Measurement of the interbronchial angle in acute viral bronchiolitis.

BACKGROUND: Acute viral bronchiolitis (AVB) is the most common lower airway infection in children under 2 years. Attempts to determine disease severity based on clinical and radiological manifestations are a major challenge. Measurements of the anatomy of the trachea and main bronchi are not only limited to pure anthropometry, but are also useful for better care of critically ill patients. The purpose of the study is to verify the association between measurements of the interbronchial angle (ITB) and the severity of respiratory disease. METHODS: A cross-sectional study, which included all patients admitted to the Santo Antônio Children's Hospital, over a period of 1 year, with diagnosis of AVB by respiratory syncytial virus (RSV) was designed. ITB angle was measured and clinical characteristics were analyzed. Quantitative variables were compared and correlation analysis was performed using Pearson's correlation coefficient. A receiving operator characteristic (ROC) curve was performed. P-value <0.05 was statistically significant. RESULTS: A total of 425 patients with AVB due to RSV were included. Most of these patients were male and the median age was 130 days, 91.11% of them required oxygen therapy through a nasal catheter, 3.3% used noninvasive ventilation and 4% used mechanical ventilation. Those who required MV or NIV and intensive care unit support were considered severe. The mean ITB was lower for these patients than for those of lesser severity (p < 0.05). CONCLUSION: The present study demonstrates that there is an association between ITB and AVB severity. The smaller the ITB, the greater the disease severity.

Factors associated with respiratory morbidity in the first year of life.

OBJECTIVES: To investigate the association between socioeconomic and nutritional factors with respiratory morbidity in the first year of life in different regions of Brazil. METHODOLOGY: A nested case-control study within a randomized field trial was conducted in three capital cities (Porto Alegre, Manaus, and Salvador), representing different macro-regions of the country. Cases were defined as children with a reported previous diagnosis of asthma, bronchiolitis, or pneumonia. Corresponding controls were matched by age and sex in a 2:1 ratio, selected consecutively from the original cohort, resulting in a sample of 222 children. Bivariate analyses were performed to assess the association between sociodemographic and nutritional variables with respiratory morbidity outcomes, calculating odds ratios (OR) and their respective confidence intervals (95% CI). Values of p < 0.05 were considered significant. Potential confounding factors were adjusted through multivariate analysis (logistic regression). RESULTS: Maternal smoking and breastfeeding for less than six months showed a significant association and increased risk of respiratory disease (OR=2.12 and 2.05, respectively). Children born in the Southern region of Brazil also demonstrated a higher association and risk of respiratory morbidity. The consumption of ultra-processed foods did not show a significant association or increased risk of respiratory disease. CONCLUSIONS: Maternal smoking, breastfeeding for less than six months, and being born in the Southern region of Brazil are risk factors for the development of respiratory morbidity in the first year of life. The consumption of ultra-processed foods does not appear to pose a risk, but it was prevalent in more than 80% of the population, limiting its discriminatory power of analysis.

Factors associated with respiratory morbidity in the first year of life

Abstract Objectives: To investigate the association between socioeconomic and nutritional factors with respiratory morbidity in the first year of life in different regions of Brazil. Methodology: A nested case-control study within a randomized field trial was conducted in three capital cities (Porto Alegre, Manaus, and Salvador), representing different macro-regions of the country. Cases were defined as children with a reported previous diagnosis of asthma, bronchiolitis, or pneumonia. Corresponding controls were matched by age and sex in a 2:1 ratio, selected consecutively from the original cohort, resulting in a sample of 222 children. Bivariate analyses were performed to assess the association between sociodemographic and nutritional variables with respiratory morbidity outcomes, calculating odds ratios (OR) and their respective confidence intervals (95% CI). Values of p < 0.05 were considered significant. Potential confounding factors were adjusted through multivariate analysis (logistic regression). Results: Maternal smoking and breastfeeding for less than six months showed a significant association and increased risk of respiratory disease (OR=2.12 and 2.05, respectively). Children born in the Southern region of Brazil also demonstrated a higher association and risk of respiratory morbidity. The consumption of ultra-processed foods did not show a significant association or increased risk of respiratory disease. Conclusions: Maternal smoking, breastfeeding for less than six months, and being born in the Southern region of Brazil are risk factors for the development of respiratory morbidity in the first year of life. The consumption of ultra-processed foods does not appear to pose a risk, but it was prevalent in more than 80% of the population, limiting its discriminatory power of analysis.

Effects of nebulized epinephrine in association with hypertonic saline for infants with acute bronchiolitis: A systematic review and meta-analysis.

