Riesgo de Retención de Secreciones en Pacientes con Ventilación Mecánica Invasiva / Risk of Retention of Secretions in Patients with Invasive Mechanical Ventilation

Introducción. Los pacientes conectados a ventilación mecánica invasiva pueden presentar complicaciones respiratorias, donde la retención de secreciones es una de las más frecuentes. El drenaje y eliminación de las secreciones depende entre otras variables de los flujos respiratorios generados, donde una diferencia absoluta entre el flujo espiratorio máximo (FEM) y flujo inspiratorio máximo (FIM) menor a 17 L•min-1 o una relación FIM/FEM mayor a 0.9 favorecerían la retención de secreciones. Sin embargo, falta por determinar los flujos respiratorios resultantes y la proporción de pacientes con riesgo de retención de secreciones según estos parámetros. Objetivo. Determinar los flujos respiratorios durante la ventilación mecánica invasiva y la proporción de pacientes que se encuentra en riesgo de retención de secreciones. Métodos. Estudio descriptivo transversal desarrollado en la Unidad de Paciente Crítico Médico-Quirúrgico del "Hospital Clínico de la Red de Salud UC-CHRISTUS". Se incluyeron pacientes adultos intubados y conectados a ventilación mecánica, en quienes se determinó los flujos respiratorios resultantes y se estimó la diferencia absoluta FEM-FIM, la relación FIM/FEM y la proporción de pacientes con riesgo de retención de secreciones. Resultados. Se incluyeron 100 pacientes, 45% presentaba entre sus diagnósticos patología respiratoria. La mediana de la diferencia absoluta entre FEM y FIM fue de 6 L•min-1 (-5 - 14.5) y la mediana de la tasa FIM/FEM de 0.87 (0.7 - 1.13). Un 84% presentó una diferencia absoluta entre FEM y FIM menor a 17 L•min-1, mientras que el 46% presentó una relación FIM/FEM mayor a 0.9. Conclusión. Una alta proporción de pacientes conectados a ventilación mecánica presenta riesgo de retención de secreciones independiente de la presencia o ausencia de patología respiratoria. Se requieren futuras investigaciones para evaluar el impacto de este criterio sobre complicaciones respiratorias.

Background. Patients connected to invasive mechanical ventilation may develop respiratory complications, where retention of secretions is one of the most frequent. The drainage and elimination of the secretions depend on other variables of the respiratory flows generated, where an absolute difference between the peak expiratory flow (PEF) and peak inspiratory flow (PIF) less than 17 L•min-1 or a PIF/PEF ratio greater than 0.9 would favor secretion retention. However, it is necessary to determine the respiratory flows and the proportion of patients, with and without respiratory pathology, with a risk of secretions retention according to these parameters. Objective. Determine respiratory flows during connection to invasive mechanical ventilation and the proportion of patients with and without respiratory pathology at risk of secretions retention. Methods. A descriptive cross-sectional study was conducted in the Medical-Surgical Intensive Care Unit of the "Hospital Clínico de la Red de Salud UC-CHRISTUS". Intubated adult patients connected to mechanical ventilation were included, in whom the respiratory flows were assessed, and the absolute PEF-PIF difference, PIF/PEF ratio, and the proportion of patients with a risk of secretions retention were determined. Results. 100 patients were included, of which 45% presented among their diagnoses acute or chronic respiratory pathology. For the total number of patients, the median of the absolute difference between PEF and PIF was 6 L•min-1 (-5 - 14.5), and the median of the PIF/PEF ratio of 0.87 (0.7 - 1.13). Of the total of patients, 84% presented an absolute difference between PEF and PIF less than 17 L• min-1, while 46% presented a PIF/PEF ratio greater than 0.9. Conclusion. Considering the absolute difference between PEF-PIF and the PIF/PEF ratio, many patients present a risk of secretions retention. However, whether this is associated with severe respiratory complications in patients connected to invasive mechanical ventilation should be clarified in future research.

