ABSTRACT Objective: To describe the role of physiotherapists in assisting patients suspected to have or diagnosed with COVID-19 hospitalized in intensive care units in Brazil regarding technical training, working time, care practice, labor conditions and remuneration. Methods: An analytical cross-sectional survey was carried out through an electronic questionnaire distributed to physiotherapists who worked in the care of patients with COVID-19 in Brazilian intensive care units. Results: A total of 657 questionnaires were completed by physiotherapists from the five regions of the country, with 85.3% working in adult, 5.4% in neonatal, 5.3% in pediatric and 3.8% in mixed intensive care units (pediatric and neonatal). In intensive care units with a physiotherapists available 24 hours/day, physiotherapists worked more frequently (90.6%) in the assembly, titration, and monitoring of noninvasive ventilation (p = 0.001). Most intensive care units with 12-hour/day physiotherapists (25.8%) did not apply any protocol compared to intensive care units with 18-hour/day physiotherapy (9.9%) versus 24 hours/day (10.2%) (p = 0.032). Most of the respondents (51.0%) received remuneration 2 or 3 times the minimum wage, and only 25.1% received an additional payment for working with patients suspected to have or diagnosed with COVID-19; 85.7% of them did not experience a lack of personal protective equipment. Conclusion: Intensive care units with 24-hour/day physiotherapists had higher percentages of protocols and noninvasive ventilation for patients with COVID-19. The use of specific resources varied between the types of intensive care units and hospitals and in relation to the physiotherapists’ labor conditions. This study showed that most professionals had little experience in intensive care and low wages.

RESUMO Objetivo: Descrever o papel dos fisioterapeutas na assistência a pacientes com suspeita ou diagnóstico da COVID-19 internados em unidades de terapia intensiva no Brasil em relação a: formação técnica, tempo de trabalho, prática assistencial, condições de trabalho e remuneração. Métodos: Foi realizado um inquérito transversal analítico com questionário eletrônico distribuído aos fisioterapeutas que atuavam no atendimento de pacientes com COVID-19 em unidades de terapia intensiva brasileiras. Resultados: Foram preenchidos 657 questionários por fisioterapeutas das cinco regiões do país, sendo que 85,3% trabalhavam em unidades de terapia intensiva adulto, 5,4% em neonatal, 5,3% em pediátrica e 3,8% em unidades de terapia intensiva mista (pediátrica e neonatal). Nas unidades de terapia intensiva com um fisioterapeuta disponível 24 horas por dia, os fisioterapeutas trabalharam com mais frequência (90,6%) na montagem, titulação e monitoramento da ventilação não invasiva (p = 0,001). A maioria das UTIs com fisioterapia 12 horas por dia (25,8%) não aplicou nenhum protocolo comparativamente às unidades de terapia intensiva com fisioterapia 18 horas por dia (9,9%) e às de 24 horas por dia (10,2%) (p = 0,032). A maioria dos entrevistados (51,0%) recebia remuneração de duas a três vezes o salário mínimo, e apenas 25,1% recebiam pagamento adicional por trabalhar com pacientes com suspeita ou diagnóstico da COVID-19; 85,7% deles não enfrentaram falta de Equipamentos de Proteção Individual. Conclusão: As unidades de terapia intensiva com fisioterapeutas 24 horas por dia apresentaram maiores porcentagens de protocolos e ventilação não invasiva para pacientes com COVID-19. A utilização de recursos específicos variou entre os tipos de unidades de terapia intensiva e hospitais e em relação às condições de trabalho dos fisioterapeutas. Este estudo mostrou que a maioria dos profissionais tinha pouca experiência em terapia intensiva e baixa remuneração.

Introduction The COVID-19 pandemic generated many controversies in the management of critically ill pediatric patients. The main ones were about ventilatory support, phenotypic differences between adults and children, and acute and subacute clinical forms. For this reason, the Respiratory Committee (RC) of the Latin American Society of Pediatric Intensive Care (SLACIP) generated a document to summarize the recommendations with the best evidence. The objective of these recommendations is to provide an update on issues related to pediatric COVID-19. Methods and Materials The Respiratory Committee created a group composed of 19 pediatric kinesiologists/physiotherapists and intensivists from 8 Latin American countries and defined on 3/27/20 the 15 most relevant topics, assigning 3 referents and 2 reviewers for each. The manuscripts went through 4 stages until their final version. The complete document was freely distributed on 22/05/20 and updated twice (07/08/20 and 02/09/21). For the current version there were 3 special collaborators. Result The material consists of a complete 94-page document and an executive summary. The topics included are case definition, epidemiology, clinical classification, subacute inflammatory syndrome, personal protective equipment, aerosolization situations (intubation, extubation, suctioning, sampling, filter replacement, cardiopulmonary resuscitation, early mobilization), high flow cannula support, invasive, non-invasive and high frequency mechanical ventilation, pharmacological treatment, laboratory and imaging. Conclusion The purpose of this document is to serve as a guide for nurses, kinesiologists/physiotherapists and physicians in the management of critically ill pediatric patients with COVID-19.