Background: Nebulized epinephrine and hypertonic saline have been extensively studied in infants with acute bronchiolitis, with conflicting results. Aims: To evaluate the efficacy on length of stay (LOS), clinical severity scores (CSS), oxygen saturation (SaO2), and safety profile of nebulized epinephrine plus hypertonic saline (HS) in infants with acute bronchiolitis. Materials & Methods: This is a systematic review and meta-analysis. Outcomes were represented by mean differences (MD) or standard mean differences (SMD) and 95% confidence intervals (CIs) were utilized. Results: Eighteen trials were systematically selected and 16 of them contributed to the meta-analysis (1756 patients). Overall, a modest but significant positive impact was observed of the combination therapy on LOS (MD of -0.35 days, 95% CI -0.62 to -0.08, p = 0.01, I 2 = 91%). Stratification by time of CSS assessment unveiled positive results in favor of the combination therapy in CSS assessed 48 and 72 h after the admission (SMD of -0.35, 95% CI -0.62 to -0.09, p = 0.008, I 2 = 41% and SMD of -0.27, 95% CI -0.50 to -0.04, p = 0.02, I 2 = 0%, respectively). No difference in SaO2 was observed. Additional data showed a consistent safety profile, with a low rate of adverse events (1%), most of them mild and transient. Conclusion: Low-quality evidence from this systematic review suggests that nebulized epinephrine plus HS may be considered as a safe and efficient therapy for decreasing LOS and CSS in infants with acute bronchiolitis, especially in those who require hospitalization for more than 48 h.

How Are Clinicians Treating Children With Sepsis in Emergency Departments in Latin America?: An International Multicenter Survey.

OBJECTIVE: Guidelines adherence in emergency departments (EDs) relies partly on the availability of resources to improve sepsis care and outcomes. Our objective was to assess the management of pediatric septic shock (PSS) in Latin America's EDs and to determine the impact of treatment coordinated by a pediatric emergency specialist (PEMS) versus nonpediatric emergency specialists (NPEMS) on guidelines adherence. METHODS: Prospective, descriptive, and multicenter study using an electronic survey administered to PEMS and NPEMS who treat PSS in EDs in 14 Latin American countries. RESULTS: We distributed 2164 surveys with a response rate of 41.5%, of which 22.5% were PEMS. Overall American College of Critical Care Medicine reported guidelines adherence was as follows: vascular access obtained in 5 minutes, 76%; fluid infusion technique, 60%; administering 40 to 60 mL/kg within 30 minutes, 32%; inotropic infusion by peripheral route, 61%; dopamine or epinephrine in cold shock, 80%; norepinephrine in warm shock, 57%; and antibiotics within 60 minutes, 82%. Between PEMS and NPEMS, the following differences were found: vascular access in 5 minutes, 87.1% versus 72.7% (P < 0.01); fluid infusion technique, 72.3% versus 55.9% (P < 0.01); administering 40 to 60 mL/kg within 30 minutes, 42% versus 29% (P < 0.01); inotropic infusion by peripheral route, 75.7% versus 56.3% (P < 0.01); dopamine or epinephrine in cold shock, 87.1% versus 77.3% (P < 0.05); norepinephrine in warm shock, 67.8% versus 54% (P < 0.01); and antibiotic administration within first 60 minutes, 90.1% versus 79.3% (P < 0.01), respectively. Good adherence criteria were followed by 24%. The main referred barrier for sepsis care was a failure in its recognition, including the lack of triage tools. CONCLUSIONS: In some Latin American countries, there is variability in self-reported adherence to the evidence-based recommendations for the treatment of PSS during the first hour. The coordination by PEMS support greater adherence to these recommendations.

Accuracy of complement activation product levels to detect infected pleural effusion in rats.

BACKGROUND: Pleural empyema is a well-known complication of pneumonia. If treatment is delayed, empyema may increase morbidity and mortality in affected patients. Therefore, the identification of empyema biomarkers in parapneumonic pleural effusion is desirable. Previous research has suggested complement activation products as candidate empyema markers. OBJECTIVE: To compare the levels of complement activation products C3a, C5a, and C5b9 in pleural effusion induced by Staphylococcus aureus (SA), Streptococcus pneumoniae (SP), or turpentine (control). METHODS: Thirty-nine male Wistar rats (mean weight 414 g; 290-546 g) were allocated as follows: 17 animals in the SA group, 12 in the SP group, and 10 in the control group. Bacteria or turpentine were injected into the pleural space. After 12 hr, intrapleural fluid was collected using ultrasound-guided thoracentesis. Levels of complement activation products were determined using ELISA kits. RESULTS: Two SA and one SP animals died before 12 hr. Mean levels were as follows: C3a: 1066.82 µg/ml (937.29-1196.35 µg/ml) in SA, 1188.28 µg/ml (1095.65-1280.92 µg/ml) in SP, and 679.13 µg/ml (601.29-756.98 µg/ml) in controls (P < 0.001); C5a: 55.727 ng/ml (41.22-70.23 ng/ml) in SA, 520.107 ng/ml (278.92-761.3 ng/ml) in SP, and 5.268 ng/ml (1.68-8.85 ng/ml) in controls (P < 0.001); C5b9: 15.02 ng/ml (13.1-16.94 ng/ml) in SA, 16.63 ng/ml (14.37-18.9 ng/ml) in SP, and 14.05 ng/ml (9.8-18.29 ng/ml) in controls (P = 0.692). ROC analysis revealed an area under the curve of 0.987 (95% CI: 0.953-1) for C3a; 1 (1-1) for C5a; and 0.757 for C5b9 (0.523-0.990). CONCLUSIONS: In the present rat model, complement activation fragments C3a and C5a accurately detected infected pleural effusion. Pediatr Pulmonol. 2017;52:757-762. © 2017 Wiley Periodicals, Inc.

