Efectos fisiológicos de las terapias de soporte respiratorio no invasivo y su potencial rol postextubación / Physiological effects of non-invasive respiratory support therapies and their potential post-extubation role

Posterior a una extubación programada existe un porcentaje de pacientes que fracasa y requiere reintubación (~20%), este evento es conocido como fracaso de extubación, el cual se asocia con mayor morbimortalidad. Para prevenir el fracaso de extubación se han propuesto terapias como la ventilación no invasiva (VNI) y la cánula nasal de alto flujo (CNAF). Estas terapias son capaces de entregar soporte respiratorio postextubación y justifican su uso en los efectos fisiológicos que son capaces de inducir, en dónde el impacto sobre el esfuerzo respiratorio e intercambio de gases sería fundamental. Con esta racionalidad fisiológica se han desarrollado diversos estudios en diferentes contextos clínicos, esto con el fin de dilucidar cuál terapia es la mejor alternativa. En esta revisión narrativa pretendemos describir y analizar los diversos efectos fisiológicos que induce la VNI y la CNAF

Exercise capacity in children and adolescents with post-infectious bronchiolitis obliterans: a systematic review / Capacidade de exercício em crianças e adolescentes com bronquiolite obliterante pós-infecciosa: uma revisão sistemática

ABSTRACT Objective: To evaluate exercise capacity in children and adolescents with post-infectious bronchiolitis obliterans. Data source: This is a systematic review based on data from PubMed, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Scientific Electronic Library Online (SciELO), and Physiotherapy Evidence Database (PEDro). We used the following search strategy: "Exercise capacity OR Exercise Test OR Physical fitness OR Functional capacity OR Six-minute walk test OR Shuttle walk test OR Cardiopulmonary exercise test AND Bronchiolitis obliterans." We selected studies that evaluated exercise capacity through maximal/submaximal testing in children and adolescents with post-infectious bronchiolitis obliterans, and no other associated disease. We searched articles in English, Portuguese, and Spanish, without restrictions regarding the period of publication. The methodological quality was assessed by the Agency for Healthcare Research and Quality (AHRQ) protocol. Data synthesis: Out of the 81 articles found, only 4 were included in this review. The studies totaled 135 participants (121 with post-infectious bronchiolitis obliterans and 14 healthy), with sample sizes between 14 and 58 subjects. All patients underwent spirometry to evaluate pulmonary function, indicating an obstructive ventilatory pattern. Among them, 3/4 had their physical performance assessed by the six-minute walk test and 2/4 by the cardiopulmonary exercise testing. These test results were compared to those of a control group (1/4) and presented as percentage of predicted and/or in meters (3/4). Lastly, 3/4 of the studies showed reduced exercise capacity in this population. The studies included were classified as having high methodological quality. Conclusions: Findings of the study demonstrate that children and adolescents with post-infectious bronchiolitis obliterans have reduced exercise capacity.

RESUMO Objetivo: Avaliar a capacidade de exercício em crianças e adolescentes com bronquiolite obliterante pós-infeciosa. Fonte de dados: Trata-se de uma revisão sistemática por meio das bases de dados PubMed, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Scientific Electronic Library Online (SciELO) e Physiotherapy Evidence Database (PEDro). Utilizou-se a seguinte estratégia de busca: "Exercise capacity OR Exercise Test OR Physical fitness OR Functional capacity OR Six minute walk test OR Shuttle walk test OR Cardiopulmonary exercise test AND Bronchiolitis obliterans". Foram selecionados estudos que avaliaram a capacidade de exercício por meio de testes máximos/submáximos em crianças e adolescentes com bronquiolite obliterante pós-infeciosa, sem qualquer outra doença associada. Buscaram-se artigos nos idiomas inglês, português e espanhol e sem restrições quanto ao período de publicação. A qualidade metodológica foi avaliada pelo protocolo da Agency for Health Care Research and Quality (AHRQ). Síntese dos dados: De um total de 81 artigos, apenas 4 foram incluídos nesta revisão. Os estudos totalizaram 135 participantes (121 com bronquiolite obliterante pós-infeciosa e 14 saudáveis), com tamanho amostral entre 14 e 58 sujeitos. Todos avaliaram a função pulmonar por meio da espirometria, observando um padrão ventilatório obstrutivo. Desses, 3/4 avaliaram o desempenho físico pelo teste de caminhada de seis minutos e 2/4 pelo teste de exercício cardiopulmonar. Os resultados desses testes foram comparados a um grupo controle (1/4), bem como apresentados em percentual do previsto e/ou em metros (3/4). Por fim, 3/4 dos estudos demostraram que a capacidade de exercício se encontra reduzida nessa população. Os estudos incluídos foram classificados com alta qualidade metodológica. Conclusões: Os achados do estudo demonstram que crianças e adolescentes com bronquiolite obliterante pós-infeciosa apresentam redução da capacidade de exercício.