Introducción La pandemia por COVID-19 generó muchas controversias en el manejo de los pacientes pediátricos críticos. Las principales fueron sobre el soporte ventilatorio, las diferencias fenotípicas entre adultos y niños y las formas clínicas aguda y subaguda.Por esa razón el Comité Respiratorio (CR) de la Sociedad Latinoamericana de Cuidados Intensivos Pediátricos (SLACIP) generó un documento para resumir las recomendaciones con mayor evidencia. El objetivo de estas recomendaciones es brindar una actualización de temas relacionados a COVID-19 pediátrico.Métodos y Materiales El Comité Respiratorio creó un grupo compuesto por 19 kinesiólogos/fisioterapeutas y médicos intensivistas pediátricos de 8 países de Latinoamérica y definió el 27/03/20 los 15 temas más relevantes, asignando 3 referentes y 2 revisores por cada uno. Los manuscritos pasaron por 4 etapas hasta su versión final. El documento completo se distribuyó libremente el 22/05/20, actualizándose en dos oportunidades (07/08/20 y el 02/09/21). Para la versión actual se contó con 3 colaboradores especiales.Resultado El material se compone de un documento completo de 94 páginas y un resumen ejecutivo. Los temas incluidos son definición de caso, epidemiología, clasificación clínica, síndrome inflamatorio subagudo, equipos de protección personal, situaciones de aerosolización (intubación, extubación, aspiración, toma de muestras, recambio de filtros, reanimación cardiopulmonar, movilización temprana), soporte con cánula de alto flujo, ventilación mecánica invasiva, no invasiva y de alta frecuencia, tratamiento farmacológico, laboratorio e imágenes.Conclusión La elaboración de este documento ha tenido como fin servir de guía para enfermeros, kinesiólogos/fisioterapeutas y médicos en el manejo de pacientes pediátricos en estado crítico por COVID-19.

RESUMO Objetivo: Apresentar as diretrizes de estimulação sensório-motora para recém-nascidos e lactentes em unidade de terapia intensiva., Métodos: Trata-se de um método de delineamento misto com revisão sistemática da literatura e recomendações com base na evidência científica e opiniões de fisioterapeutas especialistas em fisioterapia neonatal de estudos publicados entre 2010 e 2018 nas bases de dados MEDLINE® e Cochrane, que incluiu recém-nascidos (pré-termo e a termo) e lactentes (entre 28 dias e 6 meses de idade) admitidos à unidade de terapia intensiva e submetidos a métodos de estimulação sensório-motora. Os estudos encontrados foram classificados segundo o escore GRADE por cinco fisioterapeutas em diferentes regiões do país e apresentados em oito congressos científicos para discussão das diretrizes de práticas clínicas., Resultados: Foram incluídos 89 artigos para construir as diretrizes de práticas clínicas. Estimulação auditiva, gustatória e contato pele a pele se destacaram por melhorar os sinais vitais, e a massagem terapêutica, assim como a estimulação multimodal tátil-cinestésica por melhorar o peso ou a sucção., Conclusão: Embora todas a modalidades tenham boas avaliações para controle da dor ou do estresse, é recomendado que os procedimentos de estimulação sensório-motora sejam adaptados às necessidades específicas da criança, e as intervenções sejam realizadas por profissionais experientes.

