 30 meses (0,5 a 178), 60% eran hombres, 80% eutróficos. Requerían ventilación prolongada u oxigenoterapia 45%. Diagnósticos: 50% Bronquiolitis Obliterante post-infecciosa, 17,5% enfermedades de la vía aérea, 10% Displasia Broncopulmonar, 7,5% Fibrosis Quística y 15% otros. Basalmente 12,5% tuvo bajos depósitos de Fe y 20% anemia (la mayoría ferropriva). Completaron el estudio 25 niños: el grupo A disminuyó la ferritina sérica al 3ºmes (- 22,9 ± 30) y aumentó al 4ºmes (+12,8 ± 26) μg/L, (p = 0,013), sin cambio en la Hb. El grupo B tuvo ascenso de la Hb (91 ± 12 a 102 ± 12% del promedio para la edad, p = 0,04). Conclusión: La anemia ferropriva y la ferropenia son frecuentes en niños con ERC, quienes deterioran reversiblemente sus depósitos si no son suplementados. Sugerimos monitorizar con perfil de Fe y tratar precozmente, o suplementarlos en forma profiláctica (AU)

INTRODUCTION: Children with chronic respiratory disease (CRD) are at increased risk of iron deficiency and anemia, which is under-diagnosed. Aim: To describe the iron (Fe) status in children with CRD and to evaluate the effects of its prophylactic indication. METHOD: Prospective study of children with CRD and adequate Fe intake in the diet. At baseline we measured hemogram, C-reactive protein and Fe profile. Subsequently, those with normal plasma hemoglobin (Hb) were not supplemented with Fe (Group A) and those with iron deficiency anemia or at risk of developing it (group B) were supplemented. We evaluated them 3 months later and, after supplementing all, at 4th month. RESULTS: Of 40 patients, median 30 months old (0.5 to 178), 60% were male, 80% eutrophic. Ventilation or oxygen were required in 45%. Diagnoses: 50% Chronic Lung Damage, 17.5% airway diseases, 10% Bronchopulmonary Dysplasia, 7.5% Cystic Fibrosis and 13.5% other. At baseline 20% were anemic (mostly ferropenic) and 12.5% had an abnormal iron profile. At all, 25 children completed the study: in group A, serum ferritin decreased to 3(th) month (-22.9 ± 30) and incremented to 4(th)month (+12.8 ± 26) μg/L (p = 0.013), without difference in Hb. Group B had a rise in Hb (91 ± 12 to 102 ± 12% of the mean for age, p = 0.04).CONCLUSION: Anemia and ferropenia are frequent in children with CRD. Decrease of their iron reserves can be prevented if they are supplemented. We suggest monitoring properly and treating early or supplement them prophylactically (AU)

Ventilación mecánica prolongada con BiPAP a través de traqueostomía / Long-term noninvasive ventilation via tracheostomy

No existen reportes que describan el uso de equipos generadores de flujo con presión diferencial en 2 niveles (BiPAP) a través de traqueostomía para entregar ventilación mecánica prolongada (VMP) en niños. Este documento describe los criterios de selección, modalidad de uso y requerimientos tecnológicos como guía para implementar esta estrategia ventilatoria.

Hospital Josefina Martínez: una breve reseña histórica / Hospital Josefina Martinez: a brief historical review

El Hospital Josefina Martínez (HJM) es una institución privada, que nació de la disposición testamentaria de Doña Josefina Martínez de Ferrari como un Hospital para niños enfermos de tuberculosis provenientes de familias con escasos recursos económicos. Luego de hospitalizarse el último caso de tuberculosis y gracias a la disminución significativa de la tasa de ésta enfermedad en nuestro medio, se generaron cambios sustanciales en los objetivos iniciales, derivando su atención hacia otras condiciones respiratorias. En la actualidad, el HJM se especializa en el cuidado, manejo y control de enfermedades neuromusculares, fibrosis quística, displasia broncopulmonar grave, bronquiolitis obliterante post infecciosa, traqueotomizados -entre otras- provenientes de diversos hospitales base del país, existiendo cada vez más pacientes ventilados bajo la modalidad de invasiva y no invasiva, como parte del Programa Nacional de Asistencia Ventilatoria domiciliaria.

Ventilación mecánica invasiva domiciliaria (VMI): una propuesta para un nuevo programa / Domiciliary invasive mechanical ventilation: proposal for a new program

El presente escrito resume las recomendaciones, que como extensión del Programa Nacional de Asistencia Ventilatoria no Invasiva Domiciliario (AVNI), se han considerado por los autores, como las más apropiadas para ser incluidas en una propuesta que permita la entrega de prestaciones de ventilación mecánica invasiva en domicilio en niños.

Clinical characteristics of children with tracheobronchial anomalies.

Tracheobronchial anomalies (TBA) originate between the third and sixteenth week of gestation, and they primarily affect the main bronchi. The reported incidence varies between 1-3% of pediatric endoscopic studies. The objective of our review was to describe the clinical characteristics of patients with TBA diagnosed by flexible bronchoscopy (FB). During the period from March 1993-May 2001, we performed 580 FB at the Pediatric Services of the Catholic University Hospital. During this study period, 52 patients (9.65%) had a TBA (32 males, or 61.5%), with a mean age of 21.2 months (range, 7 days to 6 years). In 39 cases (75%), the diagnosis was made under age 2 years. Thirty-six patients with symptoms related to TBA were symptomatic (70%), and in 16 cases (30%) the TBA was an accidental finding during FB. The main clinical manifestations were recurrent atelectasis of the right upper lobe (RUL), recurrent pneumonia, or congenital stridor. Most of the TBA were localized at the RUL bronchus (47%) and were characterized by an anomaly at its origin, either agenesis or a supernumerary bronchus. Also, we found patients with tracheal bronchus and congenital tracheal stenosis. In 6 patients (12%), we had more than one TBA, the most frequent being the association between RUL and RML anomalies. In 12 cases we found another congenital airway anomaly, mainly laryngomalacia. Patients had associated diseases, such as genetic disorders in 16 cases (particularly Down syndrome), and congenital cardiopathies. In summary, in our clinical experience, TBA are more frequent than previously reported. The majority of young patients have symptoms or signs, and most are localized to the RUL. We found patients with more than one TBA, laryngomalacia associated with TBA, and at a high frequency related to Down syndrome.