Use of digital media for the education of health professionals in the treatment of childhood asthma / Uso de mídia digital na educação de profissionais de saúde para tratamento da asma infantil

OBJECTIVES: Inhalation therapy is the main treatment for asthma and its adequate use has been a factor responsible for disease control; therefore, the aim of the study was to determine whether a digital media tool, which features portability on mobile phones, modifies the assimilation of the inhalation technique. METHODS: A total of 66 professionals working in the health care area with the pediatric population were selected. They were submitted to a pre-test on their knowledge of inhalation therapy. The professionals were randomized into two groups (A and B). Group A received a media application on their mobile phones showing the steps of inhalation therapy, while group B received the same information in written form only. A post-test was applied after 15 days. The results (pre- and post-) were analyzed by two pediatric pulmonologists. RESULTS: Of the 66 professionals, 87.9% were females. Of a total possible score of ten, the mean score obtained in the pre-test was 5.3 ± 3, and in the second test, 7.5 ± 2 (p < 0.000). There were no significant differences when comparing the two groups (p = 0.726). The nurses had the lowest mean scores in the initial test (2.3 ± 2); however, they were the group that learned the most with the intervention, showing similar means to those of other groups in the second test (6.1 ± 3). CONCLUSION: There was significant improvement in knowledge about inhalation therapy in all professional categories using both methods, demonstrating that education, when available to professionals, positively modifies medical practice. .

OBJETIVOS: A inaloterapia representa a principal forma de tratamento da asma e seu uso adequado tem sido fator responsável pelo controle da doença. Desse modo, o objetivo do estudo foi determinar se uma ferramenta de mídia digital, dotada de portabilidade na forma de telefonia móvel, modifica a assimilação da técnica inalatória. MÉTODOS: Foram selecionados 66 profissionais que atuam na área da saúde com população pediátrica e submetidos a um pré-teste sobre seus conhecimentos de inaloterapia. Os profissionais foram randomizados em dois grupos (A e B). O grupo A recebeu em seu telefone móvel um aplicativo de mídia com os passos da inaloterapia, enquanto o grupo B recebeu as mesmas informações apenas de forma escrita. Após 15 dias, fez-se um pós-teste. Os resultados (pré e pós) foram analisados por dois pneumologistas pediátricos. RESULTADOS: Dos 66 profissionais, 87,9% eram do sexo feminino. Num escore total possível de 10, a média das notas obtidas no pré-teste foi de 5,3 ± 3 e as do segundo teste 7,5 ± 2 (p < 0,000). Não houve diferenças significativas na comparação os dois grupos (p = 0,726). Os profissionais de enfermagem apresentaram a menor média nas provas iniciais (2,3 ± 2), porém foi o grupo que aprendeu mais com a intervenção e apresentou média similar aos outros grupos na segunda prova (6,1 ± 3). CONCLUSÃO: Houve melhoria significativa no conhecimento sobre inaloterapia em todas as categorias profissionais com o uso de ambos os métodos. Isso comprovou que a educação, quando oferecida aos profissionais, modifica positivamente a prática médica. .

Use of digital media for the education of health professionals in the treatment of childhood asthma.

OBJECTIVES: Inhalation therapy is the main treatment for asthma and its adequate use has been a factor responsible for disease control; therefore, the aim of the study was to determine whether a digital media tool, which features portability on mobile phones, modifies the assimilation of the inhalation technique. METHODS: A total of 66 professionals working in the health care area with the pediatric population were selected. They were submitted to a pre-test on their knowledge of inhalation therapy. The professionals were randomized into two groups (A and B). Group A received a media application on their mobile phones showing the steps of inhalation therapy, while group B received the same information in written form only. A post-test was applied after 15 days. The results (pre- and post-) were analyzed by two pediatric pulmonologists. RESULTS: Of the 66 professionals, 87.9% were females. Of a total possible score of ten, the mean score obtained in the pre-test was 5.3 ± 3, and in the second test, 7.5 ± 2 (p<0.000). There were no significant differences when comparing the two groups (p=0.726). The nurses had the lowest mean scores in the initial test (2.3 ± 2); however, they were the group that learned the most with the intervention, showing similar means to those of other groups in the second test (6.1 ± 3). CONCLUSION: There was significant improvement in knowledge about inhalation therapy in all professional categories using both methods, demonstrating that education, when available to professionals, positively modifies medical practice.

