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Biomedical subjects

Jefferson P Piva

Publications and source records attributed to Jefferson P Piva.

10 recordsLinked to original sources
PubMed2005

Risk factors for extubation failure in mechanically ventilated pediatric patients.

OBJECTIVE: To describe the incidence of extubation failure and its associated risk factors among mechanically ventilated children. METHOD: Prospective cohort study. Children who were mechanically ventilated for longer than 12 hrs were followed up to 48 hrs after extubation. Cases of upper airway obstruction, accidental extubation, tracheostomy, or death before extubation were excluded. Extubation failure was defined as reintubation within 48 hrs after extubation. Student's t -test, Mann-Whitney, and chi-squared tests, odds ratio with 95% confidence interval, and multivariate analysis were used for data analysis. RESULTS: Extubation failure rate was 10.5% (13 of 124 patients). Variables associated with extubation failure were age between 1 and 3 mos (odds ratio [OR] = 5.68; 95% confidence interval [CI] = 1.58-20.42), mechanical ventilation >15 days (OR = 6.36; 95% CI = 1.32-30.61), mean oxygenation index (OI) >5 (OR = 4.08; 95% CI = 1.25-13.30), mean airway pressure 24 hrs before extubation lower than 5 cm H(2)O (OR = 6.03; 95% CI = 1.48-24.60), continuous positive airway pressure (CPAP) (OR = 4.71; 95% CI = 1.34-16.58), dopamine and dobutamine use (OR = 3.71; 95% CI = 1.08-12.78), intravenous sedation >10 days (OR = 6.60; 95% CI = 1.62-26.90), tachypnea and subcostal retractions (relative risk [RR] = 3.68; 95% CI = 1.14-11.93), and inspired fraction of oxygen (Fio(2)) > 0.4 after extubation (RR = 3.63; 95% CI = 1.21-10.88). After multiple logistic regression analysis, age between 1 and 3 mos, mean OI > 5, CPAP and mechanical ventilation >15 days remained associated with extubation failure. CONCLUSION: Extubation failure was more frequent among young infants who received prolonged ventilatory support and intravenous sedation, used CPAP, had impaired lung oxygenation, and required inotropic therapy.

Apnea↗
PubMed2005

A critical appraisal of a systematic review: Sokol J, Jacob SE, Bohn D: Inhaled nitric oxide for acute hypoxemic respiratory failure in children and adults. Cochrane Database Syst Rev 2003 (1): CD002787.

OBJECTIVE: To review the findings and discuss the implications of the use of inhaled nitric oxide for acute hypoxemic respiratory failure in patients beyond the neonatal period. DESIGN: A critical appraisal of a systematic review. FINDINGS: The authors conducted a systematic review with meta-analysis to determine the effect of inhaled nitric oxide on clinical outcomes of patients with acute hypoxemic respiratory failure. The outcomes included mortality, changes in oxygenation, ventilator-free days, duration of intensive care and hospital stays, and adverse effects. It was a high-quality systematic review provided with strict entry criteria, an extensive literature search, and thorough critical appraisals. Only five trials (n = 623) met entry criteria. Inhaled nitric oxide had no effect on mortality in studies without crossover of treatment failures to open-label inhaled nitric oxide (relative risk, 0.98; 95% confidence interval, 0.66-1.44). A statistically significant improvement in oxygenation was observed in one study. The effect, however, was observed only in the first 4 days of treatment and was not clinically significant. The heterogeneity in study findings precluded meta-analyses of other clinical outcomes and adverse effects in the selected studies. CONCLUSIONS: There is insufficient evidence to determine whether inhaled nitric oxide is beneficial or harmful for acute hypoxemic respiratory failure in children and adults. While awaiting further studies to prove its benefit, inhaled nitric oxide should not either be recommended as a standard management or excluded for the treatment of acute hypoxemic respiratory failure.

Adult↗
PubMed2004

Oropharyngeal aspiration in pediatric patients with endotracheal intubation.

