L`insufficienza respiratoria - Azienda Ospedaliera S.Camillo

Transcription

L’insufficienza respiratoria
Mauro Calvani
Azienda Ospedaliera S. Camillo-Forlanini
UOC di Pediatria
Ambulatorio Pediatrico Allergologico
Roma
6 e 20 febbraio 2016
In bambini con patologie
Hypoxaemia in children with severe pneumonia
in
L’ipossiemia è un
importante
fattore
di rischio per mortalità
Papua
New
Guinea
Plot della probabilità di morte in relazione alla saturazione di O2
misurata al ricovero in PS in 703 bambini con pneumopatia grave
Duke T et al, Int J Tuberc Lung Dis 2001; 5: 511-19
INALAZIONE DI
CORPO
ESTRANEO
INFEZIONI
RESPIRATORIE
STATO DI MALE
EPILETTICO
SHOCK
IPOVOLEMICO
ANAFILATTICO
SETTICO
CARDIOGENO
DEPRESSIONE
RESPIRATORIA
CENTRALE
SCOMPENSO
EMODINAMICO
AVVELENAMENTO
TRAUMA CRANICO
ASMA
IPOSSIA
ARRESTO CARDIACO
Effect of routine emergency department triage pulse oximetry
E’ utile l’impiego
in un
pronto soccorso?
screeningroutinario
on medical
management.
La Pulsossimetria come 5o segno vitale
Studio prospettico su 17383 pazienti (età nascita -104 anni; media 36)
Arruolati per lo studio 14059
1) Temperatura
2) Frequenza cardiaca
3) Frequenza respiratoria
4) Pressione arteriosa
La saturimetria, comunicata
al medico dopo la visita, la
diagnosi e la impostazione
terapeutica provocava i
seguenti cambiamenti
diagnostici o terapeutici
Mower WR et al, Chest 1995; 108: 1297-302
screening on medical management.
Conclusioni: lo studio dimostra che i medici possono non individuare condizioni
di moderata ipossia in un piccolo numero di bambini, e in questi il dato della
saturimetria cambia significativamente il trattamento medico
Mower WR et al, Pediatrics 1997; 99: 681-86
E’ utile l’impiego
in un
pronto soccorso?
screeningroutinario
on medical
management.
I soggetti in cui più spesso avveniva il cambiamento di diagnosi, indagini o
terapie sono quelli con PaO2 tra 88-91%
Mower WR et al, Chest 1995; 108: 1297-302
Pulsossimetro o saturimetro
L’apparecchio trasmette 2 fasci di luce e diversa lunghezza d’onda (di solito 660 e
940 nm) misurando l’assorbimento della luce attraverso i diversi tessuti.
Pulsossimetro
Pulsossimetro
o saturimetro
Questo assorbimento è ciclico, poiché dipende dal ciclico pulsare del sangue
arterioso. Il pulsossimetro misura le variazioni della luce trasmessa durante
la diastole da quelle durante la sistole, e attribuisce tale variazione al flusso
sanguigno e in particolare alla differente saturazione di O2 della emoglobina.
Hartert TV, Chest 1999; 115: 475-81
Generalmente vi è una buona correlazione nella saturazione
arteriosa di O2 misurata con Pulsossimetria vs Emogasanalisi
Plot delle 2 misurazioni vs
la media delle 2 misurazioni
Plot della pulsossimetria vs
la misurazione arteriosa
Shoemaker WC et al, Chest 1998; 114: 1643-52
Pulsossimetro o saturimetro
Svantaggi e limiti
Possibile erronea valutazione della saturazione per
• Erronea sistemazione del sensore per shunt ottico
• Esposizione a luce ambientale (la luce intensa ostacola la rilevazione da
parte del sensore di piccole variazioni di assorbimento)
• Artefatti da movimento per perdita della pulsatilità
• Ridotta pulsazione a livello del sensore (dita etc.)