Abstract Objective: To present guidelines on sensory motor stimulation for newborns and infants in the intensive care unit. Methods: We employed a mixed methods design with a systematic review of the literature and recommendations based on scientific evidence and the opinions of physiotherapists with neonatal expertise. The research included studies published between 2010 and 2018 in the MEDLINE® and Cochrane databases that included newborns (preterm and term) and infants (between 28 days and 6 months of age) hospitalized in the intensive care unit and submitted to sensory motor stimulation methods. The studies found were classified according to the GRADE score by five physiotherapists in different regions of Brazil and presented at eight Scientific Congresses held to discuss the clinical practice guidelines. Results: We included 89 articles to construct the clinical practice guidelines. Auditory, gustatory and skin-to-skin stimulation stand out for enhancing vital signs, and tactile-kinesthetic massage and multisensory stimulation stand out for improving weight or sucking. Conclusion: Although all modalities have good ratings for pain or stress control, it is recommended that sensory motor stimulation procedures be tailored to the infant’s specific needs and that interventions and be carried out by expert professionals.

RESUMO Objetivo: Identificar as unidades de terapia intensiva neonatais, pediátricas e mistas (neonatais e pediátricas) no Brasil que utilizam cânulas traqueais com balonete na prática clínica, e descrever as características relacionadas à utilização de protocolos e monitoração. Métodos: Para identificação das unidades de terapia intensiva no Brasil, foi acessado o Cadastro Nacional de Estabelecimentos de Saúde do Ministério da Saúde, e foram obtidas informações de 693 unidades de terapia intensiva cadastradas. Trata-se de estudo transversal analítico do tipo survey realizado por questionário eletrônico enviado para 298 unidades de terapia intensiva neonatais, pediátricas e mistas do Brasil. Resultados: Este estudo analisou 146 questionários (49,3% de unidades de terapia intensiva neonatais, 35,6% de unidades de terapia intensiva pediátricas e 15,1% de unidades de terapia intensiva pediátricas mistas). A maioria das unidades participantes (78/146) utilizou cânulas traqueais com balonete, com predomínio de uso nas unidades de terapia intensiva pediátricas (52/78). A maioria das unidades que utilizou cânulas traqueais com balonete aplicou protocolo de monitoração da pressão do balonete (45/78). O uso de protocolos de monitoração do balonete foi observado nas unidades de terapia intensiva com Serviço de Fisioterapia exclusivo da unidade (38/61) e naquelas com tempo de atuação do fisioterapeuta 24 horas/dia (25/45). A causa de falha de extubação mais frequentemente relacionada ao uso de cânulas traqueais com balonete em unidades de terapia intensiva pediátricas foi a obstrução de vias aéreas superiores. Conclusão: Nesta enquete, houve predomínio do uso de cânulas traqueais com balonete e da aplicação de protocolo de monitoração da pressão do balonete em unidades de terapia intensiva pediátricas. A utilização de protocolo de monitoração foi mais frequente em unidades de terapia intensiva com fisioterapeuta exclusivo e com tempo de atuação 24 horas/dia.

ABSTRACT Objective: To identify the neonatal, pediatric and mixed (neonatal and pediatric) intensive care units in Brazil that use cuffed tracheal tubes in clinical practice and to describe the characteristics related to the use of protocols and monitoring. Methods: To identify the intensive care units in Brazil, the Ministry of Health’s National Registry of Health Facilities was accessed, and information was collected on 693 registered intensive care units. This was an analytical cross-sectional survey conducted through electronic questionnaires sent to 298 neonatal, pediatric and mixed intensive care units in Brazil. Results: This study analyzed 146 questionnaires (49.3% from neonatal intensive care units, 35.6% from pediatric intensive care units and 15.1% from mixed pediatric intensive care units). Most of the participating units (78/146) used cuffed tracheal tubes, with a predominance of use in pediatric intensive care units (52/78). Most of the units that used cuffed tracheal tubes applied a cuff pressure monitoring protocol (45/78). The use of cuff monitoring protocols was observed in intensive care units with a physical therapy service exclusive to the unit (38/61) and in those with a physical therapist present 24 hours/day (25/45). The most frequent cause of extubation failure related to the use of cuffed tracheal tubes in pediatric intensive care units was upper airway obstruction. Conclusion: In this survey, the use of cuffed tracheal tubes and the application of a cuff pressure monitoring protocol was predominant in pediatric intensive care units. The use of a monitoring protocol was more common in intensive care units that had a physical therapist who was exclusive to the unit and was present 24 hours/day.