Índice de congestão nasal (CQ-7)na avaliação da obstrução nasalde crianças e adolescentes com rinite alérgica / Índice de congestão nasal (CQ-7) na avaliação da obstrução nasal de crianças e adolescentes com rinite alérgica

Verificar se o questionário Congestion Quantifier Seven-Item (CQ-7) permite avaliar a intensidade da rinite alérgica em crianças e adolescentes com rinite alérgica persistente (RAP) comparando-o amétodo objetivo (pico de fluxo inspiratório nasal, PFIN) e ao escore total de sintomas nasais recordatório (ETSNR).Pacientes e métodos: Pacientes (n = 64, 47 por cento gênero masculino,média idade 11 anos) acompanhados por RAP foram avaliados por: CQ-7 eETSNR (espirros, prurido, obstrução nasal e rinorreia; pontuados segundo escala de 0 = ausente a 4 = o tempo todo, tendo-se como base a última semana). A seguir realizou-se a medição do PFIN (Clements Dist®).Resultados: À avaliação clínica, 44,7 relataram obstrução nasale 51,9 respiração bucal a maior parte do tempo. Apesar disso, 84,3 não tiveram interferência da RAP com o trabalho/escola; 43,2 referiram acordar com o nariz obstruído pelo menos uma vez/semana assim comoo sono afetado (37,5 ). À admissão, o CQ-7 oscilou entre zero e 23 pontos (máximo de 28) e o ETSNR entre zero e 16 (média = 6,64) com correlação significante entre ambos (Spearman; rs = 0,748; Intervalo de Confiança [IC] de 95 :0,61-0,81). O mesmo não ocorreu ao confrontarmosos dois escores ao PFIN. Sintomas oculares foram avaliados em35 pacientes (média = 4,8, oscilando entre 0 e 12) e houve correlação significante entre o ESO e o ETSNR (média = 7,26; Spearman; rs = 0,57; IC95 :0,28-0,76).Conclusões: O CQ-7 mostrou-se comparável ao ETSNR, ambosrecordatórios, mas não à medida do PFIN posto que esta avalia a permeabilidade da cavidade nasal no momento da realização da prova. Quadros mais intensos de RAP se associaram à presença de conjuntivite.

To assess whether the Congestion Quantifier Seven-Item(QC-7) questionnaire was able to evaluate the severity of allergic rhinitis in persistent allergic rhinitis (PAR) children and adolescents in comparison to an objective method (nasal peak inspiratory flow, NPIF) and with the total nasal symptoms recordatory score (TNSRS).Casuistic and methods: Patients (n = 64, 47 percent male, mean age11 years) treated for PAR were assessed: CQ-7 and TNSRS (sneezing, itching, nasal obstruction and rhinorrhea; ranging from 0 = absent to 4 = all the time, taking as basis the last week). After this, they had the NPIF measured (Clements Dist ®).Results: Nasal obstruction and mouth breathing most of the timewere reported by 44.7 percent and 51.9 percent of the patients, respectively.Nevertheless, 84.3 percent had no work/school interference due to PAR, 43.2 percent reported waking up with a blocked nose at least once a week as well as had their sleep affected (37.5 percent). Upon admission, the CQ-7 ranged from zero to 23 points (maximum 28) and TNSRS ranged from zero to 16 (mean = 6.64) with a significant correlation between them (Spearman rs = 0.748, confidence interval [CI] 95 percent :0,61-0, 81). There were nosignificant correlation between both scores and NPIF measurement wasobserved. Ocular symptoms were evaluated in 35 patients (mean = 4.8, ranging between 0 and 12) and significant correlation between ESO and ETSNR (mean = 7.26, Spearman rs = 0.57, 95 percent CI 0.28 -0.76) wasobserved.Conclusions: CQ-7 was comparable to ETSNR, both recalls, but not with NPIF that measured nasal permeability at the evaluation. Moresevere episodes of PAR were associated with conjunctivitis.

