Tachypnoea is a good predictor of hypoxia in acutely ill infants under 2 months

Pulse oximetry values of neonates admitted for care and receiving routine oxygen therapy at a resource-limited hospital in Kenya

AIM

There are 2.7 million neonatal deaths annually, 75% of which occur in sub-Saharan Africa and South Asia. Effective treatment of hypoxaemia through tailored oxygen therapy could reduce neonatal mortality and prevent oxygen toxicity.

METHODS

We undertook a two-part prospective study of neonates admitted to a neonatal unit in Nairobi, Kenya, between January and December 2015. We determined the prevalence of hypoxaemia and explored associations of clinical risk factors and signs of respiratory distress with hypoxaemia and mortality. After staff training on oxygen saturation (SpO₂ ) target ranges, we enrolled a consecutive sample of neonates admitted for oxygen and measured SpO₂ at 0, 6, 12, 18 and 24 h post-admission. We estimated the proportion of neonates outside the target range (≥34 weeks: ≥92%; <34 weeks: 89-93%) with 95% confidence intervals (CIs).

RESULTS

A total of 477 neonates were enrolled. Prevalence of hypoxaemia was 29.2%. Retractions (odds ratio (OR) 2.83, 95% CI 1.47-5.47), nasal flaring (OR 2.68, 95% CI 1.51-4.75), and grunting (OR 2.47, 95% CI 1.27-4.80) were significantly associated with hypoxaemia. Nasal flaring (OR 2.85, 95% CI 1.25-6.54), and hypoxaemia (OR 3.06, 95% CI 1.54-6.07) were significantly associated with mortality; 64% of neonates receiving oxygen were out of range at ≥2 time points and 43% at ≥3 time points.

CONCLUSION

There is a high prevalence of hypoxaemia at admission and a strong association between hypoxaemia and mortality in this Kenyan neonatal unit. Many neonates had out of range SpO₂ values while receiving oxygen. Further research is needed to test strategies aimed at improving the accuracy of oxygen provision in low-resource settings.

Bronchiolitis – Rationale for current recommendations for diagnosis and management

Bronchiolitis is a lower respiratory infection caused commonly by RSV in the initial 2 years of life. It is responsible for a large number of hospitalizations. Pulse oximetry plays an important role in monitoring the progression of disease. Supplemental oxygen administration is not recommended at saturation levels above 90%.

The prognostic significance of respiratory rate in patients with pneumonia: a retrospective analysis of data from 705,928 hospitalized patients in Germany from 2010-2012

BACKGROUND

Measurement of the respiratory rate is an important instrument for assessing the severity of acute disease. The respiratory rate is often not measured in routine practice because its clinical utility is inadequately appreciated. In Germany, documentation of the respiratory rate is obligatory when a patient with pneumonia is hospitalized. This fact has enabled us to study the prognostic significance of the respiratory rate in reference to a large medical database.

METHOD

We retrospectively analyzed data from the external quality-assurance program for community-acquired pneumonia for the years 2010-2012. All patients aged 18 years or older who were not mechanically ventilated on admission were included in the analysis. Logistic regression was used to determine the significance of the respiratory rate as a risk factor for in-hospital mortality.

RESULTS

705,928 patients were admitted to the hospital with community-acquired pneumonia (incidence: 3.5 cases per 1000 adults per year). The in-hospital mortality of these patients was 13.1% (92 227 persons). The plot of mortality as a function of respiratory rate on admission was U-shaped and slanted to the right, with the lowest mortality at a respiratory rate of 20/min on admission. If patients with a respiratory rate of 12-20/min are used as a baseline for comparison, patients with a respiratory rate of 27-33/min had an odds ratio (OR) of 1.72 for in-hospital death, and those with a respiratory rate above 33/min had an OR of 2.55. Further independent risk factors for in-hospital death were age, admission from a nursing home, hospital, or rehabilitation facility, chronic bedridden state, disorientation, systolic blood pressure, and pulse pressure.

