Respiratory failure due to upper airway obstruction in children: use of the helmet as bridge interface

Upper airway obstruction (UAO) can cause severe respiratory distress in young children by increasing inspiratory muscle load and decreasing alveolar ventilation, ultimately resulting in hypercapnia and hypoxemia which have long term negative cardiovascular effects. Although non-invasive continuous positive airway pressure (CPAP) improves gas exchange in these patients, use of conventional interfaces (nasal mask, nasal pillow and facial mask) may cause significant discomfort and lead to CPAP intolerance. We report five cases of children affected by UAO who experienced CPAP intolerance via application of conventional interfaces. Alternatively, we acutely applied helmet-CPAP which resulted in improved breathing pattern and gas exchange. Thereafter, patients received training with respect to a nasal CPAP interface, allowing successful long term treatment. In conclusion, these five clinical cases demonstrate that helmet-CPAP can be used acutely in children with UAO if compliance to conventional modalities is problematic, allowing for sufficient time to achieve compliance to nasal-CPAP.

[Management of risk of errors in health: which representation for a systemic approach?]

The management of the risk of error in Health currently configures as an institutionalized multi/hetero-professional and "complex" activity. This implicates the need to establish rules that codify the modalities of interaction among the actors, as well as rules of communication, which, defining in a clear and univocal way the terminology used, allow the different actors to understand themselves. The representation of these rules implies a systemic and global conceptual approach in which the attention is moved from "the physician's performance" to the "performance in Health": the whole System must be structured and employed in order to pretend towards a continuous improvement of Quality and Safety.