Use of non-invasive ventilation in acute pulmonary edema and chronic obstructive pulmonary disease exacerbation in emergency medicine: predictors of failure

OBJECTIVE: This study analyzed acute respiratory failure caused by acute pulmonary edema, as well as chronic obstructive pulmonary disease exacerbation, that was treated with non-invasive mechanical ventilation to identify the factors that are associated with the success or failure non-invasive mechanical ventilation in urgent and emergency service. METHODS: This study was a prospective, descriptive and analytical study. We included patients of both genders aged &gt;18 years who used non-invasive mechanical ventilation due to acute respiratory failure that was secondary to acute pulmonary edema or chronic obstructive pulmonary disease exacerbation. Patients with acute respiratory failure that was secondary to pathologies other than acute pulmonary edema and chronic obstructive pulmonary disease or who presented with contraindications for the technique were excluded. Expiratory pressures between 5 and 8 cmH2O and inspiratory pressures between 10 and 12 cmH2O were used. Supplemental oxygen maintained peripheral oxygen saturation at &gt;90%. The primary outcome was endotracheal intubation. RESULTS: A total of 152 patients were included. The median non-invasive mechanical ventilation time was 6 hours (range 1 - 32 hours) for chronic obstructive pulmonary disease patients (n=60) and 5 hours (range 2 - 32 hours) for acute pulmonary edema patients (n=92). Most (75.7%) patients progressed successfully. However, reduced APACHE II scores and lower peripheral oxygen saturation were observed. These results were statistically significant in patients who progressed to intubation (p<0.001). BiPAP (Bi-level Positive Airway Pressure portable ventilator), as continuous positive airway pressure use increased the probability of endotracheal intubation 2.3 times (p=0.032). Patients with acute pulmonary edema and elevated GCS scores also increased the probability of success. CONCLUSION: Respiratory frequency &gt;25 rpm, higher APACHE II scores, BiPAP use and chronic obstructive pulmonary disease diagnosis were associated with endotracheal intubation. Higher GCS and SpO2 values were associated with NIV success. Non-invasive mechanical ventilation can be used in emergency services in acute respiratory failure cases caused by acute pulmonary edema and chronic obstructive pulmonary disease exacerbation, but patients with variables related to a higher percentage of endotracheal intubation should be specially monitored.OBJETIVO: Analisar os casos de insuficiência respiratória aguda decorrente de edema agudo de pulmão e de agudização da doença pulmonar obstrutiva crônica, submetidos à ventilação mecânica não invasiva, a fim de identificar fatores associados ao sucesso ou ao insucesso do método em um serviço de urgência e emergência. MÉTODOS: Estudo descritivo e analítico prospectivo. Foram incluídos pacientes de ambos os gêneros, com idade &gt;18 anos, que utilizaram ventilação mecânica não invasiva devido ao quadro de insuficiência respiratória secundária a edema agudo de pulmão ou agudização da doença pulmonar obstrutiva crônica. Foram excluídos os pacientes com insuficiência respiratória aguda secundária a patologias diferentes de edema agudo de pulmão e doença pulmonar obstrutiva crônica, ou que apresentavam contraindicação para a técnica. A rotina da instituição é utilizar a pressão expiratória entre 5 e 8 cmH2O, e a inspiratória entre 10 a 12 cmH2O, além de suplementação de oxigênio para manter a saturação periférica de oxigênio &gt;90%. A variável desfecho considerada foi a intubação endotraqueal. RESULTADOS: Foram incluídos 152 pacientes. A mediana do tempo de ventilação mecânica não invasiva foi de 6 (1 - 32) horas para os pacientes com doença pulmonar obstrutiva crônica (n=60) e de 5 (2 - 32) horas para os pacientes com edema agudo de pulmão (n=92); 75,7% evoluíram com sucesso. Foram observados pior escore de APACHE II e menor saturação periférica de oxigênio, de forma estatisticamente significante, nos pacientes que evoluíram para intubação (p<0,001). O uso de BiPAP relacionou-se a 2,3 vezes mais chance de ocorrência de intubação endotraqueal que o de CPAP (p=0,032). Entre os pacientes com diagnóstico de edema agudo de pulmão e com pontuação mais elevada na ECG também apresentaram mais chance de sucesso CONCLUSÃO: As variáveis associadas à intubação endotraqueal foram frequência respiratória &gt; 25rpm, maior valor de APACHE II, uso de BiPAP e diagnóstico de doença pulmonar obstrutiva crônica. Já maiores valores de ECG e SpO2 estão associados ao sucesso da ventilação mecânica não invasiva. A ventilação mecânica não invasiva pode ser utilizada em serviços de urgência/emergência para casos de insuficiência respiratória aguda decorrente de edema agudo de pulmão e exacerbação da doença pulmonar obstrutiva crônica, com cuidado especial na monitoração dos pacientes com variáveis relacionadas à maior porcentagem de intubação endotraqueal.27828