OBJECTIVE: To determine the prevalence and factors associated with oropharyngeal aspiration in pediatric patients submitted to mechanical ventilation and endotracheal intubation. DESIGN: Prospective cross-sectional study. SETTING: Four pediatric intensive care units. PATIENTS: Fifty infants and children with endotracheal intubation submitted to mechanical ventilation. INTERVENTIONS: Aspiration was determined by administering Evans blue dye in the oral cavity and searching the dye agent in the specimens obtained from two tracheal aspirates performed at 5- and 30-min intervals. During this period, the frequency of swallowing movements was continuously monitored using surface electromyography (biofeedback). The association between aspiration and age, sedation level, mean airway pressure, swallowing dynamics, and intubation route was tested using the chi-square and relative risk (95% confidence interval). Results also were adjusted by multivariate analysis. MEASUREMENTS AND MAIN RESULTS: The overall prevalence of aspi-ration was 28% (n = 14). At the univariate analysis, aspiration was associated with sedation level (p =.03), frequency of swallowing movements (p =.0003), and orotracheal route (p =.03). The relative risk (95% confidence interval) for aspiration was 2.92 (1.32-6.42) in patients considered to be inadequately sedated (Hartwig 8-18); 14.08 (1.99-99.67) in patients presenting frequent swallowing (>30 movements in 30 mins); and 5.57 (0.8-38.85) in patients with orotracheal intubation. The multivariate analysis identified that the orotracheal route (p =.03) and frequent swallowing movements (p =.0007) were independently associated with aspiration. CONCLUSIONS: Aspiration around the tracheal tube is a frequent finding (28%) in children undergoing mechanical ventilation. The frequent swallowing movements and the orotracheal intubation route were significantly associated with aspiration. These results suggest that the nasotracheal intubation route could be recommended as the first choice for reducing this potential clinical complication.

Child↗
PubMed2003

[Rapid airway access].

OBJECTIVE: To review the steps involved in safe airway management in critically ill children. SOURCE OF DATA: Review of articles selected through Medline until April 2003 using the following key words: intubation, children, sedation. SUMMARY OF THE FINDINGS: Airway compromise is rare, but whenever it occurs, the situation depends on professionals trained to carry out safe, early, and rapid airway management, with no harm to the patient. The method currently advocated for airway management is rapid sequence intubation, which requires preparation, sedation and neuromuscular block. We observed that it is not possible to apply one single intubation protocol to all cases, since the selection of the most adequate procedure depends on indication and patient conditions. We defined the drug doses most commonly used in our setting, since little is know so far about the real effect of sedatives and analgesics. In most situations, the association of an opioid (fentanyl at 5-10 micro g/kg) with a sedative (midazolam at 0.5 mg/kg) and a neuromuscular blocking agent are sufficient for tracheal intubation. CONCLUSIONS: Training, knowledge, and skill in airway management are of fundamental importance for pediatric intensive caregivers and are vital for the adequate treatment of critically ill children. We present an objective and dynamic text aimed at offering a theoretical basis for the generation of new protocols, to be implemented according to the strengths and difficulties of each service.

Airway Obstruction↗
PubMed2002

Heliox versus oxygen for nebulized aerosol therapy in children with lower airway obstruction.

OBJECTIVE: To compare the distribution of an inhaled labeled radioaerosol (diethilenotriaminopenthacetate labeled with technetium-99m) when either oxygen or heliox was used as a gas vehicle of nebulization. DESIGN: Randomized, double-blind, controlled study. SETTING: Nuclear medicine imagining department of tertiary university-affiliated hospital. PATIENTS: Twenty children (5-15 yrs old) with confirmed diagnosis of chronic lower airway obstruction and referred for a ventilatory scintigraphy study. INTERVENTION: Patients were randomized to use either the heliox mixture (helium/oxygen, 80:20) or oxygen during the scintigraphy study. The maximal cumulative irradiation absorbed by the lungs and the slope of the curve of the cumulative irradiation incorporated into the lungs over the time were used to compare the groups. Student's t -test, one-way analysis of variance, chi-square test, and Fisher's exact test were used to compare the groups. MEASUREMENTS AND MAIN RESULTS: Ten patients were allocated to each group with no differences in demographic data, main diagnosis, and pulmonary function tests. Ninety-five percent of the particles produced by both gases had a diameter <2.4 micro. The heliox group showed a higher slope of the irradiation incorporated curve (p <.05) than the oxygen group. When broken down into groups, these changes were more significant in those patients classified by the pulmonary function tests as having severe lower airway obstruction. They showed higher cumulative lung irradiation (p =.045) and better slope of the irradiation incorporated curve (p =.017) when heliox rather than oxygen was used as a vehicle for the diethilenotriaminopenthacetate labeled with technetium-99m. Nevertheless, in those patients with mild lower airway obstruction, heliox did not show any advantage over oxygen in the distribution the radioaerosol into the lungs. CONCLUSION: Related to its physical properties, heliox gas seems to have a strong and pronounced effect when used in patients with severe lower airway obstruction. However, in the absence of severe lower airway obstruction, there is no advantage to using heliox instead of oxygen as a vehicle of nebulization.

