Efectes fisiològics del decúbit pron i de la inhalació d'òxid nítric en malalts amb la síndrome del destret respiratori agut

Consultable des del TDXObjectiu: Estudiar els efectes gasomètrics i hemodinàmics del tractament combinat amb decúbit pron (DP) i òxid nítric inhalat (iNO) en pacients amb la síndrome del destret respiratori agut (SDRA) precoç, així com determinar la influència de l'etiologia de la SDRA en la resposta als dos tractaments i conèixer els efectes del DP sobre la mecànica respiratòria. Pacients i mètode: Estudi amb 15 pacients ingressats a UCI amb SDRA precoç (8 amb SDRA d'origen pulmonar (Pu) i 7 amb SDRA d'origen extrapulmonar (EPu)), intubats i connectats a ventilació mecànica controlada per volum amb FiO2 1. S'ha ajustat del valor de PEEP amb la determinació del punt d'inflexió inferior de la corba pressió-volum en decúbit supí (DS) i PEEP 0 cm H2O, mantenint-se constant al llarg de l'estudi. S'analitza dades gasomètriques i hemodinàmiques recollides en les quatre situacions estudiades: DS (o situació basal), DS+iNO, DP, DP+iNO (la iNO es realitza de forma randomitzada en cada posició). A 12 pacients es realitza a més el càlcul del reclutament alveolar induït per la PEEP en DS i en DP. L'estudi estadístic utilitzat ha estat una anàlisi de la variància per a dades aparellades, el test Xi-quadrat per la comparació de les variables qualitatives. Per l'estudi de mecànica respiratòria s'ha utilitzat el test U de Mann-Whitney i el test de Wilcoxon. Valors de p<0,05 s'han considerat significatius. Resultats: Tant la iNO com el DP produeixen un increment significatiu de la PaO2/FiO2 en relació a la situació basal (de 106 ± 58 mm Hg en DS a 131 ± 69 mm Hg en DS+iNO, p=0,01, i a 184 ± 67 mm Hg en DP, p < 0.001). Els efectes d'ambdós tractaments sobre l'oxigenació són de tipus additiu. Els pacients amb SDRA Pu i els pacients amb SDRA EPu mostren un augment similar de la PaO2/FiO2 amb el DP. Només els pacients amb SDRA Pu han mostrat un augment significatiu (p<0.001) de l'oxigenació induït per la iNO de 81 ± 45 mm Hg a 100 ± 50 mm Hg en DS, i de 146 ± 53 a 197 ± 98 mm Hg en DP. El DP s'associa a un augment significatiu del volum reclutat en relació al DS ( 227 ± 106 en DP i 186 ± 96 ml en DS, p=0,04). L'increment de la PaO2/FiO2 induït pel DP mostra una correlació positiva amb l'increment del volum reclutat induït pel DP (r=0,72; p=0,008). Conclusió: El DP i la iNO presenten efectes de tipus additiu sobre l'oxigenació. El DP s'associa a una millora marcada de la PaO2/FiO2, independentment de la causa de la SDRA, mentre que la iNO millora l'oxigenació predominantment en els pacients amb SDRA Pu. L'augment de volum reclutat observat en DP en relació al DS es correlaciona directament amb l'increment en la PaO2/FiO2 induït pel DP.Objective: To study the gas exchange and hemodynamic effects induced by the combination of prone position (PP) and inhaled nitric oxide (iNO) in patients with early ARDS, and to analyse whether or not pulmonary (Pu) or extrapulmonary (EPu) ARDS patients behave differently. We also studied the effects of PP on respiratory system mechanics. Patients and methods: We studied 15 intubated patients admitted in our ICU with early ARDS (8 Pu ARDS and 7 EPu ARDS) under volume controlled mechanical ventilation and FiO2 1. PEEP levels were adjusted according to the lower inflection point of the pressure-volume curve of the respiratory system in supine position (SP) and PEEP 0 cm H2O, and were kept constant through the study. Gasometric and hemodynamic data were collected in four situations: SP (or baseline situation), SP+iNO, PP, PP+iNO (iNO was randomized in each position). Measurement of alveolar recruitment induced by PEEP in SP and PP was calculated in twelve patients. An analysis of variance for repeated measures with two factors was performed to compare both treatments. Mann-Whithey U test and Wilcoxon test were used to compare the effects on respiratory mechanics. Chi-square test was applied to compare qualitative variables. A p<0.05 was considered significant. Results: In comparison with SP, iNO and PP induced significant increase in PaO2/FiO2 (from 106 ± 58 in SP to 131 ± 69 mm Hg in SP+iNO, p=0.01, and 184 ± 58 mm Hg in PP, p<0.001). Pu and EPu ARDS showed a similar improvement in PaO2/FiO2 with PP. Only Pu ARDS patients showed a significant increase (p<0.001) in oxygenation induced by iNO from 81 ± 45 to 100 ± 50 mm Hg in SP, and from 146 ± 53 to 197 ± 98 mm Hg in PP. PP is associated with a significant increase on the recruited volume in comparison with SP (227 ± 106 in PP and 186 ± 96 ml in SP, p=0.04). The improvement in PaO2/FiO2 observed with PP is directly correlated with the increase of the alveolar recruitment induced by PP (r=0.72; p=0.008). Conclusion: PP and iNO show additive effects on oxygenation. PP is associated with a marked improvement in oxygenation, irrespective of the cause of ARDS, whereas oxygenation effects of iNO are mainly seen in patients with Pu ARDS. The increase of the recruited volume observed in PP in comparison with SP is directly correlated with the increase of PaO2/FiO2 induced by PP