Clinical variables of preoperative risk in thoracic surgery

CONTEXT: Pulmonary complications are the most common forms of postoperative morbidity in thoracic surgery, especially atelectasis and pneumonia. The first step in avoiding these complications during the postoperative period is to detect the patients that may develop them. OBJECTIVE: To identify risk variables leading to early postoperative pulmonary complications in thoracic surgery. DESIGN: Prospective study. SETTING: Hospital das Clínicas, Faculdade de Ciências Médicas, Universidade Estadual de Campinas. PATIENTS: 145 patients submitted to elective surgery were classified as low, moderate and high risk for postoperative pulmonary complications using a risk assessment scale. PROCEDURES: The patients were followed up for 72 hours after the operation. Postoperative pulmonary complications were defined as atelectasis, pneumonia, tracheobronchitis, wheezing, prolonged intubation and/or prolonged mechanical ventilation. MAIN MEASUREMENTS: Univariate analysis was applied in order to study these independent variables: age, nutritional status, body mass index, respiratory disease, smoking habit, spirometry and surgery duration. Multivariate logistic regression analysis was performed in order to evaluate the relationship between independent and dependent variables. RESULTS: The incidence of postoperative complications was 18.6%. Multivariate logistic regression analysis showed that the variables increasing the chances of postoperative pulmonary complications were wheezing (odds ratio, OR = 6.2), body mass index (OR = 1.15), smoking (OR = 1.04) and surgery duration (OR = 1.007). CONCLUSION: Wheezing, body mass index, smoking and surgery duration increase the chances of postoperative pulmonary complications in thoracic surgeryCONTEXTO: As complicações pulmonares pós-operatórias, principalmente a pneumonia e atelectasia, têm sido freqüentes causas de morbidade nas cirurgias torácicas. Há interesse em se identificar fatores no processo de avaliação pré-operatória que possam, isoladamente ou associados, contribuir para o aparecimento de tais complicações. OBJETIVO: Identificar as variáveis de risco para complicação pulmonar pós-operatórias na cirurgia torácica. TIPO DE ESTUDO: Estudo prospectivo. LOCAL: Hospital das Clínicas da Universidade Estadual de Campinas PARTICIPANTES: 145 pacientes adultos, ambos os sexos, internados para cirurgia torácica eletiva e classificados em baixo, moderado e alto risco para complicação pulmonar pós-operatória utilizando-se uma escala de avaliação de risco. PROCEDIMENTO: Os pacientes foram acompanhados até as 72 horas do pós-operatório e avaliados quanto ao aparecimento de complicações pulmonares pós-operatória, definidas com o aparecimento de atelectasia, pneumonia, traqueobronquite, chiado, intubação ou ventilação mecânica prolongada. VARIÁVEIS ESTUDADAS: A análise univariada foi aplicada no estudo das variáveis independentes idade, estado nutricional, doença respiratória, hábitos tabágicos, espirometria e tempo cirúrgico. A análise dos resultados através da regressão logística multivariada mostrou relação entre as variáveis dependentes e independentes. RESULTADOS: As complicações pulmonares pós-operatórias incidiram sobre 18.6% da amostra. Através da regressão logística multivariada, verificou-se que as variáveis que aumentaram as chances de complicações pulmonar pós-operatórias foram chiado (Odds ratio, OR = 6.2), estado nutricional (OR = 1.15), tabagismo (OR = 1.04) e duração da cirurgia (OR = 1.007). CONCLUSÃO: Chiado, estado nutricional, tabagismo e duração da cirurgia aumentaram a ocorrência de complicações pulmonares pós-operatórias em cirurgia torácica.10711

[acute Respiratory Failure As A Manifestation Of Eosinophilia-myalgia Syndrome Associated With L-tryptophan Intake].

