Noninvasive Ventilation Outside Critical Care Units for Children with Severe Low Respiratory Infection: Is it a Potential Strategy for Critically Ill Children in Uruguay? Alicia Aleman 1* and Gustavo Giachetto 2 1 Department of Preventive Medicine, School of Medicine, University of the Republic, Uruguay 2 Pediatric Clinic C, School of Medicine, University of the Republic, Uruguay *Corresponding author: Alicia Aleman, Department of Preventive Medicine, School of Medicine, University of the Republic, Uruguay, Tel: +598557679; E-mail: aaleman@unicem-web.org Rec date: Mar 12, 2014, Acc date: Mar 12, 2014, Pub date: Mar 14, 2014 Copyright: © 2014 Aleman A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Low Respiratory Infection Acute lower respiratory tract infection remains as one of the frst causes of infant death in several Latin American countries [1,2]. It also represents one of the frst causes of admission in pediatric intensive care (ICU) units due to acute respiratory failure for developed and developing countries [3]. Children in this situation are provided mechanical ventilatory support and in some cases noninvasive ventilation (NIV) in a frst stage during admission in the intensive care units [4]. Lack of pediatric intensive care resources to give response to the high demands in winter time appears as one of the main public health problems for the treatment of children with acute respiratory failure due to acute lower respiratory tract infection [3]. Te study developed by Alonso et al. in 2012 has the objective to describe the results of applying noninvasive ventilation in a non- intensive care environment in children under two years with acute lower respiratory tract infection and analyze potential predictors of failure [5]. It was performed in the biggest pediatric public hospital in Montevideo, Uruguay during 2009 and 2010. It is a descriptive study with a prospective recruitment. Children under 2 years with lower respiratory tract infection and respiratory failure Tal score>8, or >6 and not responding to treatment were included. Children weighing <7 kg, unstable hemodynamics, neuro-psychic depression, pneumothorax, pneumo-mediastinum and/or mixed acidosis were excluded. NIV was applied in an area of moderate care outside intensive care units (combined with aspiration and administration of bronchodilator drugs according to requirements). A continuous monitoring of children was maintained and failure to INV was defned if no improvement or Clinical deterioration despite using maximum parameters (PS 12 EPAP 10 FI02>0.6), severe hypercapnia (pCO2 ≥ 60) Glasgow ≤ 8; mechanical complications (pneumothorax, pneumomediastinum), hemodynamic instability or pH<7.20. In all these cases mechanical ventilatory support was applied. NIV was successful in 151 of 185 children included (81.6%). No statistical diferences in terms of age, weight and severity of disease at admission were identifed between the group of children with treatment failure or success. Afer 2 hours respiratory frequency (RF) greater than 60 rpm, heart rate (HR) increased 140 cpm and support pressure (SP) greater to 9 were associated with failure (p <0.05). Two children presented pneumothorax and one died. Multivariate analysis showed that afer 2 h the RF>60 rpm increase the risk of failure 6.4 times (CI 95 1.9 to 21.7), HR>140 cpm 4.3 (CI95 1.5 to 11.8) and SP>9 increased 8.7 times (CI95 2.3 to 32.2). Although increased heart rate appears as a potential predictive value it has to be taken with caution since it is unspecifc. We need to identify factors associated with success or failure of NIV having a predictive behavior to make decisions in a timely manner. Te observed relationship between elevated heart rate at admission and 2 h with higher failure rate has limitations. Te observed diference is not clinically signifcant and the majority of these patients receive multiple treatments which modify heart rate and variations could also be explained by hypoxemia and increased respiratory work. However, we emphasize that, as observed in other studies, the severity of respiratory work, particularly respiratory rate was an indicator of treatment failure with a more specifc behavior [6,7]. Tis study has some methodological limitations that should be mention. Te frst one is absence of a control group that could provide unbiased comparisons of results. Another issue is limited sample size what could explain the broad confdence intervals that increase imprecision in the estimation of potential predictor factors of failure. On the other hand, it is one of the very few studies performed in low-middle income countries regarding this type of health problem. Data collection was prospective avoiding limitation of retrospective studies based in records review. Te routine clinical application of NIV in critical lower respiratory tract infections management outside ICU requires further study but it appears as a promising strategy to optimize use of resource with good results. Future research should be directed to promote multicenter randomized clinical studies with appropriate sample sizes that could prove the beneft of promote NIV outside ICU for selected critically ill children. NIV applied outside of ICU could reduce the demand for beds in these units at the most critical period of the year and also reduce complications associated with conventional mechanical ventilation. It should be the frst option when possible since, according to current evidence, success or failure can be assessed shortly (two hours afer implementation). However, some concerns should be addressed, mainly to assure the accessibility to mechanic ventilation support for those children not responding to NIV and the availability of enough trained staf able to Aleman and Giachetto, J Neonatal Biol 2014, 3:2 DOI: 10.4172/2167-0897.1000e109 Editorial Open Access J Neonatal Biol ISSN:2167-0897 JNB, an open access journal Volume 3 • Issue 2 • 1000e109 J o u r n a l o f N e o n a t a l B i o l o g y ISSN: 2167-0897 Journal of Neonatal Biology