Clinical Trial↗
PubMedDate not supplied

[Plastic bronchitis in a child with thalassemia alpha].

OBJECTIVE: Plastic bronchitis is an unusual condition in children, associated with formation of mucofibrinous casts and mucous plugging of the tracheobronchial tree. Given that this illness is part of the differential diagnosis of acute respiratory failure, early treatment is important for improved prognosis. The aim of this report is to describe a case of plastic bronchitis in a child with alpha-thalassemia that was treated successfully with endoscopy. DESCRIPTION: A three year old, black, male child, previously healthy, presented with acute respiratory failure and a chest x-ray showing pulmonary atelectasis. There was no evidence of respiratory symptoms or previous allergy state. The diagnosis of plastic bronchitis was made using flexible and rigid bronchoscopy, and confirmed by histopathologic findings. The child progressed well, treatment was based on supportive care and antibiotics were not used. Ten days after discharge, radiographic appearance was normal. Alpha thalassemia was diagnosed through hemoglobin electrophoresis. COMMENTS: Plastic bronchitis is clinically important because has similar presentation to other prevalent diseases, such as foreign body aspiration and asthma. When plastic bronchitis is suspected, endoscopy is indicated in order to confirm diagnosis and define treatment. Plastic bronchitis has been previously described in patients with cystic fibrosis, cardiac surgery and sickle cell disease. In this case, an association with alpha-thalassemia was observed.

Bronchitis↗
PubMedDate not supplied

[The influence of poor nutrition on the necessity of mechanical ventilation among children admitted to the Pediatric Intensive Care Unit].

OBJECTIVE: To determine the relation between children's nutritional status when they are admitted to the Pediatric Intensive Care Unit, the necessity and length of mechanical ventilation and the mortality rate. METHODS: A cohort study was conducted between July 1st, 1995 and June 30th, 1996. This study involved all children (28 days old to 48 months old) admitted to the pediatric intensive care unit of Hospital São Lucas, who stayed there longer than 8 hours. Exclusion criteria were complex cardiac disease, admission to the pediatric intensive care unit for elective procedure (regardless of pediatric intensive care unit admission criteria) or elective mechanical ventilation (cardiac, thoracic or other postoperative period). The staff responsible for the daily data collection were not involved with patient care or assistance decisions. On the day of admission to the pediatric intensive care unit, patients were evaluated regarding their nutritional status through the z score and the severity of the disease using the Pediatric Risk Mortality score. Demographic data, necessity and length of mechanical ventilation as well as main diagnosis and evolution of each patient were evaluated every day. RESULTS: Malnourishment increased significantly the need for mechanical ventilation, especially when associated with (a) age under one year old (RR=2.4; 1.4-3.8); (b) children admitted to the pediatric intensive care unit with low Pediatric Risk Mortality score (less than 10) (RR=2.5; 1.3-4.7); (c) presence of respiratory disease (RR=2.1; 1.3-4.7). Otherwise, malnourishment did not show any influence on the mortality rate. CONCLUSION: In our study, we could demonstrate that malnourishment in children under 4 years old admitted to the pediatric intensive care unit represented a decisive factor on evolution, increasing significantly the necessity and the length of mechanical ventilation as well as the length of stay at the pediatric intensive care unit.

English Abstract↗