Eosinophilia-myalgia syndrome was described in 1989 in patients who presented progressive and incapacitating myalgia and eosinophilia in blood, fluids and secretions. Most patients report previous L-tryptophan intake. Respiratory manifestations are found in up to 80% of the cases, occasionally as the only manifestation. Treatment includes drug discontinuation and administration of corticosteroids. Here, we describe the case of a 61-year-old female admitted with acute respiratory failure after using L-tryptophan, hydroxytryptophan and other drugs. The patient presented eosinophilia, together with elevated eosinophil counts in the bronchoalveolar lavage and pleural effusion. After discontinuation of the drugs previously used, corticosteroids were administered, resulting in clinical and radiological improvement within just a few days.33747-5

Mature autologous dendritic cell vaccines in advanced non-small cell lung cancer: a phase I pilot study

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Background: Overall therapeutic outcomes of advanced non-small-cell lung cancer (NSCLC) are poor. The dendritic cell (DC) immunotherapy has been developed as a new strategy for the treatment of lung cancer. The purpose of this study was to evaluate the feasibility, safety and immunologic responses in use in mature, antigen-pulsed autologous DC vaccine in NSCLC patients. Methods: Five HLA-A2 patients with inoperable stage III or IV NSCLC were selected to receive two doses of 5 x 107 DC cells administered subcutaneous and intravenously two times at two week intervals. The immunologic response, safety and tolerability to the vaccine were evaluated by the lymphoproliferation assay and clinical and laboratorial evolution, respectively. Results: The dose of the vaccine has shown to be safe and well tolerated. The lymphoproliferation assay showed an improvement in the specific immune response after the immunization, with a significant response after the second dose (p = 0.005). This response was not long lasting and a tendency to reduction two weeks after the second dose of the vaccine was observed. Two patients had a survival almost twice greater than the expected average and were the only ones that expressed HER-2 and CEA together. Conclusion: Despite the small sample size, the results on the immune response, safety and tolerability, combined with the results of other studies, are encouraging to the conduction of a large clinical trial with multiples doses in patients with early lung cancer who underwent surgical treatment.30Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Department of Radiology of the Hospital Estadual Sumare UNICAMPSCOGConselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)CNPq [401327/05-1

Challenges and implementation of the “Programa Mais Médicos Campineiro”

The aim of this study is to describe the experience of implementing the Programa Mais Médicos Campineiro (PMMC) in Campinas city, State of São Paulo, Brazil, from April 2019 to April 2020, as the result of a health policy that suited the municipality’s needs to the doctors’ training program in Family and Community Medicine. For such purpose, information from meeting registries was assembled from several sources, to recover the series of actions taken to achieve an effective proposal. The situation of primary health care in the municipality until 2019 was analyzed in detail, which revealed difficulties in fixating doctors in Health Units. As a solution, the institution of a medical residency program was chosen. To preserve the doctor’s maintenance in the PMMC, he was admitted to the Family Health Strategy. Funding was allocated to guarantee sufficient compensation to attract and engage professionals to the proposal. The selection process of medical residents and preceptors was widely discussed and a pedagogical program was created and the program’s management was established. An increase in the number of vacancies offered was noted, demonstrating that, through public policy aimed at training Family and Community Physicians, it is possible to change the scenario of idleness as well as the high turnover of vacancies in medical residency programs in Campinas.O objetivo deste trabalho é descrever a experiência da implementação do Programa Mais Médicos Campineiro (PMMC) na cidade de Campinas, Estado de São Paulo, no período de abril de 2019 a abril de 2020, como resultado de política de saúde que adequou as necessidades do município à formação de médicos especialistas em Medicina da Família e Comunidade. Para tal, foram compilados registros de reuniões realizadas entre integrantes da Secretaria Municipal de Saúde e instituições de ensino superior do município e recuperada a trajetória percorrida pelos diversos atores envolvidos. A situação da atenção básica de saúde no município até 2019 foi analisada com detalhes, o que revelou dificuldades em fixar o médico nas Unidades de Saúde. Como solução optou-se pela instituição de programa de residência médica. Para preservar a manutenção do médico no programa, garantiu-se a sua vinculação à Estratégia de Saúde da Família, foram estabelecidas parcerias com instituições de saúde e foi planejado o financiamento que garantiu remuneração suficiente para atrair e manter profissionais à proposta. O processo seletivo de médicos residentes e preceptores foi amplamente discutido. Foi criado um programa pedagógico e estabelecida a gestão do programa. Foi verificado incremento da ocupação de vagas oferecida, demonstrando-se que por meio de política pública direcionada à formação de Médico da Família e Comunidade é possível alterar o panorama de ociosidade assim como a alta rotatividade de vagas em programas de residência médica em Campinas