CONCLUSION

Respiratory rate is an independent risk marker for in-hospital mortality in community-acquired pneumonia. It should be measured when patients are admitted to the hospital with pneumonia and other acute conditions.

Approach to a child with breathing difficulty

Breathing difficulty and respiratory distress is the most common cause of admission to the Pediatric Emergency. Respiratory distress presents as altered breathing pattern, forced breathing efforts or obstructed breathing, and chest indrawing; respiratory failure is defined as paCO(2) >50 mmHg (inadequate ventilation) and/or a paO(2) < 60 mmHg (inadequate oxygenation). Rapid assessment is aimed to ascertain adequacy of airway patency, breathing, and circulation. Immediate care is directed at (a) restoration of airway patency- by positioning (head tilt -chin lift), cleaning the oropharynx, and/or insertion of oropharyngeal airway; (b) supporting breathing- with high flow oxygen and assisted ventilation (with bag and mask or endotracheal intubation and ventilation), and (c) restoration of circulation- using fluid boluses and inotropes, if necessary. Immediate specific management may require endotracheal intubation/tracheostomy for upper airway obstruction; needle thoracotomy and drainage of pneumothorax; and first dose of antibiotic for febrile children. Thereafter meticulous history, focused physical examination, and specific laboratory/radiological investigations are undertaken to identify the underlying cause. At the end of this, one should be able to categorize the child to one of the following: (a) upper airway obstruction, (b) pneumonia (syndrome of cough, fever and breathing difficulty), (c) lower airway obstruction, (d) slow or irregular breathing without pulmonary signs, and (e) respiratory distress with cardiac findings, to initiate specific treatment. Further respiratory support by Continuous Positive Airways Pressure (CPAP) and mechanical ventilation may be required in some cases. All children with respiratory distress must be monitored for early detection of worsening/complications, assessment of response to therapy and rapid documentation of clinical state.

Acute community acquired pneumonia in emergency room

Community acquired pneumonia is the leading killer of children under the age of 5 years. In ER, a diagnosis of pneumonia may be made and the severity graded on basis of WHO's classification for pneumonia in children up to 5 years of age. It relies on age-specific respiratory rate, presence of lower chest indrawing and signs of severe illness. A diagnosis of pneumonia is made if a febrile child has history of cough and difficult or rapid breathing and a respiratory rate above age specific threshold; however, signs of airway obstruction should be ruled out. Severe pneumonia is diagnosed if with the above features lower chest wall retraction is present; nonetheless, all infants below 2 months and children with moderate to severe malnutrition with pneumonia are categorized as having severe pneumonia. A chest radiograph is indicated only if the diagnosis is in doubt; complications are suspected and there is severe/very severe or recurrent pneumonia. Non-severe pneumonia is treated at home with oral amoxicillin for 3-5 days. If there is no improvement in 48 h it is changed to amoxicillin-clavulanate. Azithromycin is added for atypical pneumonia. Indications for hospitalization include age <2 months, treatment failure on oral antibiotics, severe/very severe or recurrent pneumonia, shock, hypoxemia, severe malnutrition, immunocompromised state. Severe pneumonia is treated with injectable ampicillin; Cloxacillin is added if clinical/radiographic features suggest Staphylococcal infection. On review after 48 h, if improved, the child may be sent home on oral amoxicillin for 5 more days; if not, it is treated as very severe pneumonia. Very severe pneumonia is treated with injectable Ampicillin plus gentamicin. If improved after 48 h, oral amoxicillin and gentamicin are continued for 10 days. If not, respiratory support is enhanced, antibiotics are changed to intravenous ceftriaxone and amikacin and further work up is planned. Children with chronic diseases and recurrent pneumonia require specific antibiotics depending on the underlying cause.