• Necessità di una pressione sistolica > 30 mm Hg (poco attendibile nello
shock, ipotensione, ipotermia, farmaci vasocostrittori
• Valori alterati in presenza di emoglobine anomale (metaomoglobinemia,
anemia falciforme, nel pretermine (HbF) e nella intossicazione da CO2
(carbossiemoglobina)
• Ridotta sensibilità alla iperossia
• Variabile anche in funzione del pH, temperatura, pressione parziale di CO2
Does pulse oximeter use impact health outcomes?
A systematic review
Evidence suggests that pulse oximeters identify 20–30% additional
hypoxic children compared with using clinical signs alone, for
example, grunting and depressed consciousness, which can be
imprecise
In the complex world of health systems, pulse oximetry could
lead to improved health outcomes and system efficiencies, and
reduced resource use, by helping health workers promptly
diagnose children and initiate treatment, and by improving
diagnostic accuracy, thereby preventing unnecessary admissions
and treatments. Alternatively, pulse oximetry could lead to
unnecessary admissions, treatment, referrals, and/or discharge
delays, if thresholds for admission, referral or intervention are
inappropriate.
Henoch AJ et all, Arch Dis Child 2015; 0: 1-7
A systematic review
We addressed the question “Do newborns, children and adolescents
aged up to 19 years have lower mortality rates, lower morbidity,
and shorter length of stay where pulse oximeters are used to inform
diagnosis and treatment (excluding operative surgical care)
compared with where pulse oximeters are not used?”
Our secondary research question was, “What proportion of
newborns, children and adolescents are given oxygen therapy
where pulse oximeters are used compared with where pulse
oximeters are not used.”
A systematic review
CONCLUSIONS
Pulse oximeters are routinely used in high-income countries and
international organisations are investing in programmes to promote
pulse oximetry in low-income countries, but there is little evidence,
from any region or setting, on the impact or optimal use of pulse
oximeters when children present to a health facility. More
research is needed on how pulse oximetry impacts health outcomes
and services, how knowledge of SaO2 should be integrated with
other clinical findings, whether defining ‘one-size fits all’ thresholds
is possible or even useful, for hypoxaemia and in diagnosing/
monitoring specific diseases, and how pulse oximetry affects
resource utilisation. Such pragmatic research could accompany pulse
oximeter implementation efforts and would provide much needed
evidence.
Hypoxaemia as a Mortality Risk Factor in Acute Lower
Respiratory Infections in Children in Low and Middle-Income
Countries: Systematic Review and Meta- Analysis
In conducting this review we followed the guidelines reported in the
PRISMA (Preferred Reporting Items for systematic reviews and
meta-analyses) [11]. and the MOOSE (Meta-analysis of
Observational Studies) [12]. A protocol including detailed methods
of the review was developed before starting the review.
Observational studies were eligible for inclusion if they reported the
association between death from ALRI and hypoxaemia, in children
under 5 years of age in LMIC, as defined by the World Bank
Lazzerini M et al, PLOS OnePLOS ONE | DOI:10.1371/2015
La ipossiemia (sia <
92% o < 90% o <
85%) costituiscono un
fattore di rischio per la
mortalità nei bambini
di età inferiore a 5 anni
con infezioni acute
della basse vie
respiratorie (OR 3,6 <
92 e 5,6 < 90%)
QUANDO INIZIARE LA OSSIGENOTERAPIA?
< 90%
(WHO, AAP nella bronchiolite)
World Health Organization (2013)Technical Recommendations for
management of common childhood conditions. Evidence for technical
update of pocket book recommendations,
< 92% (BTS nelle polmoniti)
British Thoracic Society Standards of Care Committee. British Thoracic
Society guidelines for the management of community acquired
pneumonia in children: update 2011. Thorax. 2011; 66 Suppl 2:ii1–23. doi:
Tra 90 e 92%
Working Groups of the Paediatric Assembly of the South African Thoracic
Society. Diagnosis and management of community-acquired pneumonia in
childhood— South African Thoracic Society Guidelines. S AfrMed J.