Assessing quality of care for the dying from the bereaved relatives’ perspective: using pre-testing survey methods across seven countries to develop an international outcome measure

Background: The provision of care for dying cancer patients varies on a global basis. In order to improve care, we need to be able to evaluate the current level of care. One method of assessment is to use the views from the bereaved relatives. Aim: The aim of this study is to translate and pre-test the ‘Care Of the Dying Evaluation’ (CODETM) questionnaire across seven participating countries prior to conducting an evaluation of current quality of care. Design: The three stages were as follows: (1) translation of CODE in keeping with standardised international principles; (2) pre-testing using patient and public involvement and cognitive interviews with bereaved relatives; and (3) utilising a modified nominal group technique to establish a common, core international version of CODE. Setting/participants: Hospital settings: for each country, at least five patient and public involvement representatives, selected by purposive sampling, fed back on CODETM questionnaire; and at least five bereaved relatives to cancer patients undertook cognitive interviews. Feedback was collated and categorised into themes relating to clarity, recall, sensitivity and response options. Structured consensus meeting held to determine content of international CODE (i-CODE) questionnaire. Results: In total, 48 patient and public involvement representatives and 35 bereaved relatives contributed to the pre-testing stages. No specific question item was recommended for exclusion from CODETM. Revisions to the demographic section were needed to be culturally appropriate. Conclusion: Patient and public involvement and bereaved relatives’ perceptions helped enhance the face and content validity of i-CODE. A common, core international questionnaire is now developed with key questions relating to quality of care for the dying

Carcinoma bronquico : analise de uma serie de casos atendidos no ambulatorio de oncopneumologia das disciplinas de pneumologia e cirurgia toraxica da Faculdade de Ciencias Medicas da Unicamp