Nuclear abnormalities in cells from nasal epithelium: a promising assay to evaluate DNA damage related to air pollution in infants / Anormalidades nucleares em células do epitélio nasal: uma técnica promissora para avaliar dano no DNA relacionado à poluição atmosférica em neonatos

OBJECTIVES: This study intends to provide a quick, easy, and inexpensive way to assess nuclear abnormalities such as micronuclei and bud frequencies; binucleated, karyorrhectic, karyolytic, pycnotic, and condensed chromatin cells in nasal scrapings of infants, which are particularly important for conducting genotoxic studies related to the inhaled atmosphere in pediatric populations. METHODS: Nasal swab samples were collected from 40 infants under 12 months of age using a small cytobrush. 2,000 cells from each infant sample were analyzed and classified according to the frequency of nuclear abnormalities. RESULTS: Rates of nuclear abnormalities found agree with values reported in other studies of neonates and children. This study found 0.13% of cells with micronuclei; 1.20% karyorrhexis; 0.03% pyknosis; 10.85% karyolysis; 1.11% condensed chromatin; 0.54 binucleated cells; and 0.02% nuclear bud. Differences were not observed between genders or environmental passive smoking, nor was any age correlation found. CONCLUSION: The assay proposed here is suitable for assessing the frequency of nuclear abnormalities from nasal cells in infants. .

OBJETIVOS: Este estudo pretendeu fornecer uma forma rápida, fácil e barata de avaliar anormalidades nucleares, como frequências de micronúcleos e gêmea, células binucleadas, cariorréticas, cariolíticas, picnóticas e com cromatina condensada, em esfregados nasais de neonatos, o que é particularmente importante para a realização de estudos genotóxicos relacionados ao ar inalado nas populações pediátricas. MÉTODOS: Foram coletadas amostras de esfregaço nasal de 40 neonatos com menos de 12 meses de idade, utilizando uma pequena escova citológica. Foram analisadas 2.000 células da amostra de cada neonato e classificadas de acordo com a frequência de anormalidades nucleares. RESULTADOS: As taxas de anormalidades nucleares encontradas neste estudo são compatíveis com os valores relatados em outros estudos de neonatos e crianças. Encontramos 0,13% de células com micronúcleos, 1,20% com cariorrexe, 0,03% com picnose, 10,85% com cariólise, 1,11% com cromatina condensada, 0,54 com células binucleadas e 0,02% com células nucleares gêmeas. Não observamos diferenças entre os gêneros, tabagismo passivo e nenhuma correlação entre idades. CONCLUSÃO: O ensaio proposto neste estudo é adequado para avaliar a frequência de anormalidades nucleares de células nasais em neonatos. .

Nuclear abnormalities in cells from nasal epithelium: a promising assay to evaluate DNA damage related to air pollution in infants.

OBJECTIVES: This study intends to provide a quick, easy, and inexpensive way to assess nuclear abnormalities such as micronuclei and bud frequencies; binucleated, karyorrhectic, karyolytic, pycnotic, and condensed chromatin cells in nasal scrapings of infants, which are particularly important for conducting genotoxic studies related to the inhaled atmosphere in pediatric populations. METHODS: Nasal swab samples were collected from 40 infants under 12 months of age using a small cytobrush. 2,000 cells from each infant sample were analyzed and classified according to the frequency of nuclear abnormalities. RESULTS: Rates of nuclear abnormalities found agree with values reported in other studies of neonates and children. This study found 0.13% of cells with micronuclei; 1.20% karyorrhexis; 0.03% pyknosis; 10.85% karyolysis; 1.11% condensed chromatin; 0.54 binucleated cells; and 0.02% nuclear bud. Differences were not observed between genders or environmental passive smoking, nor was any age correlation found. CONCLUSION: The assay proposed here is suitable for assessing the frequency of nuclear abnormalities from nasal cells in infants.

Use of helium-oxygen mixture (Heliox®) in the treatment of obstructive lower airway disease in a pediatric emergency department.