Internaciones en pacientes con ventilación domiciliaria crónica / Hospital admissions in patients with chronic home ventilation

La ventilación mecánica domiciliaria representa un estándar de cuidados en la insuficiencia de la bomba ventilatoria. El modelo de seguimiento podría modificar la tasa de internaciones. Con la finalidad de estudiar las internaciones en pacientes con ventilación mecánica domiciliaria se diseñó un estudio descriptivo, sobre una base de datos de recolección sistemática. Participaron pacientes con ventilación no invasiva o asistencia respiratoria mecánica invasiva incluidos en forma consecutiva en un programa de hospital de día entre julio 2014 y diciembre 2016. Se analizaron internaciones y modalidad de las mismas, un año antes y después del programa. Participaron 94 pacientes; 52 hombres (55%), edad 64.4 ± 15.9 años; índice de masa corporal medio 28.60 ± 8.46 kg/m². El 50% presentaba obesidad. Recibían ventilación mecánica domiciliaria 80 participantes (85%); no invasiva en 77 casos e invasiva en tres (4%). En un año de seguimiento fueron re-admitidos al hospital 32 pacientes. Existieron diferencias significativas entre la tasa de internación global antes y después del programa (0.68 ± 0.47 vs. 0.42 ± 0.50 internaciones por caso), p 0.044, internaciones en terapia intensiva; 32 vs. 14, p 0.005 y días en UTI (12.9 ± 7.75 vs. 10.57 ± 7.5) p 0.048. La población a la que se ofreció ventilación mecánica domiciliaria presentó una elevada tasa de internaciones que se redujo mediante este modelo de seguimiento.

Home mechanical ventilation represents a standard of care in the insufficiency of the ventilatory pump. The follow-up model could change the hospitalization rate. In order to study hospitalizations in patients with home mechanical ventilation, a descriptive study was designed on a systematic collection database. Participants were patients with non-invasive ventilation or invasive mechanical ventilation consecutively included in a day hospital program between July 2014 and December 2016. Hospitalizations and their modality one year before and after the program were analyzed. Ninety four patients participated; 52 men (55%), age 64.4 ± 15.9 years; mean body mass index; 28.60 ± 8.46 kg/m²; 50% had obesity. Eighty patients (85%) received home mechanical ventilation; non-invasive in 77 cases and invasive in three (4%). Thirty two patients were re-admitted to the hospital in one year of follow-up. There were significant differences between the global admission rate before and after the program (0.68 ± 0.47 vs. 0.42 ± 0.50 hospitalizations per patient) p 0.044, intensive care unit hospitalizations; 32 vs. 14, p 0.005 and days in ICU (12.9 ± 7.75 vs. 10.57 ± 7.5) p 0.048. The population to whom home mechanical ventilation was offered had a high hospitalization rate that was reduced by this follow-up model.