2005; 95):977–81, 984–90.
Conclusions
The results of this review support the routine evaluation of oxygen
saturation rate for identifying children with ALRI at higher risk of
death. Despite the lack of direct evidence in support of any
specific Sp02 threshold for starting supplementation with oxygen,
this review shows that both an Sp02 value of 92% and 90%
equally identify children at increased risk of mortality. Further
studies should focus on children living at high altitudes. Policy
makers should aim at improving the availability of pulse oximetry
and oxygen in LMIC.
Risk Factors for Mortality from Acute Lower Respiratory Infections
(ALRI) in Children under Five Years of Age in Low and Middle Income
Countries: A Systematic Review and Meta-Analysis of Otrbservational
Studies
We searched to January 2014 the following databases: MEDLINE
through Pubmed; Embase through OVID; Global Health Library
(WHO web site), LILACS through the Virtual Health Library;
Science Citation Index Expanded (SCI-EXPANDED) through Web
of Science; Social Sciences Citation Index (SSCI) through Web of
Science. Observational studies were eligible for inclusion if they
satisfied the following three criteria: 1) the study reported on
children under 5 years of age in LMIC, as defined by the World
Bank [18]; 2) the outcome of interest was death from ALRI, as
defined by the study authors; 3) the study reported the association
between death from ALRI and at least one possible risk factor.)
Sonego S et al, PLOS One | DOI:10, 2015
Studies
Child-related factors showing the stronger association with
mortality were: diagnosis of very severe pneumonia as defined by
WHO (odds ratio 9.42, 95% confidence interval 6.37 13.9); age
<2 months (5.22, 1.70 16.03); diagnosis of Pneumocystis
Carinii (4.79, 2.67 8.61); co-morbidity with chronic diseases
(4.76, 3.27 6.93); HIV/AIDS (4.68, 3.72 5.90), and severe
malnutrition (4.27, 3.47 5.25). An increased risk of death was
also associated with: prematurity (2.43, 1.65 3.57); low birth
weight (2.78, 2.03 3.82) inadequate breastfeeding practices
(1.79, 1.18 2.70); co-morbidity with malaria (1.46, 1.02
2.11); co-morbidity with diarrhoea (2.82, 1.80 4.43), comorbidity with measles (3.78, 1.81 7.87), and a previous
episode of ALRI (2.78, 1.55 4.98).
Studies
Mother-related factors
In 14 studies on 26130 children, low maternal education level was
associated with significantly increased odds in ALRI mortality
(1.43, 1.13 1.82, I2 42.3%) (Fig. 5). Mother’s young age was
associated in four studies to an increased risk of death (1.84, 1.03
3.31; 1225 children, I2 66.9%); three small studies reported on the
effect of the mother having a paid job, without significant
association with ALRI deaths. Other maternal factors were
investigated in single studies only.
Studies
Socioeconomic and environmental factors
Low socioeconomic status was associated in nine studies on 13908
children with a significant 62% increased odds of mortality
compared with higher socioeconomic status and no heterogeneity
between the studies. Indoor pollution from solid fuels was
associated with a significantly increased risk of ALRI mortality in
six studies on 32635 children (3.02, 2.11 4.31, I2 42.9%).
Second-hand smoke was associated with an increased mortality in
eight studies on 3044 children (1.52 1.20 1.93; I2 0%).
Viral Bronchiolitis in Children
Meissner HD, N Engl J Med 2016; 374: 62-72
Various definitions of bronchiolitis have been
proposed, but the term is generally applied to a
first episode of wheezing in infants younger than
12 months of age. Apnea, especially in preterm
infants in the first 2 months of life, may be an early
manifestation of viral bronchiolitis.
