NAC pediátrica: recomendaciones y certeza

Recomendaciones 1–4 del original.

Recommendations · síntesis

NAC moderada/grave, hipoxemia sostenida <90% a nivel del mar o distrés; considerar lactantes de 3–6 meses con sospecha bacteriana, patógenos virulentos y barreras de observación/seguimiento.

Evidence Summary · cómo leer el sustento

La valoración integra fisiología y condiciones de cuidado; un corte no reemplaza el examen.

Recomendaciones 5–11 del original.

Recommendations · síntesis

Ventilación invasiva, soporte no invasivo agudo, insuficiencia respiratoria inminente, compromiso hemodinámico, SpO₂ <92% pese a FiO₂≥0,50 o alteración mental.

Evidence Summary · cómo leer el sustento

Los puntajes no son criterio exclusivo de UCI. La tabla 4 se adapta de criterios adultos y requiere contexto pediátrico.

Recomendaciones 12–38 del original.

Recommendations · síntesis

Seleccionar pruebas según gravedad, ámbito y capacidad de modificar decisiones. Evitar hemocultivos y Rx rutinarios en niños ambulatorios estables.

Evidence Summary · cómo leer el sustento

Se desarrolla cada subtítulo diagnóstico debajo: rendimiento, referencia imperfecta y utilidad clínica son distintos.

Recomendaciones 39–40 del original.

Recommendations · síntesis

Aspirado traqueal al intubar y estudios virales dirigidos; técnicas invasivas reservadas a enfermedad grave sin diagnóstico inicial.

Evidence Summary · cómo leer el sustento

Colonización de tráquea puede producir cultivos que no representan el agente pulmonar. Más detección no implica mejor exactitud.

Recomendaciones 41–49 del original.

Recommendations · síntesis

Outpatients: muchos preescolares con cuadro viral no requieren antibiótico; amoxicilina para sospecha bacteriana, macrólido ante atípicos e influenza antiviral según contexto. Inpatients: ampicilina/penicilina si vacunado y resistencia local apropiada; cefalosporina en situaciones indicadas; añadir cobertura de atípicos o S. aureus cuando se sospechen.

Evidence Summary · cómo leer el sustento

La selección se basa en edad, vacunación, epidemiología y gravedad; no en la opacidad aislada.

Recomendaciones 50–53 del original.

Recommendations · síntesis

Limitar exposición, espectro, dosis insuficientes y duración; usar el curso eficaz más corto.

Evidence Summary · cómo leer el sustento

La guía señala que reducir consumo no demuestra automáticamente menos infecciones por organismos resistentes: son desenlaces diferentes.

Recomendaciones 54–55 del original.

Recommendations · síntesis

Diez días eran los cursos mejor estudiados en 2011; admite que cursos menores podrían servir en enfermedad leve. SAMR puede requerir más tiempo.

Evidence Summary · cómo leer el sustento

“Mejor estudiado” no significa “única duración eficaz”. No se presenta como pauta actual.

Recomendaciones 56 del original.

Recommendations · síntesis

Esperar mejoría clínica y de laboratorio en 48–72 h; investigar falta de mejoría o deterioro.

Evidence Summary · cómo leer el sustento

El curso radiográfico puede rezagarse respecto del clínico; una imagen residual no prueba fracaso.

Recomendaciones 57 del original.

Recommendations · síntesis

Confirmar líquido pleural con Rx; ecografía o TC si no es concluyente.

Evidence Summary · cómo leer el sustento

La ecografía también define tamaño y loculaciones; diagnóstico y planificación de drenaje cumplen funciones distintas.

Recomendaciones 58–59 del original.

Recommendations · síntesis

Tamaño y compromiso respiratorio; tabla 8 y figura 1 organizan la decisión.

Evidence Summary · cómo leer el sustento

Las categorías de riesgo no son porcentajes calibrados de mal resultado.

Recomendaciones 60–63 del original.

Recommendations · síntesis

Gram y cultivo; PCR puede aumentar detección. pH, glucosa, proteínas y LDH no se recomiendan rutinariamente por escaso cambio de conducta; celularidad ayuda a diferenciar otras etiologías.

Evidence Summary · cómo leer el sustento

Cultivo negativo no excluye infección, especialmente con antibióticos previos.

Recomendaciones 64–66 del original.

Recommendations · síntesis

Pequeños no complicados: antibiótico sin drenaje habitual. Moderados con distrés, grandes o purulentos: drenaje. Tubo con fibrinólisis o VATS según experiencia; libre flujo puede permitir tubo solo.

Evidence Summary · cómo leer el sustento

Los ensayos pequeños no establecen superioridad universal de una técnica; similitud observada no demuestra equivalencia formal.

Recomendaciones 67 del original.

Recommendations · síntesis

VATS ante derrame moderado/grande y compromiso persistente tras unos 2–3 días de tubo y fibrinólisis completada; decorticación abierta como alternativa de mayor morbilidad.

Evidence Summary · cómo leer el sustento

Fiebre persistente aislada no define fracaso del drenaje.

Recomendaciones 68 del original.

Recommendations · síntesis

Sin fuga aérea y drenaje <1 mL/kg/24 h, habitualmente estimado desde las últimas 12 h.

Evidence Summary · cómo leer el sustento

Recomendación fuerte con evidencia muy baja: útil para distinguir fuerza de certeza. No es una calculadora clínica validada.

Recomendaciones 69–71 del original.

Recommendations · síntesis

Dirigir por cultivo y susceptibilidad; con cultivo negativo seguir esquema hospitalario. Duración según drenaje y respuesta, habitualmente 2–4 semanas en el texto.

Evidence Summary · cómo leer el sustento

Rango de duración no es comparación aleatorizada de dos contra cuatro semanas.

Recomendaciones 72–75 del original.

Recommendations · síntesis

A las 48–72 h reevaluar gravedad, imágenes y agentes persistentes/resistentes/nuevos; BAL en ventilados y otras muestras invasivas para situaciones graves sin diagnóstico.

Evidence Summary · cómo leer el sustento

Falta de respuesta puede deberse al huésped, fármaco, complicación o diagnóstico alternativo; no sólo a resistencia.

Recomendaciones 76 del original.

Recommendations · síntesis

Antibióticos IV iniciales; abscesos periféricos definidos sin comunicación bronquial pueden drenarse por imagen. Muchos drenan por árbol bronquial.

Evidence Summary · cómo leer el sustento

Recomendación débil y evidencia muy baja; las intervenciones se individualizan.

Recomendaciones 77–84 del original.

Recommendations · síntesis

Mejoría global y fiebre disminuida 12–24 h; SpO₂>90% en aire 12–24 h; estado mental estable, sin trabajo respiratorio importante, tolerancia del tratamiento y cuidados/seguimiento asegurados.

Evidence Summary · cómo leer el sustento

No todos los criterios tienen la misma calidad de evidencia; capacidad familiar y barreras importan tanto como parámetros clínicos.

Recomendaciones 85–87 del original.

Recommendations · síntesis

Si ya no requiere cuidados agudos pero sí vía parenteral, programa pediátrico adecuado; preferir transición oral cuando es posible.

Evidence Summary · cómo leer el sustento

Evidencia para vías y programas es limitada; estancia y costos dependen del sistema.

Recomendaciones 88–92 del original.

Recommendations · síntesis

Vacunación contra neumococo, Hib, pertussis e influenza; proteger contactos de lactantes e inmunoprofilaxis VSR en alto riesgo según guías de su época.

Evidence Summary · cómo leer el sustento

Las vacunas, formulaciones y criterios son históricos. Un efecto relativo no indica beneficio absoluto sin riesgo basal.

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