OBJECTIVE: To determine whether the use of salbutamol, in a helium-oxygen mixture (80:20), can modify outcome and risk of hospitalization of pediatric patients. METHODS: A controlled cohort study including patients aged 2 months to 12 years with diagnoses of asthmatic crisis or viral bronchiolitis. Intensity was characterized from moderate to severe, as measured by clinical score (pulmonary index, PI) for obstructive disease. Scores > 8 were considered eligible. The Heliox® group was composed of 20 patients and the Oxygen group of 40 patients. Patients received sequentially, at 20-min intervals, until six nebulization cycles were completed (2-h period): salbutamol 0.15 mg/kg/dose (maximum 5 mg). The nebulized drug was driven either by Heliox® mixture (80:20) or 100% oxygen. Patients diagnosed with acute asthmatic crisis received, additionally, prednisolone (2 mg/kg) orally. RESULTS: Eleven patients in the Heliox® group still required treatment at 6 h, against 38 patients in the group receiving oxygen-driven nebulization (p = 0.034). At 12 h, 7 patients in the Heliox® group remained under observation, against 27 in the Oxygen group. Differences regarding the need for supplemental oxygen were observed only at 6 h of treatment (p = 0.02). CONCLUSIONS: Heliox® (80:20), for salbutamol administration, is effective in the treatment of pediatric obstructive disease that responds to bronchodilator therapy. Compared to usual aerosol delivery technique, Heliox®-driven salbutamol nebulization is associated with shorter stay in the observation room after 6 h of treatment.

Uso da mistura gasosa de hélio e oxigênio (Heliox®) no tratamento da doença respiratória obstrutiva da via aérea inferior em serviço de emergência pediátrica / Use of helium-oxygen mixture (Heliox®) in the treatment of obstructive lower airway disease in a pediatric emergency department

OBJETIVO: Determinar se a utilização de salbutamol, em uma mistura de hélio-oxigênio (80:20), modifica a evolução e o risco de internação em pacientes pediátricos. MÉTODOS: Delineado estudo de coorte controlada que incluiu pacientes de 2 meses a 12 anos de idade, com diagnósticos de crise de asma ou bronquiolite viral. Intensidades caracterizadas de moderada a grave, aferidas através de escore clínico (pulmonary index, PI) para doença obstrutiva. Foram considerados elegíveis escores > 8. Vinte pacientes constituíram o grupo Heliox® e 40 o grupo Oxigênio. Os pacientes receberam sequencialmente, em intervalos de 20 min, até completar seis nebulizações (período de 2 h): salbutamol 0,15 mg/kg/dose (máximo 5 mg). A droga utilizou como veículo gerador do aerossol a mistura de Heliox® (80:20) ou oxigênio a 100 por cento. Os pacientes com diagnóstico de crise aguda de asma receberam, adicionalmente, prednisolona (2 mg/kg) via oral. RESULTADOS: Onze pacientes do grupo Heliox® permaneceram necessitando de tratamento na 6ª h de atendimento, enquanto que no grupo que recebia nebulização veiculada em oxigênio, esse número foi de 38 (p = 0,034). Na 12ª h, 7 pacientes do grupo Heliox® permaneciam em observação, enquanto no grupo Oxigênio foram 27 (p = 0,02). Diferenças quanto à necessidade de suplementação de oxigênio foram observadas apenas na 6ª h de tratamento (p = 0,02). CONCLUSÕES: Heliox® (80:20), para administração de salbutamol, é efetivo no tratamento da doença obstrutiva infantil que apresente resposta à terapêutica broncodilatadora. Comparado à técnica usual de nebulização, está associado à menor permanência em sala de observação após 6 h de tratamento.

OBJECTIVE: To determine whether the use of salbutamol, in a helium-oxygen mixture (80:20), can modify outcome and risk of hospitalization of pediatric patients. METHODS: A controlled cohort study including patients aged 2 months to 12 years with diagnoses of asthmatic crisis or viral bronchiolitis. Intensity was characterized from moderate to severe, as measured by clinical score (pulmonary index, PI) for obstructive disease. Scores > 8 were considered eligible. The Heliox® group was composed of 20 patients and the Oxygen group of 40 patients. Patients received sequentially, at 20-min intervals, until six nebulization cycles were completed (2-h period): salbutamol 0.15 mg/kg/dose (maximum 5 mg). The nebulized drug was driven either by Heliox® mixture (80:20) or 100 percent oxygen. Patients diagnosed with acute asthmatic crisis received, additionally, prednisolone (2 mg/kg) orally. RESULTS: Eleven patients in the Heliox® group still required treatment at 6 h, against 38 patients in the group receiving oxygen-driven nebulization (p = 0.034). At 12 h, 7 patients in the Heliox® group remained under observation, against 27 in the Oxygen group. Differences regarding the need for supplemental oxygen were observed only at 6 h of treatment (p = 0.02). CONCLUSIONS: Heliox® (80:20), for salbutamol administration, is effective in the treatment of pediatric obstructive disease that responds to bronchodilator therapy. Compared to usual aerosol delivery technique, Heliox®-driven salbutamol nebulization is associated with shorter stay in the observation room after 6 h of treatment.