Orientador: Ilma Aparecida PaschoalTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias MedicasResumo: Foram analisados 261 pacientes com carcinoma brônquico, atendidos entre janeiro de 1988 a dezembro de 1990, no ambulatório de Onco-pneumologia do Hospital de Clínicas da Unicamp. A maioria dos pacientes era do sexo masculino (80%), . tabagista (95% dos homens e 63% das mulheres) e da região de Campinas. (52,5%). A faixa etária entre 60-69 anos foi responsável por 42% dos casos e foram raros os casos abaixo dos 40 anos. O carcinoma epidermóide, com 44,1% dos casos, seguido do adenocarcinoma, foi o mais freqüente. No grupo dos fumantes o carcinoma epidermóide e o carcinoma de pequenas células foram os mais encontrados, principalmente, entre as mulheres. No grupo dos não tabagistas o adenocarcinoma foi o mais com um sendo que neste grupo não houve nenhum caso de carcinoma de pequenas células e de carcinoma epidermóide em homens. A maioria dos pacientes eram sintomáticos (96,2%). Com queixa de curta duração e estádios anatômicos avançados. A tosse foi o sintoma mais relatado em todos os tipos histológicos. O carcinoma brônquico foi mais freqüente no pulmão direito, nos lobos superiores e de localização central. Alteração radiológica foi a principal causa de encaminhamento e o termo "massa", genericamente, o mais usado para descrevê-lo. No estadiamento, metade dos casos foram considerados irressecáyeis localmente, 36% apresentavam metástases à distância e 66% dos casos acometiam gânglios mediastinais. Na admissão predominaram metástases para fígado, ossos e cérebro enquanto que durante o seguimento e no estádio tenl1inal estas predominaram para cérebro e ossos. Quarenta e nove (18%) pacientes foram submetidos à cirurgia nos seguintes estádios cirúrgicos: 17(35%) estádio I; 7(14%) estádio II; 13(27%) estádio IIIa; 11(22%) estádio IIIb e 1(2%) estádio IV. Em 9(18%) ocorreram complicações, sendo que 2(4%) foram a óbito. De 30 pacientes avaliados pós-cirurgia, 14(46,7%) apresentaram recidiva em menos de 2 anos. A recidiva no estádio I foi de 25%, no estádio 11 de 60% e no estádio IIIa de 67%. A recidiva local, metástases em ossos e cérebro foram os locais mais freqüentes. Cento e um(39%) pacientes abandonaram o tratamento, 57 nos primeiros 2 meses. Apenas em 3% dos casos, a causa do óbito não estava relacionada ao carcinoma brônquico. A broncoscópia e a punção percutânea quando disponíveis, deverão ser os métodos diagnósticos de escolha por serem seguros e com excelente positividade, alem do que, a broncoscopia permite fazer o estadiamento local. O baixo número de pacientes assintomáticos, o elevado número de pacientes em estádios avançados e a maior parte dos paciente com queixas em até 6 meses, permitem concluir que: o carcinoma de pulmão apresenta sintomas tardios; os pacientes e médicos sub-valorizam as queixas; e o encaminhamento aconteceu mais em função do comprometimento do estado geral do paciente do que ao tempo de queixas.As enzimas hepáticas(AST, ALT, GGT) mostraram-se excelente método de detecção de metástase hepática. A predominância de lnetástase óssea e cerebral nos pacientes tratados pode estar relacionada a uma baixa eficácia do tratamento realizado para erradicar metástase nestes sítios. Com estas observações somadas aos dados da literatura conclui-se que, brevemente, haverá uma epidemia de carcinoma brônquico e campanhas de esclarecimento devem ser feitas, visando principalmente os jovens. Finalmente, conclui-se que a formação de um grupo multidisciplinar em oncopneumologia é fundamental, assim como a padronização de atendi1llento e a formação de banco de dados para aquisição de conhecimento, visando o beneficio do paciente e acúmulo de material de pesquisaAbstract: We analysed 261 patients with bronchogenic carcinoma, between january 1988 until december 1990, at the oncopneumology ambulatory at the Hospital de Clínicas da Unicamp. The majority of the patients were inale (80%), tobacco users (95% Inale and 63% female), from the region of Campinas. They were between 60-69 years old, and few under 40 years. The squamous cell carcinoma with 44,1 % cases, followed by the adenocarcinoma was the most frequent. In the group of smokers, the squamous cell carcinoma and the small cell carcinoma were the most seen, specially in females. In the group of non-smokers, the adenocarcinoma was the most frequent and there were no cases af small cell carcinoma and adenocarcinoma in males. The majority of the patients were symptomatic (96,2%) for short period of time before diagnosis and in advanced anatomic stages. Cough was the principal syinptom in hystologic groups. The bronchogenic carcinoma was most found in right lung, superior lobes and with centrallocation. X-ray findings were the principal cause of reference to the service, and the term "mass" was generically used to describe them. At staging, half of the patients were considered locally unresectable, 36% with distant metastasis and 66% with mediastinal lymph nodes involvement. On adInission there was predominance of liver, bone and brain metastasis, and in the follow-up, the Inetastasis to brain and bones were more frequently found. Forty nine (18%) patients were submitted to surgery: 17(35%) stage I; 7(14%) stage II; 13(27%) stage IIIa; 11(22%) stage IIIb and 1(2%) stage IV. Nine(18%) had complications and 2(4%) died. Of thirty patients, who could be evaluated after surgery, 14(46,7%) had reccurence in less than 2 years. The recurrence at stage I was 25%, at stage 11 60% and at stage IlIa 67%. The local reccurence, brain and bone lnetastasis were more frequent. 101(39%) patients abandoned treatment, 57 during the first 2 months. Only 3% of the cases do not died because of the bronchogenic carcinoma. Bronchoscopy and percutaneus needle biopsy whenever possible, should be chosen for diagnosis, because of their safeness and excellent positivity, and because the bronchoscopy can do the local staging. The low number of assymptomatic patients, the high number of patients in advanced stages and with recent complaints allow us to conclude: lung cancer has late symptons; patients and doctors do not value the complaints. So, they arrive 'at this service in bad performapce status because of their complaints. The hepatic enzilnes(ASAT, ALAT, GGT) were very good to detect liver metastasis. The supremacy of bone and brain metastasis in treated patients were probably associated with the low effectiveness of the treatment done to erradicate this metastasis at these sites. The literature and this data show that soon we will see a bronchogenic carcinoma epidelmy in Brazil and an educational campaign must begin, addressed to young people. Finally, we conclude that it is necessary to make a multidisciplinary group in order to approach this problem, and a standard evaluation of the patients, in order to obtain data about the subject that would benefit the patients and the research program of the serviceDoutoradoDoutor em Ciências Médica