This review aims to verify the main epidemiologic, clinical, laboratory-related, and therapeutic aspects of coronavirus disease 2019 (COVID-19) in critically ill pediatric patients. An extensive review of the medical literature on COVID-19 was performed, mainly focusing on the critical care of pediatric patients, considering expert opinions and recent reports related to this new disease. Experts from a large Brazilian public university analyzed all recently published material to produce a report aiming to standardize the care of critically ill children and adolescents. The report emphasizes on the clinical presentations of the disease and ventilatory support in pediatric patients with COVID-19. It establishes a flowchart to guide health practitioners on triaging critical cases. COVID-19 is essentially an unknown clinical condition for the majority of pediatric intensive care professionals. Guidelines developed by experts can help all practitioners standardize their attitudes and improve the treatment of COVID-19.

RESUMO A síndrome respiratória aguda grave (SRAG) pelo novo coronavirus (SARS-CoV-2) é um novo desafio para todos os países e crianças estão predispostas a adquirir a doença. Alguns estudos demonstraram quadros mais graves em adultos, mas crianças criticamente doentes foram descritas em todas as idades. O envolvimento pulmonar é a principal característica e a necessidade de suporte ventilatório é comum nos casos mais graves. Entretanto, outras abordagens terapêuticas importantes devem ser consideradas. Nesse artigo revisamos extensamente a literature médica até o momento a fim de citar os principais recursos terapêuticos para o manejo dos pacientes pediátricos durante o período de suporte ventilatório. Achados radiológicos, terapia fluídica, terapia antiviral, o uso de corticosteroides, terapia antitrombótica e o uso de imunoglobulinas foram analisados a fim de guiar os profissionais durante o período de hospitalização desses pacientes. Nós reforçamos a importância de uma abordagem multiprofissional para recuperação adequada.

SUMMARY Severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2 infection) is a new challenge for all countries, and children are predisposed to acquire this disease. Some studies have demonstrated more severe diseases in adults, but critically ill pediatric patients have been described in all ages. Pulmonary involvement is the major feature, and ventilatory support is common in critical cases. Nevertheless, other very important therapeutic approaches must be considered. In this article, we reviewed extensively all recent medical literature to point out the main clinical attitudes to support these pediatric patients during their period in respiratory support. Radiologic findings, fluid therapy, hemodynamic support, use of inotropic/vasopressors, nutritional therapy, antiviral therapy, corticosteroids, antithrombotic therapy, and immunoglobulins are analyzed to guide all professionals during hospitalization. We emphasize the importance of a multi-professional approach for adequate recovery.

Coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), became a pandemic in March 2020, affecting millions of people worldwide. However, COVID-19 in pediatric patients represents 1-5% of all cases, and the risk for developing severe disease and critical illness is much lower in children with COVID-19 than in adults. Multisystem inflammatory syndrome in children (MIS-C), a possible complication of COVID-19, has been described as a hyperinflammatory condition with multiorgan involvement similar to that in Kawasaki disease or toxic shock syndrome in children with evidence of SARS-CoV-2 infection. This review presents an update on the diagnostic methods for COVID-19, including reverse-transcriptase polymerase chain reaction (RT-PCR) tests, serology tests, and imaging, and summarizes the current recommendations for the management of the disease. Particular emphasis is placed on respiratory support, which includes noninvasive ventilation and invasive mechanical ventilation strategies according to lung compliance and pattern of lung injury. Pharmacological treatment, including pathogen-targeted drugs and host-directed therapies, has been addressed. The diagnostic criteria and management of MIS-C are also summarized.

This review aims to verify the main epidemiologic, clinical, laboratory-related, and therapeutic aspects of coronavirus disease 2019 (COVID-19) in critically ill pediatric patients. An extensive review of the medical literature on COVID-19 was performed, mainly focusing on the critical care of pediatric patients, considering expert opinions and recent reports related to this new disease. Experts from a large Brazilian public university analyzed all recently published material to produce a report aiming to standardize the care of critically ill children and adolescents. The report emphasizes on the clinical presentations of the disease and ventilatory support in pediatric patients with COVID-19. It establishes a flowchart to guide health practitioners on triaging critical cases. COVID-19 is essentially an unknown clinical condition for the majority of pediatric intensive care professionals. Guidelines developed by experts can help all practitioners standardize their attitudes and improve the treatment of COVID-19.