Plasma concentrations of salbutamol in the treatment of acute asthma in a pediatric emergency. Could age be a parameter of influence?

OBJECTIVE: The objective was to determine if the plasma concentrations of salbutamol, obtained during inhalation treatment of infantile acute asthma, are influenced by age range and by the aerosol system used. METHOD: A randomized clinical trial was conducted in 46 children (1-5 years of age) with a diagnosis of acute asthma crisis, established in an emergency room pediatric service. Twenty-five children received salbutamol using a pressurized metered-dose inhaler with spacer (50 microg/kg), and 21 children received salbutamol by nebulization (150 microg/kg),three times during a 1-h period. At the end of the treatment, one blood sample was drawn and the plasma was stored for later determination of salbutamol concentration (liquid chromatography). Salbutamol plasma concentrations were compared in two age groups (< or =2 years and >2 years of age). The type of device used (pressurized metered-dose inhaler or nebulizer) and the need of hospitalization were also tested. The Mann-Whitney U test was used with the level of significance set at 5% (P < 0.05). RESULTS: No differences were detected regarding either the aerosol delivery system used or the need for hospitalization in relation to the plasma concentrations of salbutamol. However, higher plasma levels were found in patients >2 years vs patients < or =2 years [median (IQR): 9.40 (6.32-18.22) vs. 4.65 (2.77-10.10) ng/mL], demonstrating a significance difference (P = 0.05). CONCLUSION: Salbutamol plasma concentrations were influenced by age group of the patients submitted to inhalation therapy, even with doses adjusted for body weight. After correcting for the differences in the biovailabilities of the delivery systems, the concentrations were independent of the aerosol delivery device used.

Determinação das concentrações plasmáticas de salbutamol pós-nebulização em serviço de emergência pediátrica / Determination of plasma salbutamol concentrations after nebulization in a pediatric emergency department

OBJETIVOS: Validar parcialmente a metodologia para determinação do salbutamol em plasma humano por cromatografia líquida de alta eficiência (detecção por fluorescência). Analisar as concentrações plasmáticas de salbutamol em um grupo de pacientes pediátricos com indicação de nebulizações em sala de emergência. MÉTODO: Estudo transversal, analítico, prospectivo, do tipo série de casos. Foram selecionados consecutivamente 15 pacientes com idade entre 12 e 37meses, com diagnóstico de crise aguda de asma, atendidos no Serviço de Emergência Pediátrica do Hospital da Criança Santo Antônio - Complexo Hospitalar Santa Casa, Porto Alegre, Brasil. Os pacientes foram tratados conforme a rotina da unidade para manejo de crise aguda de asma: nebulização (fluxo 6-8 L/min) com salbutamol (0,15 mg/kg) diluídosem4mL de NaCL 0,9 por cento. A nebulização era administrada seqüencialmente, em intervalos de 20 minutos, por três vezes. Concomitantemente às nebulizações, todos os pacientes recebiam prednisolona via oral (1 mg/kg). RESULTADOS: As concentrações plasmáticas evidenciaram grande variabilidade em portadores de crise aguda de asma que receberam três nebulizações com salbutamol (0,15 mg/kg). Níveis plasmáticos médios foram de 12,09±10,8 ng/mL, com mediana de 8,9 (IQ25-75 por cento 2,75-17,65) e coeficiente de variação da amostra de 92,4 por cento. CONCLUSÕES: As concentrações plasmáticas após inalação de salbutamol apresentam grande dispersão na população pediátrica, a exemplo de outros estudos. As possíveis causas e implicações relacionadas ao achado permanecem alvo de controvérsias e avaliações complementares.

OBJECTIVES: To partially validate the methodology for determining salbutamol in human plasma through high-efficiency liquid chromatography and fluorescence detection. To analyze plasma salbutamol concentrations in a group of pediatric patients with indication for nebulization in the emergency room. METHOD: Analytical, prospective cross-sectional case series. Fifteen patients aged 12 to 37 months with a diagnosis of acute asthma crisis were selected at the Pediatric Emergency Service at Hospital da Criança Santo Antônio - Complexo Hospitalar Santa Casa, Porto Alegre, Brazil. The patients were treated following the unit's routine for the management of acute asthma crises: nebulization with salbutamol (flow rate of 6-8 L/min) (0.15 mg/kg) suspended in 4 mL of 0.9 percent saline solution. Nebulization was administered sequentially, three times, at 20 minute intervals. All patients were given prednisolone orally (1 mg/kg) concurrently with the nebulizations. RESULTS: Plasma concentrations exhibited great variability in acute asthma crisis patients given three nebulizations of salbutamol (0.15 mg/kg). The mean level in plasma was 12.09 ± 10.8 ng/mL, with a median of 8.9 ng/mL (IQ25-75 percent 2.75-17.65). The sample's coefficient of variation was 92.4 percent. CONCLUSIONS: Post-inhalation plasma salbutamol concentrations exhibit great variation in the pediatric population, as seen in other studies. The possible causes and implications of this finding remain the subject of disagreements and of further assessments.