Clinical consensus recommendations regarding non-invasive respiratory support in the adult patient with acute respiratory failure secondary to SARS-CoV-2 infection

La enfermedad por coronavirus 2019 (COVID-19) es una infección del tracto respiratorio causada por un nuevo coronavirus emergente que se reconoció por primera vez en Wuhan, China, en diciembre de 2019. Actualmente la Organización Mundial de la Salud (OMS) ha definido la infección como pandemia y existe una situación de emergencia sanitaria y social para el manejo de esta nueva infección. Mientras que la mayoría de las personas con COVID-19 desarrollan solo una enfermedad leve o no complicada, aproximadamente el 14% desarrollan una enfermedad grave que requiere hospitalización y oxígeno, y el 5% pueden requerir ingreso en una unidad de cuidados intensivos. En casos severos, COVID-19 puede complicarse por el síndrome de dificultad respiratoria aguda (SDRA), sepsis y shock séptico y fracaso multiorgánico. Este documento de consenso se ha preparado sobre directrices basadas en evidencia desarrolladas por un panel multidisciplinario de profesionales médicos de cuatro sociedades científicas españolas (Sociedad Española de Medicina Intensiva y Unidades Coronarias [SEMICYUC], Sociedad Española de Neumología y Cirugía Torácica [SEPAR], Sociedad Española de Urgencias y Emergencias [SEMES], Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor [SEDAR]) con experiencia en el manejo clínico de pacientes con COVID-19 y otras infecciones virales, incluido el SARS, así como en sepsis y SDRA. El documento proporciona recomendaciones clínicas para el soporte respiratorio no invasivo (ventilación no invasiva, oxigenoterapia de alto flujo con cánula nasal) en cualquier paciente con presentación sospechada o confirmada de COVID-19 con insuficiencia respiratoria aguda. Esta guía de consenso debe servir como base para una atención optimizada y garantizar la mejor posibilidad de supervivencia, así como permitir una comparación fiable de las futuras intervenciones terapéuticas de investigación que formen parte de futuros estudios observacionales o de ensayos clínicos.Coronavirus disease 2019 (COVID-19) is a respiratory tract infection caused by a newly emergent coronavirus, that was first recognized in Wuhan, China, in December 2019. Currently, the World Health Organization (WHO) has defined the infection as a global pandemic and there is a health and social emergency for the management of this new infection. While most people with COVID-19 develop only mild or uncomplicated illness, approximately 14% develop severe disease that requires hospitalization and oxygen support, and 5% require admission to an intensive care unit. In severe cases, COVID-19 can be complicated by the acute respiratory distress syndrome (ARDS), sepsis and septic shock, and multiorgan failure. This consensus document has been prepared on evidence-informed guidelines developed by a multidisciplinary panel of health care providers from four Spanish scientific societies (Spanish Society of Intensive Care Medicine [SEMICYUC], Spanish Society of Pulmonologists [SEPAR], Spanish Society of Emergency [SEMES], Spanish Society of Anesthesiology, Reanimation, and Pain [SEDAR]) with experience in the clinical management of patients with COVID-19 and other viral infections, including SARS, as well as sepsis and ARDS. The document provides clinical recommendations for the noninvasive respiratory support (noninvasive ventilation, high flow oxygen therapy with nasal cannula) in any patient with suspected or confirmed presentation of COVID-19 with acute respiratory failure. This consensus guidance should serve as a foundation for optimized supportive care to ensure the best possible chance for survival and to allow for reliable comparison of investigational therapeutic interventions as part of randomized controlled trials

