Insuficiencia respiratoria aguda, hipoxemia refractaria y ventilación mecánica. Una revisión sistemática.

Acute respiratory distress syndrome (ARDS) or also known as respiratory distress, is an interruption of homeostasis at the alveolar level that can promote: hypoventilation, deterioration of diffusion, shunt and mismatch between ventilation - perfusion or a combination of both. Refractory hypoxemia is defined as a partial blood oxygen pressure measured by blood gas (PaO2) 60 mmHg or a divided oxygen blood pressure ratio for the oxygen inspiratory fraction, PaO2/FiO2 or (PAFI) 100. Mechanical ventilation is a necessary life support measure in the treatment of severe acute respiratory failure. General Objective: To determine the ventilatory management of patients with acute respiratory failure and refractory hypoxemia. Specific objectives: To evaluate the use of ECMO in refractory hypoxemia 2) To determine the usefulness of non-invasive mechanical ventilation, oxygen therapy and adjuvant therapy. METHODS: a systematic review of the literature according to the PRISMA 2020 declaration was carried out with articles from the last 5 years in the vast majority. Databases such as academic Google, Pubmed, IntechOpen, Mendeley, ScienceDirect, journals: JAMA, BMJ, critical care, NEJM, respiratory care were consulted: randomized studies, multicenter studies, clinical cases, review articles, meta-analysis, systematic review, guidelines, observational, descriptive, retrospective studies and consensus documents on the topics: acute respiratory failure, refractory hypoxemia and mechanical ventilation. RESULTS: Position in a prone position is of great importance during distress, as is support with extracorporeal circulation membrane, neuromuscular block and corticosteroids in the treatment of ARDS. As for the ventilatory strategies in this group of patients, intubation is the first step, via translaringea and connection to invasive mechanical ventilation, after which, we can apply the following strategies to improve oxygenation: Use of low Vt in volume-controlled ventilatory modes, low plateau pressures <30 in controlled modes that minimize barotrauma and low FiO2, to prevent oxygen-free radical-related injuries. Current evidence supports use of tidal volume (Vt) lower 6 ml/kg. DISCUSSION: Mechanical ventilatory management of the critical patient with acute respiratory failure presenting refractory hypoxemia includes evaluating oxygenation by PaO2/FiO2. the primary objective is to achieve adequate airway pressure values, apply low Vt, maintain an adequate plateau pressure and measure the conduction pressure to titrate the PEEP at the lowest possible value. Pronation is vital to improve oxygenation and airway pressures. The results of this research showed that, there is benefit of mechanical ventilation with the use of ECMO in this group of patients, in addition, it was determined that high flow oxygen therapy only decreases hypoxemia before intubation, without altering mortality. Dexamethasone, if it provides benefit, as adjuvant therapy in the treatment of acute respiratory failure, with refractory hypoxemiaIntroducción: El síndrome de dificultad respiratoria aguda (SDRA) o también conocido como distress respiratorio, es una interrupción del homeostasis a nivel alveolar que puede promover: hipoventilación, deterioro de la difusión, derivación y desajuste entre la ventilación - perfusión o una combinación de ambas

Encefalitis autoinmune por anticuerpos antirreceptor N-metil D-aspartato (NMDA). Reporte de caso

N-Methyl-D-Aspartate (NMDA) antibody encephalitis is a newly discovered disease characterized by neuropsychiatric disorders accompanied by ovarian tumor in almost 50% of cases, predominantly affecting the female and reproductive sex, although in Ecuador 5 cases have been reported in which the majority were male with a relationship 4: 1.  The aim of this work is to publish a case of NMDA autoantibody encephalitis, its diagnosis and clinical management. Materials and methods: a qualitative, descriptive study was carried out; a clinical case was presented. Relevant aspects of this pathology and the importance of timely diagnosis and treatment are described. Authorization was obtained from the Department of Teaching and Research, allowing the review of clinical history and images for the publication of the present case. Results: we present the clinical case of a 17-year-old female patient with neuropsychiatric and neurological symptoms with a long history of hospitalization, who confirmed the diagnosis of encephalitis by anti NMDA antibodies by study of cerebrospinal fluid, received complex treatment with corticosteroids, broad spectrum antibiotics and rituximab obtaining good clinical results. Conclusions: NMDA antibody encephalitis is a recent disease that should be part of the differential diagnosis in young patients with neuropsychiatric disorders, since it should not overlook this disease, whose treatment is curative and has nothing to do with dementia, however, symptoms are often confused and misdiagnosed with incorrect treatment.La encefalitis por anticuerpos N-Metil-D-Aspartato (NMDA) es una enfermedad recientemente descubierta que se caracteriza por trastornos neuropsiquiátricos acompañado de tumor de ovario en casi el 50 %  de los casos, afecta predominantemente al sexo femenino y en etapa reproductiva,  aunque en Ecuador se han reportado 5 casos en los cuales la mayoría fueron sexo masculino con una relación 4: 1. El objetivo de este trabajo es publicar un caso en encefalitis por autoanticuerpos anti NMDA,  su diagnóstico y  manejo clínico. Materiales y métodos: se realizó un estudio cualitativo, descriptivo; presentación de un caso clínico. Se describen aspectos relevantes de esta patología y la importancia del diagnóstico y tratamiento oportuno.  Se obtuvo la autorización del Departamento de docencia e investigación, permitiendo la revisión de historia clínica e imágenes para la publicación del presente caso. Resultados: se presenta el caso clínico de una paciente de sexo femenino de 17 años con síntomas neuropsiquiátricos y neurológicos con larga data de hospitalización, en quien se confirma el diagnóstico de encefalitis por anticuerpos anti NMDA mediante estudio de líquido cefalorraquídeo, recibió tratamiento complejo con corticoide, antibióticos de amplio espectro y rituximab obteniendo buenos resultados clínicos. Conclusiones: la encefalitis por anticuerpos anti NMDA, es una enfermedad reciente que debe formar parte del diagnóstico diferencial en los pacientes jóvenes con trastornos neuropsiquiátricos, ya que no debe pasar por alto esta enfermedad cuyo tratamiento es curativo y no tiene nada que ver con demencia, no obstante, muchas veces existe la confusión con los síntomas y se realiza un diagnóstico erróneo con terapéutica incorrecta