Determination of plasma salbutamol concentrations after nebulization in a pediatric emergency department.

OBJECTIVES: To partially validate the methodology for determining salbutamol in human plasma through high-efficiency liquid chromatography and fluorescence detection. To analyze plasma salbutamol concentrations in a group of pediatric patients with indication for nebulization in the emergency room. METHOD: Analytical, prospective cross-sectional case series. Fifteen patients aged 12 to 37 months with a diagnosis of acute asthma crisis were selected at the Pediatric Emergency Service at Hospital da Criança Santo Antônio - Complexo Hospitalar Santa Casa, Porto Alegre, Brazil. The patients were treated following the unit's routine for the management of acute asthma crises: nebulization with salbutamol (flow rate of 6-8 L/min) (0.15 mg/kg) suspended in 4 mL of 0.9% saline solution. Nebulization was administered sequentially, three times, at 20 minute intervals. All patients were given prednisolone orally (1 mg/kg) concurrently with the nebulizations. RESULTS: Plasma concentrations exhibited great variability in acute asthma crisis patients given three nebulizations of salbutamol (0.15 mg/kg). The mean level in plasma was 12.09 +/- 10.8 ng/mL, with a median of 8.9 ng/mL (IQ25-75% 2.75-17.65). The sample's coefficient of variation was 92.4%. CONCLUSIONS: Post-inhalation plasma salbutamol concentrations exhibit great variation in the pediatric population, as seen in other studies. The possible causes and implications of this finding remain the subject of disagreements and of further assessments.

[Concentrations of interleukin-2 in the nasopharyngeal secretion of children with acute respiratory syncytial virus bronchiolitis]. / Concentrações de interleucina-2 na secreção nasofaríngea de crianças com bronquiolite viral aguda pelo vírus respiratório sincicial.

OBJECTIVE: To assess interleukin-2 concentrations in nasopharyngeal secretion of children (0-24 months) with acute respiratory syncytial virus bronchiolitis, within the first 12 hours of hospital admission, and compare the levels of IL-2 with the severity of the illness. METHODS: Prospective study performed between June and August 1999. The study included 62 patients, previously healthy, hospitalized with acute viral bronchiolitis characterized by recent prodromes of coryza and/or nasal obstruction, which evolved to at least two of the following signs: respiratory dysfunction, tachypnea, wheezing or rales, and detection of respiratory syncytial virus in nasopharyngeal aspirate. The nasopharyngeal specimens were collected within 12 hours of hospital admission. The interleukin-2 levels were obtained by enzyme immunoassay. Severity of illness was assessed through oxygen saturation by pulse oximetry, Modified Clinical Score System, time of supplemental oxygen required, length of hospital stay, and mechanical ventilation. Spearman's correlation and Kruskal-Wallis test were used to compared these variables in relation to the median of interleukin-2. The chi-square test was used for categorical analysis of interleukin-2. RESULTS: The mean age of patients was 2.2 (1.3-4) months. Males comprised 54% of cases. Hemoglobin oxygen saturation by pulse oximetry at hospital admission was below 95% in 66.1% of patients. The mean time of supplemental oxygen use was 4.7 days (+/-3.54). The mean length of hospital stay was 4.25 days (+/-1.76). Mechanical ventilation was used in 4.8% of patients. The values of interleukin-2 in nasopharyngeal aspirates varied from 0 to 40,256 ng/ml with median of 86 ng/ml (4.4 - 457.3). The study showed no statistical difference between levels of IL-2 and severity of illness. CONCLUSIONS: The interleukin-2 levels showed a heterogeneous behavior. We found no association between interleukin-2 levels in nasopharyngeal secretion and respiratory syncytial virus bronchiolitis.