Early Tracheostomy for Managing ICU Capacity During the COVID-19 Outbreak: A Propensity-Matched Cohort Study

10 p.Background: During the first wave of the COVID-19 pandemic, shortages of ventilators and ICU beds overwhelmed health care systems. Whether early tracheostomy reduces the duration of mechanical ventilation and ICU stay is controversial. Research question: Can failure-free day outcomes focused on ICU resources help to decide the optimal timing of tracheostomy in overburdened health care systems during viral epidemics? Study design and methods: This retrospective cohort study included consecutive patients with COVID-19 pneumonia who had undergone tracheostomy in 15 Spanish ICUs during the surge, when ICU occupancy modified clinician criteria to perform tracheostomy in Patients with COVID-19. We compared ventilator-free days at 28 and 60 days and ICU- and hospital bed-free days at 28 and 60 days in propensity score-matched cohorts who underwent tracheostomy at different timings (≤ 7 days, 8-10 days, and 11-14 days after intubation). Results: Of 1,939 patients admitted with COVID-19 pneumonia, 682 (35.2%) underwent tracheostomy, 382 (56%) within 14 days. Earlier tracheostomy was associated with more ventilator-free days at 28 days (≤ 7 days vs > 7 days [116 patients included in the analysis]: median, 9 days [interquartile range (IQR), 0-15 days] vs 3 days [IQR, 0-7 days]; difference between groups, 4.5 days; 95% CI, 2.3-6.7 days; 8-10 days vs > 10 days [222 patients analyzed]: 6 days [IQR, 0-10 days] vs 0 days [IQR, 0-6 days]; difference, 3.1 days; 95% CI, 1.7-4.5 days; 11-14 days vs > 14 days [318 patients analyzed]: 4 days [IQR, 0-9 days] vs 0 days [IQR, 0-2 days]; difference, 3 days; 95% CI, 2.1-3.9 days). Except hospital bed-free days at 28 days, all other end points were better with early tracheostomy. Interpretation: Optimal timing of tracheostomy may improve patient outcomes and may alleviate ICU capacity strain during the COVID-19 pandemic without increasing mortality. Tracheostomy within the first work on a ventilator in particular may improve ICU availability

Hyperoxemia and excess oxygen use in early acute respiratory distress syndrome : Insights from the LUNG SAFE study