This article presents expert recommendations for assisting newborn children of mothers with suspected or diagnosed coronavirus disease 2019 </mac_aq>(COVID-19). The consensus was developed by five experts with an average of 20 years of experience in neonatal intensive care working at a reference university hospital in Brazil for the care of pregnant women and newborns with suspected or confirmed COVID-19. Despite the lack of scientific evidence regarding the potential for viral transmission to their fetus in pregnant mothers diagnosed with or suspected of COVID-19, it is important to elaborate the lines of care by specialists from hospitals caring for suspected and confirmed COVID-19 cases to guide multidisciplinary teams and families diagnosed with the disease or involved in the care of pregnant women and newborns in this context. Multidisciplinary teams must be attentive to the signs and symptoms of COVID-19 so that decision-making is oriented and assertive for the management of the mother and newborn in both the hospital setting and at hospital discharge.

RESUMO Objetivo: Descrever as práticas de desmame da ventilação mecânica (VM), quanto ao uso de protocolos, métodos e critérios, em UTIs pediátricas (UTIPs), neonatais (UTINs) e mistas - neonatais e pediátricas (UTINPs) - no Brasil. Métodos: Estudo transversal, tipo inquérito, realizado por meio do envio de questionário eletrônico a 298 UTINs, UTIPs e UTINPs de todo o país. Resultados: Foram avaliados 146 questionários respondidos (49,3% recebidos de UTINs, 35,6%, de UTIPs e 15,1%, de UTINPs). Das unidades pesquisadas, 57,5% aplicavam protocolos de desmame. Nas UTINs e UTINPs que utilizavam esses protocolos, o método de desmame da VM mais empregado (em 60,5% e 50,0%, respectivamente) foi a redução gradual padronizada do suporte ventilatório, enquanto o empregado na maioria (53,0%) das UTIPs foi o teste de respiração espontânea (TRE). Durante o TRE, o modo ventilatório predominante em todas as UTIs foi a ventilação com pressão de suporte (10,03 ± 3,15 cmH2O) com pressão expiratória final positiva. A duração média do TRE foi de 35,76 ± 29,03 min nas UTINs, contra 76,42 ± 41,09 min nas UTIPs. Os parâmetros do TRE, modos ventilatórios de desmame e tempo considerado para falha de extubação não se mostraram dependentes do perfil etário da população das UTIs. Os resultados da avaliação clínica e da gasometria arterial são frequentemente utilizados como critérios para avaliar a prontidão para extubação, independentemente da faixa etária atendida pela UTI. Conclusões: No Brasil, a prática clínica na condução do desmame da VM e extubação varia de acordo com a faixa etária atendida pela UTI. Protocolos de desmame e o TRE são utilizados principalmente nas UTIPs, enquanto a redução gradual do suporte ventilatório é mais utilizada nas UTINs e UTINPs.

ABSTRACT Objective: The aim of this study was to describe practices for weaning from mechanical ventilation (MV), in terms of the use of protocols, methods, and criteria, in pediatric ICUs (PICUs), neonatal ICUs (NICUs), and mixed neonatal/pediatric ICUs (NPICUs) in Brazil. Methods: This was a cross-sectional survey carried out by sending an electronic questionnaire to a total of 298 NICUs, PICUs, and NPICUs throughout Brazil. Results: Completed questionnaires were assessed for 146 hospitals, NICUs accounting for 49.3% of the questionnaires received, whereas PICUs and NPICUs accounted for 35.6% and 15.1%, respectively. Weaning protocols were applied in 57.5% of the units. In the NICUs and NPICUs that used weaning protocols, the method of MV weaning most commonly employed (in 60.5% and 50.0%, respectively) was standardized gradual withdrawal from ventilatory support, whereas that employed in most (53.0%) of the PICUs was spontaneous breathing trial (SBT). During the SBTs, the most common ventilation mode, in all ICUs, was pressure-support ventilation (10.03 ± 3.15 cmH2O) with positive end-expiratory pressure. The mean SBT duration was 35.76 ± 29.03 min in the NICUs, compared with 76.42 ± 41.09 min in the PICUs. The SBT parameters, weaning ventilation modes, and time frame considered for extubation failure were not found to be dependent on the age profile of the ICU population. The findings of the clinical evaluation and arterial blood gas analysis are frequently used as criteria to assess readiness for extubation, regardless of the age group served by the ICU. Conclusions: In Brazil, the clinical practices for weaning from MV and extubation appear to vary depending on the age group served by the ICU. It seems that weaning protocols and SBTs are used mainly in PICUs, whereas gradual withdrawal from ventilatory support is more widely used in NICUs and NPICUs.