Clinical Practice Guideline: The Diagnosis,
Management, and Prevention of Bronchiolitis
Key Action Statement 6b
Clinicians may choose not to use continuous pulse oximetry
for infants and children with a diagnosis of bronchiolitis
(Evidence Quality: C; Recommendation Strength: Weak
Recommendation [based on lowerlevel evidence]).
Ralston L et al, Pediatrics 2014; 134: e1474
A retrospective study of the role of continuous measurement of
oxygenation in infants hospitalized with bronchiolitis found that
1 in 4 patients incur unnecessarily prolonged hospitalization
as a result of a perceived need for oxygen outside of other
symptoms and no evidence of benefit was found.
False reliance on pulse oximetry may lead to less careful
monitoring of respiratory status. In one study, continuous
pulse oximetry was associated with increased risk of minor
adverse events in infants admitted to a general ward. The pulse
oximetry–monitored patients were found to have lesseffective surveillance of their severity of illness when
controlling for other variables.
Longitudinal assessment of hemoglobin oxygen saturation in healthy
infants during the first 6 months of age.
Collaborative Home Infant Monitoring Evaluation (CHIME) Study Group.
Limitations in home monitoring technology have precluded longitudinal
studies of hemoglobin oxygen saturation during unperturbed sleep…
We studied 64 healthy term infants at 2 to 25 weeks of age.
The median baseline SpO(2) was 97.9% and did not change with age or
sleep position.
Acute decreases in SpO(2) occurred in 59% of infants; among these,
the median number of episodes was 4. The median lowest SpO(2)
during an acute decrease was 83%; 79% of acute decreases were
associated with periodic breathing, and >/=16% were associated with
isolated apnea. We conclude that healthy infants generally have
baseline SpO(2) levels >95%. The transient acute decreases are
correlated with younger age, periodic breathing, and apnea and
appear to be part of normal breathing and oxygenation behavior.
Hunt CE et al, J Pediatr 1999; 135: 580-6
Key Action Statement 1a
Clinicians should diagnose bronchiolitis and assess disease
severity on the basis of history and physical
examination (Evidence Quality: B; Recommendation
Strength: Strong Recommendation).
Counting respiratory rate over the course of 1 minute is
more accurate than shorter observations.
The presence of a normal respiratory rate suggests that
risk of significant viral or bacterial lower respiratory tract
infection or pneumonia in an infant is low (negative
likelihood ratio approximately 0.5), but the presence of
tachypnea does not distinguish between viral and bacterial
disease.
Tachypnea, defined as a respiratory rate ≥70 per
minute, has been associated with increased risk of severe
disease in some studies but not others.
La tachipnea (> 60 atti/min) (in quiete e ripetuta) è un indice
discretamente attendibile di ipossiemia (SaO2 < 90%) nei lattanti di età
< 2 mesi con e senza infezione delle basse vie respiratorie
Rajesh VT et al, Arch Dis Child 2000; 82: 46-49
Segni clinici predittivi di ipossiemia
Polipnea (dipende dall’età, febbre, tempo di insorgenza dell’ipossia, etc)
Cianosi (molto specifico ma poco sensibile)
Respiro appoggiato (nei piccoli predittivo di addensamento polmonare, etc)
Rientramenti inspiratori
Segno di Funk (movimento del capo sincrono con il respiro), discretamente specifico
Alitamento delle pinne nasali (molto sensibile, scarsamente specifico)
Condizioni generali
Agitazione o irritabilità
Segni ascoltatori al torace
Segni clinici correlati alla ipossiemia
Weber MW et al, Arch Dis Child 1997; 76: 310-314
PERCORSO DEI PAZIENTI AFFETTI DA BRONCHIOLITE
Iniziali del bambino: ………..
