Health care professionals and end-of-life care during the COVID-19 pandemic

SUMMARY OBJECTIVE: The aim of this study was to estimate self-perception of anguish and low quality of life among health care professionals who cared for the dying patients during the COVID-19 pandemic and to determine the characteristics of health care professionals and patients and end-of-life care. METHODS: An online survey that included health care professionals who cared for the dying patient from July 1 to October 31, 2020 was conducted. Low quality of life, anguish, characteristics of patients and health care professionals, and end-of-life care were recorded. Poisson regression was performed to assess the predictors of anguish and low quality of life. RESULTS: A total of 102 health care professionals, including 14 males (13.7%), with a median age of 37 years, composed of 41 physicians (40.2%), 36 physiotherapists (35.3%), and 25 nurses (24.5%) were included in this study. Self-perception of anguish occurred in 69.6% and was associated with physicians and disagreement with end-of-life care offered. Low quality of life was reported in 64.7% and was associated with not having time to talk to patients' relatives. The agreement that medical care was enough reduced self-perception of low quality of life. CONCLUSION: Self-reported anguish was more frequent in physicians and when the disagreement about end-of-life care occurred. Low quality of life was more frequent when health care professionals did not have time to talk to patients' relatives and was less frequent when health care professionals agreed that medical care was enough. Strategies should be done by health services to reduce the impact of the pandemic on health care professionals.

Utilização da ventilação não invasiva em edema agudo de pulmão e exacerbação da doença pulmonar obstrutiva crônica na emergência: preditores de insucesso / Use of non-invasive ventilation in acute pulmonary edema and chronic obstructive pulmonary disease exacerbation in emergency medicine: predictors of failure

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 >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 >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 > 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.

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 >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 >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 >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.