Publisher Copyright: © 2020 The Author(s). Copyright: Copyright 2020 Elsevier B.V., All rights reserved.Background: Concerns exist regarding the prevalence and impact of unnecessary oxygen use in patients with acute respiratory distress syndrome (ARDS). We examined this issue in patients with ARDS enrolled in the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study. Methods: In this secondary analysis of the LUNG SAFE study, we wished to determine the prevalence and the outcomes associated with hyperoxemia on day 1, sustained hyperoxemia, and excessive oxygen use in patients with early ARDS. Patients who fulfilled criteria of ARDS on day 1 and day 2 of acute hypoxemic respiratory failure were categorized based on the presence of hyperoxemia (PaO2 > 100 mmHg) on day 1, sustained (i.e., present on day 1 and day 2) hyperoxemia, or excessive oxygen use (FIO2 ≥ 0.60 during hyperoxemia). Results: Of 2005 patients that met the inclusion criteria, 131 (6.5%) were hypoxemic (PaO2 < 55 mmHg), 607 (30%) had hyperoxemia on day 1, and 250 (12%) had sustained hyperoxemia. Excess FIO2 use occurred in 400 (66%) out of 607 patients with hyperoxemia. Excess FIO2 use decreased from day 1 to day 2 of ARDS, with most hyperoxemic patients on day 2 receiving relatively low FIO2. Multivariate analyses found no independent relationship between day 1 hyperoxemia, sustained hyperoxemia, or excess FIO2 use and adverse clinical outcomes. Mortality was 42% in patients with excess FIO2 use, compared to 39% in a propensity-matched sample of normoxemic (PaO2 55-100 mmHg) patients (P = 0.47). Conclusions: Hyperoxemia and excess oxygen use are both prevalent in early ARDS but are most often non-sustained. No relationship was found between hyperoxemia or excessive oxygen use and patient outcome in this cohort. Trial registration: LUNG-SAFE is registered with ClinicalTrials.gov, NCT02010073publishersversionPeer reviewe

Estudo prospectivo de extubação endotraqueal não programada em doentes de cuidados intensivos

RESUMO: A extubação endotraqueal não programada (ENP) é uma ocorrência frequente em doentes submetidos a ventilação mecânica ou em fase de desmame ventilatório, associando-se a um aumento da morbilidade e mortalidade, devido à própria ENP ou a acidentes relacionados com a reentubação. Este trabalho propõe­se analizar a magiutude do problema numa UCI assim como determinar as variáveis com valor predictivo da necessidadc de reentubação.Foram incluídos no estudo todos os doentes requerendo entubação endotraqueal>48 horas admitidos entre Maio 1993 e Janeiro de 1996 (n=750). As ENP classificaram-se em extubações acidentais (EA) durante mobilizações, etc. - e em autoextubações (AE) sempre que devidas à intervenção activa do doente. Foram analizados a idade, sexo, SAPS, tipo de suporte ventilatório (suporte ventilatório âtotalâ ou desmame), diâmetro do tubo, dias de ventilação, mortalidade, causa da reentubação e nível de sedação. As modalidades de desmame foram: Pressão Assistida (PA), CPAP ou peça em T, conforrne protocolo pré-definido, e os critérios para iniciar desmame foram: 1) PMI>25cmH2O; 2) FR 10 ml/Kg; 4) SatO2>com FiO2=0,4; 5) Temp48 horas foi 34,4%, sendo de 13% nas AE e de 23% nas EA. As únicas variáveis com valor predictive foram os dias de ventilação e a modalidade de desmame.Concluiu-se que a reentubação depende fundamental mente do tipo de suporte ventilatório. A probabilidade de necessitar de reentubação é maior durante o suporte ventilatório âtotalâ do que em fase de desmame, sendo sugerido que nalguns doentes o tempo de ventilação é demasiadamente prolongado. COMENTÃRIO: Para todos os que trabalham em euldados intenslvos, a escolha de um processo de desmame ventilatório que pennita conduzir à rápída extubação e à eventual alta dos doentes ventilados continua a ser um dos problemas que mais tempo e energias consome. O trabalho apresentado, partindo de uma situação que se verifica com alguma frequência (1.2) - a extubação não programada-levanta várias questões.As primeiras são de ordem prãtica e mais imediatas. Perante um episódio de extubação não programada, quais os critérios e parâmetros que permitem condescender na reentubação dos doentes? Segundo os dados apresentados, a necessidade de reentubação depende fundamentalmente da fase de desmame, sendo que os doentes com modalidades mais autónomas-CPAP e peça em T-tem maior probabilidade de se manterem extubados (2-3).A segunda ordem de questões deriva precisamente dos resultados apresentados. Será que o desmame ventilatório é prolongado para além do tempo necessário? Os números parecem confirmar esta afi rmação. No presente estudo, apenas 15,6% dos doentes em desmame necessitaram de reentubação, passando estc número para 8,3% nos submetidos a modalidades mais autónomas.Um estudo anterior (4) responsabilizou o período de desmame por cerca de 40% do tempo total de ventilação. Se forem tomadas em consideração as complicações relacionadas eo custo económico destes doentes, fácilmente se conclui que são necessárias algumas mudanças nas estratégias normalmente utilizadas.Foram publicados alguns trabalhos (5-7) que prõpoem actuações protocolizadas para o desmame e extubação dos doentes ventilados. As estratégias e protocolos utilizados permitiram reduzir o tempo de desmame e o custo económico de uma forma significativa. A forma de mudar as atitudes começa pela divulgação dos dados conhecidos, sendo no entanto imperative que os protocolos nao suplantem o julgamento clinico, servindo antes como instrumentos dinâmicos. Embora esta mudança de atitude leve necessáriamente algum tempo, talvez em breve deixemos de ouvir a frase âdesmamar lentamente conforme toleradoâ e passemos a ouvir âo doente está estável e cumpre parâmetres protocolizados-vamos extubá-lo!â(8)