Data ricovero: ………………
Medico di PSP:
1) RILEVAZIONE PARAMETRI VITALI E CALCOLO DELLO SCORE RESPIRATORIO
0 PUNTI
1 PUNTO
2 PUNTI
3 PUNTI
<2 mesi
<60
61-69
>70
2-12 mesi
<50
51-59
>60
1-2 anni
<40
41-44
>45
FREQUENZA RESPIRATORIA
CONDIZIONI GENERALI
Buone, tranquillo
Piange quando toccato, ma si consola Moderatamente
subito
DISPNEA
No
Media
irritabile, Molto irritabile, letargico,
difficile da consolare
(rientramenti
/intercostali)
sottocostali Moderata
si alimenta poco
(rientramenti
al Severa
giugolo e diaframmatici)
(rientramenti
importanti con alitamento
delle
pinne
oscillazioni
del
nasali
capo
(neonati))
AUSCULTAZIONE
Assenza
wheezing
di Wheezing presente solo nella fase Wheezing
terminale dell’espirazione
espiratoria
rispetto
SATURAZIONE 02
>96%
93-95%
Bronchiolite lieve
Score < 5
Bronchiolite moderata
Score 6-10
Bronchiolite severa
Score >10
durante
(più
alla
fase
la
fase Wheezing espiratorio ed
prolungato inspiratorio o diminuzione
terminale del suono polmonare o
dell’espirazione)
entrambi
90-92%
<90%
2) VALUTAZIONE STATO DI IDRATAZIONE E CAPACITA’ DI ALIMENTARSI PER BOCCA NELLE
ALL’ARRIVO IN PS (80ML/KG/DIE)
24 ORE PRECEDENTI
1b. Clinicians should assess risk factors for severe disease, such
as age less than 12 weeks, a history of prematurity, underlying
cardiopulmonary disease, or immunodeficiency, when making
decisions about evaluation and management of children with
bronchiolitis (Evidence Quality: B; Recommendation Strength:
Moderate recommendation).
1c. When clinicians diagnose bronchiolitis on the basis of history
and physical examination, radiographic or laboratory studies
should not be obtained routinely (Evidence Quality: B;
Recommendation Strength: Moderate Recommendation).
NUTRITION AND HYDRATION
Key Action Statement 9
Clinicians should administer nasogastric or intravenous
fluids for infants with a diagnosis of bronchiolitis
who cannot maintain hydration orally (Evidence Quality:
X; Recommendation Strength: Strong Recommendation).
One study found that food intake at less than 50% of normal
for the previous 24 hours is associated with a pulse oximetry
value of <95%.... When the respiratory rate exceeds 60 to 70
breaths per minute, feeding may be compromised, particularly
if nasal secretions are copious
One case series and 2 randomized trials,examined the comparative
efficacy and safety of the intravenous and nasogastric routes for
fluid replacement. A pilot trial in Israel that included 51 infants
younger than 6 months demonstrated no significant differences in
the duration of oxygen needed or time to full oral feeds
between infants receiving intravenous 5% dextrose in normal
saline solution or nasogastric breast milk or formula.
In a larger open randomized trial including infants between
2 and 12 months of age and conducted in Australia and New
Zealand, there were no significant differences in rates of
admission to ICUs, need for ventilatory support, and adverse
events between 381 infants assigned to nasogastric hydration
and 378 infants assigned to intravenous hydration. The
nasogastric route had a higher success rate of insertion than
the intravenous route. Parental satisfaction scores did not
differ between the intravenous and nasogastric groups
HAND HYGIENE
Key Action Statement 11a
All people should disinfect hands before and after direct
contact with patients, after contact with inanimate
objects in the direct vicinity of the patient, and after
removing gloves (Evidence Quality: B; Recommendation
Key Action Statement 11b
All people should use alcohol-based rubs for hand
decontamination when caring for children with
bronchiolitis.
When alcohol-based rubs are not available, individuals
should wash their hands with soap and
water (Evidence Quality: B; Recommendation
RSV, as well as many other viruses, can survive better
on hard surfaces than on porous surfaces or hands. It can
remain infectious on counter tops for ≥6 hours, on gowns or
paper tissues for 20 to 30 minutes, and on skin for up to
20 minutes…
In these studies, health care workers contaminated their hands
(or gloves) with RSV and inoculated their oral or conjunctival
mucosa. Frequent hand washing by health care workers
has been shown to reduce the spread of RSV in the health
care setting.
