Sedação e estenose subglótica em crianças gravemente doentes

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Abstract

As mortality rates have decreased over the past few decades, the focus of contemporary pediatric critical care has shifted toward minimizing long-term morbidity. Children requiring endotracheal intubation and mechanical ventila-tion are at risk for a number of lasting sequelae, including chronic respiratory failure, neuropathy/myopathy, and cog-nitive impairment. 1 Risk factors for individual complications have been described, and actions to avoid these risk fac-tors should be considered. However, avoiding one action invariably causes a reaction that may confer its own adverse effects. For example, a dry lung strategy shortens the duration of mechanical ventilation in the acute respira-tory distress syndrome (ARDS), but may worsen long-term neurologic status. 2,3 A lung-protective strategy may reduce ventilator-associated lung injury and the risk of chronic respiratory failure, but the resultant acidosis and elevated intrathoracic pressures can be poorly tolerated in children with fluid-refractory shock, pulmonary hypertension, and/or intracranial hypertension. 4 When faced with multiple ther-apeutic options, pediatric intensivists must be cognizant of the risks and benefits of all possible paths. Another risk of endotracheal intubation is the devel-opment of subglottic stenosis. Investigators from Hospital de Clínicas de Porto Alegre have established themselves ଝ Please cite this article as: Shein SL, Rotta AT. Sedation and subglottic stenosis in critically ill children. at the forefront of research into this important condition. They have previously shown that subglottic stenosis is a common problem among their intubated patients, occur-ring in approximately 10% of cases. 5,6 In this issue of the Jornal de Pediatria, they aimed to take an important next step ---identifying risk factors associated with the develop-ment of subglottic stenosis. 7 Understanding risk factors for developing subglottic stenosis may allow a reduction in its occurrence, which may in turn reduce extubation failure, the need for diagnostic procedures and therapeutic inter-ventions. However, if risk factors are identified, one must be cautious to think of the possible reactions, in order to avoid them. Before considering any identified risk factors, one must evaluate the validity of the study and its applicability to one's own patient population. Schweiger et al. 7 should be commended for the several strengths of their meth-ods, including the subglottic stenosis assessment, which was prospective and uniformly thorough the study, and the use of a validated and widely used sedation assess-ment score (COMFORT-B). 8 However, their sample size was small (n = 36), which limited the power of their statisti-cal analysis. This small sample size also likely influenced the distribution of the COMFORT-B scores, which were pre-sumably not normally distributed (as they were evaluated using a non-parametric test) but were reported in the style typically used for normally-distributed data (mean and standard deviation), which limits our ability to fully inter-pret their findings. We look forward to their future work, which will hopefully evaluate for risk factors in a larger cohort.

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Shein, S. L., & Rotta, A. T. (2017). Sedação e estenose subglótica em crianças gravemente doentes. Jornal de Pediatria, 93(4), 317–319. https://doi.org/10.1016/j.jped.2017.03.001

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