Effective and Ineffective Elements of Community-based Treatment for Delinquents: An Interview Survey of Volunteer Probation Officers

Additional file 1. Digital Content

Immunocompromised patients with acute respiratory distress syndrome: Secondary analysis of the LUNG SAFE database

Background: The aim of this study was to describe data on epidemiology, ventilatory management, and outcome of acute respiratory distress syndrome (ARDS) in immunocompromised patients. Methods: We performed a post hoc analysis on the cohort of immunocompromised patients enrolled in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) study. The LUNG SAFE study was an international, prospective study including hypoxemic patients in 459 ICUs from 50 countries across 5 continents. Results: Of 2813 patients with ARDS, 584 (20.8%) were immunocompromised, 38.9% of whom had an unspecified cause. Pneumonia, nonpulmonary sepsis, and noncardiogenic shock were their most common risk factors for ARDS. Hospital mortality was higher in immunocompromised than in immunocompetent patients (52.4% vs 36.2%; p &lt; 0.0001), despite similar severity of ARDS. Decisions regarding limiting life-sustaining measures were significantly more frequent in immunocompromised patients (27.1% vs 18.6%; p &lt; 0.0001). Use of noninvasive ventilation (NIV) as first-line treatment was higher in immunocompromised patients (20.9% vs 15.9%; p = 0.0048), and immunodeficiency remained independently associated with the use of NIV after adjustment for confounders. Forty-eight percent of the patients treated with NIV were intubated, and their mortality was not different from that of the patients invasively ventilated ab initio. Conclusions: Immunosuppression is frequent in patients with ARDS, and infections are the main risk factors for ARDS in these immunocompromised patients. Their management differs from that of immunocompetent patients, particularly the greater use of NIV as first-line ventilation strategy. Compared with immunocompetent subjects, they have higher mortality regardless of ARDS severity as well as a higher frequency of limitation of life-sustaining measures. Nonetheless, nearly half of these patients survive to hospital discharge. Trial registration: ClinicalTrials.gov, NCT02010073. Registered on 12 December 2013