Actualización en el manejo respiratorio de pacientes con enfermedades neuromusculares / Update in the respiratory management of patients with neuromuscular diseases

Resumen: Los días 24 y 25 de noviembre del 2016, en Montevideo, Uruguay, tuvo lugar un encuentro de capacitación en cuidados respiratorios no invasivos con más de 200 profesionales médicos, kinesiólogos y licenciadas de enfermería. El encuentro fue presidido por el Dr. John Bach, Director Médico del Centro de Ventilación Mecánica No Invasiva en la Escuela de Medicina de Rutgers, New Jersey en Newark, New Jersey, quien es reconocido a nivel mundial por su amplia trayectoria en estudios y trabajos publicados sobre ventilación no invasiva y enfermedades neuromusculares Los cuidados respiratorios no invasivos, combinando la asistencia ventilatoria, inicialmente nocturna y luego durante las 24 horas del día, incluso en pacientes con capacidad vital mínima, y la implementación de estrategias para asistencia de la tos y respiración glosofaríngea, han contribuido a una mejor calidad de vida y sobrevida de los pacientes con enfermedades neuromusculares. Los avances tecnológicos, la capacitación de los pacientes y sus cuidadores facilitan su estadía en el hogar sin depender de instituciones o cuidados de enfermería permanentes promoviendo su autonomía e integración. Resulta esencial que los profesionales de la salud, conozcan todas las opciones terapéuticas posibles para ofrecer a sus pacientes y sus familias, de modo que, conforme avanza la enfermedad, ellos puedan expresar sus voluntades en forma anticipada y sin apremios derivados de eventos "inesperados". Es necesario impulsar un cambio de paradigma en la forma en que los profesionales de la salud ven a estos individuos. Las recomendaciones claves de ese encuentro están resumidas en este artículo.

Summary: A November 2016 Noninvasive Ventilatory Support workshop and meeting with more than 200 medical professionals, physiotherapists, respiratory therapists and nurses took place in the city of Montevideo, Uruguay. It was conducted by Dr. John Robert Bach, Medical Director of the Center for Non-Invasive Mechanical Ventilation at Rutgers New Jersey School of Medicine in Newark, New Jersey, who is recognized worldwide for his extensive background in studies and publications on noninvasive ventilation and neuromuscular diseases. Non-invasive respiratory care which combines ventilatory support initially at night and then support continuously 24 hours per day, even in patients with minimal vital capacity combined with the implementation of specifics techniques for assisted coughing and glossopharyngeal breathing have contributed to a better quality of life and survival of patients with neuromuscular diseases. Technological advances and proper training for patients and caregivers facilitates the patient's ability to stay at home and also promotes their autonomy and integration, without them having to depend on hospice or permanent nursing care. It is essential for health care professionals to know all the therapeutic possibilities available for their patients and share with both the patients and the patient's family, so as the disease progresses it will help everyone clearly understand all options during conscious decision-making. It is necessary to promote a paradigm shift in the way health professionals approach individuals with neuromuscular diseases. The key recommendations from that meeting are summarized in this article.

Cuidados respiratorios para pacientes con enfermedades neuromusculares / Respiratory care for patients with neuromuscular diseases

Non-invasive respiratory care, combining with ventilatory support, initially at night and then during 24 hours/day, even in patients with minimal vital capacity and the implementation of specifics techniques like mechanically assisted coughing, glossopharyngeal breathing and air stacking, have contributed to a better quality of life and survival of patients with neuromuscular diseases. It is essential for health care professionals to know all the therapeutic possibilities for their patients and their families, so as the disease progresses it would facilitate their decision-making. Technological advances and proper training for patients and caregivers facilitate the stay at home and promote their autonomy and integration, without depending on hospital nor permanent nursing care. In November 2016 it was carried out the Noninvasive Ventilatory Support workshop/meeting with more than 200 physicians, physiotherapists, respiratory therapists and nurses in Montevideo, Uruguay. It was conducted by Dr. John Robert Bach, Medical Director of the Center for Non-Invasive Mechanical Ventilation at Rutgers New Jersey School of Medicine in Newark, New Jersey. Dr Bach is recognized worldwide for his extensive background in studies and publications on noninvasive ventilation and neuromuscular diseases.