Concentrações de interleucina-2 na secreção nasofaríngea de crianças com bronquiolite viral aguda pelo vírus respiratório sincicial / Concentrations of interleukin-2 in the nasopharyngeal secretion of children with acute respiratory syncytial virus bronchiolitis

OBJETIVO: Avaliar as concentrações de interleucina-2 (IL-2) na secreção nasofaríngea de crianças (0-24 meses) acometidas de bronquiolite viral aguda pelo vírus respiratório sincicial nas primeiras 12 horas de hospitalização e correlacionar os níveis encontrados com a gravidade da doença. MÉTODOS: Estudo prospectivo com amostragem seqüencial realizado no período de junho a agosto de 1999. Foram incluídos 62 pacientes previamente hígidos, internados com diagnóstico de bronquiolite viral aguda caracterizado por pródromos recentes de coriza e/ou obstrução nasal que evoluíram com pelo menos dois dos seguintes sinais: disfunção respiratória, taquipnéia, sibilos ou crepitações. Todos os pacientes tiveram a presença de vírus respiratório sincicial detectada no aspirado nasofaríngeo. As amostras de secreção nasofaríngea foram obtidas nas primeiras 12 horas de hospitalização. As dosagens de IL-2 foram realizadas por ensaio imunoenzimático. A gravidade da doença foi avaliada por: medida da saturação de oxigênio da hemoglobina por oximetria de pulso, sistema de escore clínico modificado, tempo de uso de oxigênio, tempo de hospitalização e necessidade de ventilação mecânica, sendo estas variáveis comparadas em relação às medianas de IL-2 através dos testes de Spearman e Kruskal-Wallis e, para a análise categorizada da interleucina, através do teste de qui-quadrado. RESULTADOS: A mediana de idade dos pacientes foi 2,2 (1,3-4) meses. O sexo masculino foi observado em 54 por cento dos casos. Saturação de oxigênio da hemoglobina por oximetria de pulso na hospitalização foi < 95 por cento em 66,1 por cento dos pacientes. A média do tempo de uso de oxigênio foi 4,7 dias (±3,54). A média do tempo de hospitalização foi de 4,25 dias (±1,76). Ventilação mecânica foi utilizada em 4,8 por cento dos casos. Os níveis de IL-2 na secreção nasofaríngea variaram de 0 a 40.256 ng/ml, com mediana de 86 ng/ml (4,4-457,3). Não houve diferença estatisticamente significativa entre os níveis de IL-2 e a gravidade da doença. CONCLUSÕES: Os níveis de IL-2 apresentaram valores com grande dispersão. Não houve associação entre bronquiolite viral aguda pelo vírus respiratório sincicial e aumento nos níveis de IL-2 na secreção nasofaríngea.

Induction of pleural empyema in rats by thoracentesis with intrapleural pressure monitoring.

Our objective was to evaluate experimental induction of empyema in rats by intrapleural inoculation of Staphylococcus aureus by means of thoracentesis with pleural pressure monitoring. Forty female albino Wistar rats, anesthetized with droperidol and fentanyl, underwent intrapleural inoculation of a 0.2-ml solution. Group I ( N=25) received 10(10) colony-forming units/ml of Staphylococcus aureus cultivated in brain-heart infusion agar (BHI); group II (N = 15), the control group, received sterile BHI agar. Rats were inoculated after right hemithorax thoracentesis with a needle connected to an oscilloscope for pressure monitoring to confirm that the needle was inside the pleural space. Animals were killed after 3 (groups Ia and IIa) to 5 (groups Ib and IIb) days with sodium pentobarbital. The macroscopic changes, amount of pleural fluid, and anatomopathological aspects of pleura and lungs were recorded, as well as death causes and bacteriological findings of pleural fluid for animals that died before the time established for euthanasia. In group I, three animals died of thoracentesis complications, and five others died in the first 24 h due to septicemia; blood and spleen cultures isolated the bacteria previously inoculated. In group II, there was one death of unknown cause. Of the 17 rats inoculated with bacteria, nine (group Ia) were killed on the 3rd day; all had bacteria in pleural fluid (volume 0.5-3.8 ml). The other eight rats (group Ib) were killed on the 5th day; three (39.5%) had pleural fluid with bacteria (0.5-1.5 ml), and five (60.5%) had no pleural fluid. Rats from group II killed on the 3rd (group IIa) and 5th (group IIb) days had no pleural fluid. Pathologic examination revealed inflammatory infiltrate (93.75%) and fibrin (18.75%) in pleura, and inflammatory interstitial infiltrate (12.5%) in the right lung in group I; no changes were observed in 93.3% of the lungs in group II. Macroscopic examination revealed only turbid and bloody pleural fluid (class I) without pleural adhesions. Pleural inflammatory infiltrate was found in rats that received the bacteria but had no fluid at necropsy (class 0). One control rat, although with no clinical signs of disease or pleural fluid, had signs of pleural and pulmonary infection at necropsy. We conclude that empyema may be induced in rats by the inoculation of Staphylococcus aureus by means of thoracentesis with pleural pressure monitoring. The highest amount of pleural fluid was observed 3 days after bacterial inoculation.