Estimation of the Possible Age for Using Various Types of Inhaler by In-Check Inspiratory Flow Meter(TM)

PURPOSE: It is important to select and use kinds of Inhaler appropriate to the age of the patient and severity of symptoms. Several kinds of Inhaler have been developed and recommended according to each inhaler's resistance and usage method. We evaluated the usable age of 4 inhalers (turbulent flow inhalers, multi unit dose inhalers, breath actuated MDI, and autohalers) by measuring peak inspiratory flow(PIF) using In-Check(TM) Inspiratory Flow Meter. METHODS: Ninety three patients aged from 3 to 7 years(mean 57+/-12.9 mo.) who had admitted to CHA hospital from July 2000 to April 2001 were enrolled. Study patients were divided into 4 groups according to age:3-4 years of age(group A, n=31), 4-5 years of age(group B, n=32), 5-6 years of age(group C, n=18), and 6-7 years of age(group D, n=12). RESULTS: Out of total 93 patients, 23(71%), 27(84%), 17(94%) patients of each group A, B, C and all 12 patients of group D could use the 4 types of inhaler through adequated education. In all four groups, height, body weight and age were significantly correlated(P<0.05). Usable age, height and weight of children who can use turbulent flow inhaler(TFI) were each 8 year 7 month old, 144 cm, 32.0 kg, and those of multi unit dose inhaler(MUD) were 2 year 10 month old, 92 cm, 12.0 kg. Also that of breath-actuated MDI were 1 yr 8 months, 83 cm, 8.5 kg and that of autohaler were 2 yr 8 months, 91 cm, 11.0 kg. CONCLUSION: We concluded that the ability to use inhalers correlated with height, weight and age of the patients. Multi unit dose inhalers, Breath actuated MDI and Autohaler are useful after 3 years of age through adequate education.

Clinical Significance of Nasal Peak Inspiratory Flow Rate in Patients with Chronic Cough / 결핵

BACKGROUND: The upper respiratory tract is the primary target organ of various airborne pollutants and is easily accessible part of the respiratory tract, and also is the predominant structure where chronic cough originates. The nasal peak inspiratory flow(PIFn), which is the peak inspiratory flow via nose with nasal mask and spirometry, could be a reliable parameter of nasal obstruction. The validity of PIFn has been evaluated in several studies by assessing the correlation between PIFn measurements and other parameters of nasal air flow. This study was designed to show the reproducibility of PIFn, the difference of PIFn between patients with chronic cough and normal subjects, and the usefulness of PIFn in the evaluation of nasal obstruction in patients with chronic cough. METHODS: PIFn was measured by spirometry with nasal mask, twice a day for 3 consecutive days in 7 young normal subjects to evaluate validity of the test. In 32 patients with chronic cough and 25 age-matched normal subjects, PIFn and pulmonary function test(FEV1, FEV1%pred, FVC, and FVC%pred) were measured at first visiting. RESULTS: Values of PIFn, FEV1, and FVC were nearly constant in 7 young normal adults. Patients with chronic cough were 32 (14 males and 18 females) and the mean age was 41.4+/-15.9 years. Normal subjects were 32 (22 males and 10 females) and the mean age was 39.8+/-18.6 years. There was no significant difference of age and pulmonary function test between patients with chronic cough and normal subjects(p<0.05). The PIFn values in patients with chronic cough was significantly lower than those of normal subjects(2.25+/-0.68 L/sec vs. 2.75+/-1.00 L/sec; p=0.02). The postnasal drip syndrome(PNDS) comprised the majority of patients with chronic cough(27). The PIFn in patients with PNDS was significantly lower than that of normal subjects(meanD; 2.18+/-0.66 vs. 2.75+/-1.00 L/sec, p=0.006). CONCLUSION: There was a significant difference of PIFn between patients with chronic cough and normal subjects. Among the patients with chronic cough, patients with PNDS showed the most significant difference with normal subjects in PIFn. The PIFn could be a useful parameter of nasal obstruction in patients with chronic cough, especially in patients with PNDS.