Minerva pediatrica
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The aims of this paper are: to examine the physiological rationale for noninvasive respiratory support (NRS) in children with acute respiratory failure (ARF); to review clinical available data and to give some practical recommendations to its safe application. NRS is the delivery of ventilatory support without the need of an invasive airway. Two types of NRS are commonly used in the pediatric population: non-invasive continuous positive airway pressure (nCPAP) and non-invasive positive pressure ventilation (nPPV). ⋯ However, two randomized studies have been recently published suggesting that nPPV ameliorates clinical signs and gas exchange while reducing the need for endotracheal intubation. Moreover, nCPAP and heliox may improve clinical scores and CO2 washout in infants with severe bronchiolitis, without major complications. Data from non controlled studies show that NRS unloads the respiratory muscles and that the helmet can be a valid alternative to facial and/or nasal mask when nCPAP is administered to children in the early stage of ARF.
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Neonatal and paediatric intensive care units (NICUs and PICUs) are growing in number, size and complexity, and each unit is staffed by a highly specialized group of doctors and nurses. Indeed, practitioners within these subspecialties acquire specific cognitive and procedural skills garnered from focused multidisciplinary training, as well as from experience with critically ill newborns and children. Although the NICUs and PICUs share many commonalities, the relationship between caregivers in the neonatal and paediatric critical care units often is characterized by rivalry and antagonism rather than by cooperation. ⋯ Indeed, in some situations, such as shortage of PICU beds or patients not easily transferable to a PICU, neonatologists are occasionally called to take care of critically ill infants and young children. However, these "paediatric" patients may often present with complex pathologies which the neonatologist may not be familiar with. This condition raises important issues about the advisability to provide specific education and training in paediatric intensive care also to neonatologists, according to local needs and caregivers' expectations.
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Mechanical ventilation is considered a supportive, nontherapeutic technology used to perform the work of breathing for patients who are unable to do so on their own. In neonatology, mechanical ventilation is often used for premature neonates who are unable to sustain ventilation because of reduced functional residual capacity due to surfactant deficiency. Mechanical ventilation is thus an attempt to mimic the respiratory system's physiological function of gas exchange until the respiratory system reaches maturation. ⋯ There are no specific guidelines for the use of mechanical ventilation in children and the low number of infants with ARDS in PICU makes it difficult to run randomized controlled trials in this population. Thus the algorithms are based on the results of either adult or neonatal studies. The advantage of extrapolating data from the neonatal evidence relates mainly to the prevention of ventilator induced lung injury (e.g., CPAP, HFOV, NIV, permissive hypercapnia, surfattant), of which neonatologists are particularly expert.
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Chylothorax is the accumulation of chyle in the pleural space. In newborns the congenital form is often prenatal diagnosed, while the late variety originates to damage to the thoracic duct by cardiac surgery, diaphragmatic hernia, etc. Clinical presentation results from the accumulation of pleural fluid and the symptoms depends on the size of the effusion. ⋯ Surgery should be considered when medical management fails. Some approaches are reported, and thoracic duct ligation, pleurodesis and pleuroperitoneal shunts are the most utilized. The prognosis of chylothorax depends on the etiology, and it is consequence of a variety of treatments that may influence the outcome.