The Centers for Disease Control and Prevention published an
extensive review of the hand-hygiene literature and made
recommendations as to indications for hand washing and hand
antisepsis. Among the recommendations are that hands
should be disinfected before and after direct contact with
every patient, after contact with inanimate objects in the
direct vicinity of the patient, and before putting on and after
removing gloves. If hands are not visibly soiled, an alcoholbased rub is preferred. In guidelines published in 2009, the
World Health Organization also recommended alcohol-based
hand-rubs as the standard for hand hygiene in health care.
Grazie per
l’attenzione
In bambini con patologie
E’ utile l’impiego routinario in un pronto soccorso pediatrico?
Studio prospettico su tutti i bambini (2602) giunti nel periodo
di tempo al PS
1) Temperatura
2) Frequenza cardiaca
3) Frequenza respiratoria
4) Pressione arteriosa
Mower WR et al, Pediatrics 1997; 99: 681-86
Monitor transcutanei
Misurano la pressione parziale di O2 (e alcuni anche della CO2) a livello della
superficie cutanea per mezzo di tecniche elettrochimiche, basate sulla presenza di un
elettrodo sensibile alla diffusione di gas accopppiato ad una fonte di calore
Il sensore consiste in un catodo di platino e un anodo di argento incassati in una soluzione
elettrolitica e separati dalla cute da una membrana permeabile all’ossigeno. Una bobina
riscaldante causa una iperemia locale in modo da arterializzare il circolo capillare nelle
vicinanze dell’elettrodo. L’ossigeno quindi diffonde attraverso la cute e la mambrana e
viene ridotto dal catodo. Ciò genera una corrente elettrica proporzionale alla quantità di O2
diffusa e questo viene visualizzato sul monitor, di solito convertito in mmHg
Svantaggi
1)
2)
3)
4)
5)
6)
Bisogna calibrare il sensore
Bisogna far attenzione alla quantità di gel applicato
Bisogna attendere circa 15’ che la cute si riscaldi
Bisogna togliere il sensore dopo 2 ore nei pretermine e al massimo dopo 8 ore
nel neonato a termine per evitare ustioni (la temperatura del sensore è 43c)
Bruschi cali della saturazione di O2 vengono evidenziati in ritardo
In alcuni bambini (specie con displasia broncopolmonare o neonati non
pretermine)si verifica una scarsa correlazione tra saturazione cutanea e arteriosa
di O2
Studies
Female sex was associated with a 15% increase in the odds
for mortality in 23 studies on 20385 children, with low
heterogeneity between studies (I2 11.7%). A diagnosis of
Respiratory Syncytial Virus was significantly associated
with a decreased odds of mortality (0.46 (0.29 0.74; 7595
children), with high heterogeneity among studies (I2 3.9%).
Esami strumentali ed/o esami ematochimici:
La radiografia del torace può essere indicata:
a) nei lattanti con febbre ed età inferiore a 3 mesi,
b) in presenza di un reperto auscultatorio localizzato, per escludere alcune condizioni che rientrano in diagnosi differenziali
d) se il bambino ricoverato non migliora
Gli esami ematochimici possono essere indicati
a)nel lattanti con febbre
b)nei casi di Rx torace positivo
c)nei lattanti con disidratazione
It is recommended that scheduled spot checks of pulse oximetry be utilized in
infants with bronchiolitis (Local Expert Consensus [E]).
Note 1: Continuous oximetry measurement has been associated with increased
length of stay of 1.6 days (95% CI, 1.1 to 2.0) on average (Schroeder et al., 2004
[D]).