The prevalence of hypoxaemia among ill children in developing countries: a systematic review

Hypoxaemia is a common complication of childhood infections, particularly acute lower respiratory tract infections. In pneumonia-a disease that disproportionately impacts developing countries, and accounts for more than two million deaths of children worldwide-hypoxaemia is a recognised risk factor for death, and correlates with disease severity. Hypoxaemia also occurs in severe sepsis, meningitis, common neonatal problems, and other conditions that impair ventilation and gas exchange or increase oxygen demands. Despite this, hypoxaemia has been overlooked in worldwide strategies for pneumonia control and reducing child mortality. Hypoxaemia is also often overlooked in developing countries, mainly due to the low accuracy of clinical predictors and the limited availability of pulse oximetry for more accurate detection and oxygen for treatment. In this Review of published and unpublished studies of acute lower respiratory tract infection, the median prevalence of hypoxaemia in WHO-defined pneumonia requiring hospitalisation (severe and very severe classifications) was 13%, but prevalence varied widely. This corresponds to at least 1.5 to 2.7 million annual cases of hypoxaemic pneumonia presenting to health-care facilities. Many more people do not access health care. With mounting evidence of the impact that improved oxygen systems have on mortality due to acute respiratory infection in limited-resource health-care facilities, there is a need for increased awareness of the burden of hypoxaemia in childhood illness.

Implementing an oxygen programme in hospitals in Papua New Guinea

In Papua New Guinea (PNG), the most common cause of death among children under 5 years of age is pneumonia. Children with severe pneumonia need antibiotics and oxygen but oxygen shortages are common owing to the cost and complex logistics of transporting it in cylinders. Detection of hypoxaemia using clinical signs can be difficult, especially in highly pigmented children in whom cyanosis is difficult to recognise. Pulse oximetry is the most reliable, non-invasive way of detecting hypoxaemia. However, most hospitals in PNG do not have pulse oximetry. We proposed that the installation of a reliable, sufficient and cheap supply of oxygen in hospitals coupled with the use of pulse oximetry would make a significant difference to child survival rates in PNG. Oxygen concentrators, which extract oxygen from ambient air, were installed in the children's wards of five hospitals during 2005. Pulse oximeters were also introduced to enable better detection of hypoxaemia. This paper describes the technical aspects of this programme: the equipment used and the rationale behind choosing it, the installation, commissioning and testing processes. The ongoing training of clinical and engineering staff as well as two follow-up evaluations are described.

Hypoxaemia among children in rural hospitals in Papua New Guinea: epidemiology and resource availability--a study to support a national oxygen programme

AIMS

To support a national approach to oxygen systems in Papua New Guinea, we conducted a study to document the incidence of hypoxaemia, its geographical distribution, epidemiological determinants and resource availability in several regions of the country. We also established baseline mortality rate data for all children admitted to five hospitals, for children with a diagnosis of pneumonia and for neonates to evaluate a future intervention.

METHODS

Data were collected prospectively from over 1300 hospital admissions in five hospitals in 2004. To establish the baseline case fatality rates, data on outcome were collected retrospectively over 3 years (2001-2003) for over 20,000 children admitted to five hospitals.

RESULTS

A total of 1313 admissions were studied prospectively in the five hospitals. Altogether, 384 (29.25%, 95% CI 26.8-31.8) had hypoxaemia, defined as SpO(2) <90%. The incidence of hypoxaemia was much greater in highland hospitals (40% of all admissions) than on the coast (10% of all admissions). This large difference in incidence persisted when the uniform definition of hypoxaemia was adjusted for altitude, and was largely because of differences in the incidence of acute respiratory tract infection. Oxygen was not available on the day of admission for 22% of children (range between hospitals, 3-38), including 13% of all children with hypoxaemia. Oxygen was less available in remote rural district hospitals than in provincial hospitals in regional towns. Clinical signs proposed by WHO as indicators for oxygen would have missed 29% of children with hypoxaemia and, if these clinical signs were used, 30% of children without hypoxaemia would have been considered in need of supplemental oxygen.

CONCLUSIONS

Based on this study, an approach to improving the detection of hypoxaemia and the availability of oxygen has been trialled in these five hospitals where a programme of clinical and technical training in the use and maintenance of pulse oximetry and oxygen concentrators has been introduced.