Los cuidados respiratorios no invasivos, combinando la asistencia ventilatoria, inicialmente nocturna y luego durante las 24 h del día, incluso en pacientes con capacidad vital mínima, más la implementación de estrategias complementarias de tos asistida, respiración glosofaríngea y apilamiento de aire (air stacking) en forma activa o pasiva han contribuido a una mejor calidad de vida y sobrevida de los pacientes con enfermedades neuromusculares. Resulta esencial que los profesionales de la salud, conozcan todas las opciones terapéuticas al informar a sus pacientes y sus familias, de modo que ellos puedan tomar sus mejores decisiones en la medida que la debilidad e hipoventilación progresen. Los avances tecnológicos, la capacitación de los pacientes y sus cuidadores facilitan su estadía en el hogar sin depender de instituciones o cuidados de enfermería permanentes, promoviendo su autonomía e integración, disminuyendo el riesgo de falla respiratoria conducente a intubación endotraqueal y/o a traqueostomia. Los días 24 y 25 de noviembre del 2016, en Montevideo tuvo lugar un encuentro de capacitación en cuidados respiratorios no invasivos con más de 200 profesionales médicos, kinesiólogos y licenciadas de enfermería, destacando los avances y experiencia consolidad por el Dr. John Bach en más de 30 años de ejercicio profesional en pacientes con síndromes de hipoventilación secundario a enfermedades neuromusculares y otras condiciones que debilitan la bomba respiratoria. Las recomendaciones claves se resumen en este articulo, destacando como estos avances requieren impulsar un cambio de paradigma en la forma en que los profesionales de la salud ven y tratan a estos individuos.

Influence of the ventilatory mode on acute adverse effects and facial thermography after noninvasive ventilation / Influência do modo ventilatório nos efeitos adversos agudos e na termografia da face após ventilação não invasiva

ABSTRACT Objective: To compare the incidence and intensity of acute adverse effects and the variation in the temperature of facial skin by thermography after the use of noninvasive ventilation (NIV). Methods: We included 20 healthy volunteers receiving NIV via oronasal mask for 1 h. The volunteers were randomly divided into two groups according to the ventilatory mode: bilevel positive airway pressure (BiPAP) or continuous positive airway pressure (CPAP). Facial thermography was performed in order to determine the temperature of the face where it was in contact with the mask and of the nasal dorsum at various time points. After removal of the mask, the volunteers completed a questionnaire about adverse effects of NIV. Results: The incidence and intensity of acute adverse effects were higher in the individuals receiving BiPAP than in those receiving CPAP (16.1% vs. 5.6%). Thermographic analysis showed a significant cooling of the facial skin in the two regions of interest immediately after removal of the mask. The more intense acute adverse effects occurred predominantly among the participants in whom the decrease in the mean temperature of the nasal dorsum was lower (14.4% vs. 7.2%). The thermographic visual analysis of the zones of cooling and heating on the face identified areas of hypoperfusion or reactive hyperemia. Conclusions: The use of BiPAP mode was associated with a higher incidence and intensity of NIV-related acute adverse effects. There was an association between acute adverse effects and less cooling of the nasal dorsum immediately after removal of the mask. Cutaneous thermography can be an additional tool to detect adverse effects that the use of NIV has on facial skin.