Note 2: Wide variability has been demonstrated in the manner in which clinicians
use and interpret pulse oximetry readings in children with bronchiolitis. This
variability has been shown to be associated with increased preferences for hospital
admission and increased length of stay for children admitted with bronchiolitis
(Schroeder et al., 2004 [D]; Mallory et al., 2003 [O]).
Note 3: In a prospective study of healthy, term infants, transient oxygen
desaturation episodes were documented and were determined to be representative
of normal breathing and oxygenation behavior. This study excluded any decreases
in oxygen saturation related to the infants‘ movement which would interfere with
measurement (Hunt et al., 1999 [C])
May 2006 Review
Pulse oximetry has been erroneously used in bronchiolitis as a
proxy for respiratory distress. Accuracy of pulse oximetry is
poor, especially in the 76% to 90% range
There is very poor correlation between respiratory distress and
oxygen saturations among infants with lower respiratory tract
infections
E’ possibile sospettare la ipossiemia in base alla clinica?
Bambini di 2 mesi-5 anni affetti da infezione delle basse vie respiratorie
1) 69 Casi: SaO2 < 90%;
2) 67 Controlli 1:
stessa diagnosi ma SaO2 > 90%
3) 83 Controlli 2:
stessa diagnosi e SaO2 ignota
Weber MW et al, Arch Dis Child 1997; 76: 310-314
CALCOLO SCORE RESPIRATORIO
VALUTAZIONE IDRATAZIONE E CAPACITA’ DI ALIMENTAZIONE
Una delle seguenti condizioni
•apnea, bradicardia, tachicardia o cianosi
•Insufficienza respiratoria scompensata
•Segni di shock
Una delle seguenti condizioni
•prematurità o età < 2 mesi
•patologie croniche
•Letargia
•Disidratazione, scarsa alimentazione
(<80ml/kg/die)
•Score > 5
•Contesto familiare non affidabile
> 1-2 mesi e una delle seguenti condizioni
•Score 5-10
•Alimentazione orale inferiore alla norma
(<80ml/kg/die)
•Contesto familiare affidabile
> 2 mesi e tutte le seguenti:
•Assenza di fattori di rischio (prematurità patologia
di base)
• Score < 5
•Alimentazione orale adeguata nelle precedenti 24
ore (>80ml/kg/die)
•Miglioramento dopo terapia con salbutamolo e
ipertonica nell’ultima ora
•Contesto familiare affidabile che garantisce il
trattamento e la verifica delle condizioni del bambino
Ricovero in TIP
Considerare il ricovero
in reparto
Valutazione e Ossrrvazione in OBI
con valutazione alimentazione e PV
terapia con Salbutamolo e ipetonica
per aerosol
Dimissione
Algoritmi per la predizione di ipossiemia
Incapacità ad alimentarsi o bere ± cianosi
± rientramenti ± FR > 70
WHO, 1993
FR > 70 (< 1 anno) o FR > 60 (> 1 anno)
± respiro appoggiato ± rientramenti
Onyango FE, 1993
Respiro appoggiato ± FR > 90 ± cianosi
± sonno disturbato
Dyke T, 1995
Cianosi ± pianto poco valido
± movimenti di assenso del capo
Cianosi ± pianto poco valido ±
movimenti di assenso del capo ± FR > 90
FR > 70 (< 1 anno) ± rantoli crepitanti
± rumori bronchiali (> 1 anno)
Weber MW, 1997
Usen S, 1999
Smyth A, 1998
Alitamento delle pinne nasali ± rientramenti
± respiro appoggiato
Lozano JM, 1994
Dispnea ± rientramenti (< 1 anno) ± tachipnea
Reuland DS, 1991
In generale ogni algoritmo fallisce nell’individuare il 30-40% di bambini
con ipossiemia lieve-moderata

L`insufficienza respiratoria - Azienda Ospedaliera S.Camillo

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L`accoglienza dei minori in arrivo via mare

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La Pediatria Medica e Chirurgica