Role of Acute Illness Observation Scale (AIOS) in managing severe childhood pneumonia

OBJECTIVE

In the perspective of integrated management of childhood illness (IMCI) strategy and recent evidence favoring use of oral antibiotics in severe pneumonia, a generic illness severity index--Acute Illness Observation Scale (AIOS)--was prospectively validated in children with severe pneumonia in a civil hospital in remote hilly region.

METHODS

AIOS was used in quantifying overall severity of illness for eighty-nine consecutive children (age, 2-59 months) hospitalized with community-acquired severe pneumonia. A detailed clinimetric evaluation of scale was carried out and logistic regression analyses predicted the following outcomes: 1) mode of initial antimicrobial therapy (oral vs. parenteral); and 2) need for intravenous fluids at admission.

RESULTS

Majority of children (80.9%) with severe pneumonia scored abnormally (AIOS score> 10) at initial evaluation. Children with abnormal AIOS scores (>10) had significantly greater severity of respiratory distress and higher incidence of radiological pneumonia. Outcome measures i.e. time to defervescence and length of hospital stay were also positively and significantly correlated with the scores. The six-item scale had good internal consistency (Cronbach's alpha 0.81); and its factor analysis yielded a single latent factor explaining 54% of variance in illness severity at admission. Furthermore, logistic regression analyses revealed an independent predictive ability of AIOS in aiding clinician to decide the mode of initial antimicrobial therapy (oral or parenteral), as well as need for intravenous fluids.

CONCLUSION

Authors study indicates the clinimetric validity of AIOS in managing, Severe childhood pneumonia and suggests its role in further enriching IMCI strategy.

Neonatal pneumonia in developing countries

Pneumonia contributes to between 750,000 and 1.2 million neonatal deaths and an unknown number of stillbirths each year world wide. The aetiology depends on time of onset. Gram negative bacilli predominate in the first week of life, and Gram positive bacteria after that. Streptococcus pneumoniae probably causes about 25% of neonatal pneumonia. Interventions that would reduce mortality from this condition would have a large range of beneficial effects: improved maternal health, better management of other common neonatal conditions, and reduced long term childhood and adult morbidity.

The management of sick young infants at primary health centres in a rural developing country

AIMS

To investigate the epidemiology of illness among young infants at remote health clinics in a rural developing country, and to determine risk factors for mortality that might be used as triggers for emergency treatment or referral.

METHODS

Multi-site 12 month observational study of consecutive presentations of infants less than 2 months, and an investigation of neonates who died in one district without accessing health care.

RESULTS

Forty per cent of 511 young infant presentations occurred in the first week of life and most of these in the first 24 hours. Twenty five deaths were recorded: 18 in the health facilities and seven in villages. In addition there were eight stillbirths. Clinical signs predicting death were: not able to feed, fast respiratory rate, apnoea, cyanosis, "too small", "skin-cold", and severe abdominal distension. Signs indicating severe respiratory compromise were present in 25% of young infants; failure to give oxygen therapy was a modifiable factor in 27% of deaths within health facilities. A high proportion of seriously ill young infants were discharged from health facilities early without adequate follow up. A common reason for not seeking care for fatally ill neonates was the perception by parents that health staff would respond negatively to their social circumstances.

CONCLUSIONS

Clinical signs with moderate positive predictive value for death may be useful triggers for emergency treatment and longer observation or urgent referral. The results of this study may be useful in planning strategies to address high neonatal mortality rates in developing countries.

Diagnosis and investigation of bacterial pneumonias

This overview has been supported by a review of the literature referring to the management of community-acquired pneumonia (in preparation). Difficulties diagnosing bacterial pneumonia include identifying the pathogens and the validation of radiographic signs suggesting bacterial or mycoplasmal infection. The World Health Organisation (WHO) has published guidelines for diagnosis which seem to be as relevant for developed as developing countries. The main diagnostic features are tachypnoea, fever greater than 38.5 degrees C and chest recession without wheeze. Radiographic features lag behind clinical findings and provide little additional help when antibiotic treatment is considered but are crucial in the proper management of complications.