Pneumonia without complications
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Adult infection of the lower respiratory tract without signs of
severity.
A child without signs of severe pneumonia with cough or difficulty
breathing and rapid breathing.
Observation: Follow the respiratory rate reference values according to
the age range for evaluation: *respiratory incursions per minute
(ripm).
1 to 12 months: 30 to 53 ripm
1 to 2 years: 22 to 37 ripm
3 to 5 years: 20 to 28 ripm
School: 18 to 25 ripm
Adolescent: 12 to 20 ripm
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Severe pneumonia
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Adolescent or adult: lower respiratory tract infection with any of the
following signs of severity described below: respiratory
rate> 30 incursions per minute; severe respiratory
effort; SpO2 <93% in room air; cyanosis; organic
dysfunction.
Children with a cough or difficulty breathing more than at least one
of the following criteria:
central cyanosis or spO2 <90%;
severe respiratory effort;
signs of PNM with aspects of severity (use of accessory muscles for
breathing; inability or refusal to breastfeed or drink fluids;
wheezing or stridor at rest; unavoidable vomiting; altered sensory:
irritability or drowsiness; convulsions).
The respiratory rate that denotes severity in children will depend on
age, namely:
<2 months: ≥60 ripm
2 to 11 months: ≥50 ripm
1 to 5 years: ≥40 ripm
The diagnosis is clinical. Chest images can identify or exclude
complications.
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Acute respiratory distress syndrome (ARDS)
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Onset or worsening of respiratory symptoms, up to one week after the
onset of the disease. It may also present: radiological changes
(infiltrates, bilateral opacities, lobar/pulmonary atelectasis, or
nodules); pulmonary edema not explained by heart failure or
hyperhydration.
Oxygenation impairment in adults and children:
ADULTS:
Lightweight: 200 mmHg <PaO2 / FiO2 ≤ 300 mmHg (with Peep or
Cpap ≥ 5 cm H2O, or not ventilated).
Moderate Sara: 100 mmHg <PaO2 / FiO2 ≤ 200 mmHg (with PEEP ≥
5 cm H2O, or not ventilated).
Severe Sara: PaO2 / FiO2 ≤ 100 mmHg (with PEEP ≥ 5 cm H2O, or not
ventilated).
When PaO2 is not available, SpO2 / FiO2 ≤ 315 suggests Sara (including
in unventilated patients).
CHILDREN:
OI = Oxygenation Index and OIU = Oxygenation Index using SpO2. Use the
PaO2 based metric, when available. If PaO2 is not available, wean FiO2
to maintain SpO2 ≤ 97% to calculate OSI or SpO2 / FiO2 ratio:
Non-invasive ventilation or Cpap bi-level ≥ 5 cm H2O through a full
face mask: PaO2 / FiO2 ≤ 300 mmHg or SpO2 / FiO2 ≤ 264.
Light Sara (with invasive ventilation): 4 ≤ OI <8 or 5 ≤ OSI
<7.5.
Moderate Sara (with invasive ventilation): 8 ≤ OI <16 or 7.5
≤ OIU <12.3.
Severe condition (with invasive ventilation): OI ≥ 16 or OIU ≥ 12.3.
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Sepsis
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Systemic inflammatory response syndrome with organ dysfunction in the
presence of presumed or confirmed infection. Frequent signs of organ
dysfunction are altered level of consciousness, oliguria, tachy and/or
dyspnoea, low oxygen saturation, tachycardia, weak pulse, cold
extremities, coagulopathy, thrombocytopenia, acidosis, elevated serum
lactate or bilirubin.
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Septic shock
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Sepsis accompanied by hypotension [mean arterial pressure (MAP)
<65 mmHg] despite adequate volume resuscitation and
requiring the use of vasopressors to maintain MAP> = 65
mmHg.
Children: any type of hypotension (SBP <5th percentile
or> 2 SD below normal for age) or two or three of the
following: altered mental status; tachycardia or bradycardia (HR
<90 bpm or> 160 bpm in children under 12 months
and HR <70 bpm or> 150 bpm in children);
prolonged capillary filling (> 2 sec) or weak pulse;
tachypnea; stained or cold skin or petechial or purple rash; increased
lactate; oliguria; hyperthermia or hypothermia.
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