RESUMO Objetivo: Comparar a incidência e a intensidade de efeitos adversos agudos e a variação da temperatura da pele da face através da termografia após a aplicação de ventilação não invasiva (VNI). Métodos: Foram incluídos 20 voluntários sadios, de ambos os gêneros, submetidos à VNI com máscara oronasal por 1 h e divididos aleatoriamente em dois grupos de acordo com o modo ventilatório: bilevel positive airway pressure (BiPAP) ou continuous positive airway pressure (CPAP). A termografia da face foi realizada para determinar a temperatura na região de contato da máscara e no dorso do nariz em momentos diferentes. Os voluntários preencheram um questionário de efeitos adversos após a retirada da VNI. Resultados: A incidência e a intensidade dos efeitos adversos agudos foram maiores naqueles submetidos a BiPAP em relação aos submetidos a CPAP (16,1% vs. 5,6%). A análise termográfica evidenciou um esfriamento significativo da pele facial nas duas regiões de estudo imediatamente após a retirada da máscara. Os efeitos adversos agudos em maior intensidade ocorreram predominantemente no grupo de participantes cuja redução da temperatura média no dorso do nariz foi menor (14,4% vs. 7,2%). A análise visual termográfica de zonas de esfriamento e aquecimento na face identificou regiões de hipoperfusão ou hiperemia reativa. Conclusões: O uso do modo BiPAP associou-se a maior incidência e intensidade de efeitos adversos agudos associados à VNI. Houve associação entre efeitos adversos agudos e menor esfriamento da pele do dorso do nariz imediatamente após a retirada da máscara. A termografia cutânea pode ser uma ferramenta adicional na detecção de efeitos adversos na pele da face associados ao uso da VNI.

Extracorporeal respiratory support in adult patients / Suporte respiratório extracorpóreo em pacientes adultos

ABSTRACT In patients with severe respiratory failure, either hypoxemic or hypercapnic, life support with mechanical ventilation alone can be insufficient to meet their needs, especially if one tries to avoid ventilator settings that can cause injury to the lungs. In those patients, extracorporeal membrane oxygenation (ECMO), which is also very effective in removing carbon dioxide from the blood, can provide life support, allowing the application of protective lung ventilation. In this review article, we aim to explore some of the most relevant aspects of using ECMO for respiratory support. We discuss the history of respiratory support using ECMO in adults, as well as the clinical evidence; costs; indications; installation of the equipment; ventilator settings; daily care of the patient and the system; common troubleshooting; weaning; and discontinuation.

RESUMO Em pacientes com insuficiência respiratória grave (hipoxêmica ou hipercápnica), o suporte somente com ventilação mecânica pode ser insuficiente para suas necessidades, especialmente quando se tenta evitar o uso de parâmetros ventilatórios que possam causar danos aos pulmões. Nesses pacientes, extracorporeal membrane oxygenation (ECMO, oxigenação extracorpórea por membrana), que também é muito eficaz na remoção de dióxido de carbono do sangue, pode manter a vida, permitindo o uso de ventilação pulmonar protetora. No presente artigo de revisão, objetivamos explorar alguns dos aspectos mais relevantes do suporte respiratório por ECMO. Discutimos a história do suporte respiratório por ECMO em adultos; evidências clínicas; custos; indicações; instalação do equipamento; parâmetros ventilatórios; cuidado diário do paciente e do sistema; solução de problemas comuns; desmame e descontinuação.

Impaired pulmonary function after treatment for tuberculosis: the end of the disease? / Comprometimento da função pulmonar após tratamento para tuberculose: o resultado final da doença?

ABSTRACT Objective: To evaluate the prevalence of pulmonary function abnormalities and to investigate the factors affecting lung function in patients treated for pulmonary tuberculosis. Methods: A total of 214 consecutive patients (132 men and 82 women; 20-82 years of age), treated for pulmonary tuberculosis and followed at a local dispensary, underwent spirometry and plethysmography at least one year after treatment. Results: Pulmonary impairment was present in 102 (47.7%) of the 214 patients evaluated. The most common functional alteration was obstructive lung disease (seen in 34.6%). Of the 214 patients, 60 (28.0%) showed reduced pulmonary function (FEV1 below the lower limit of normal). Risk factors for reduced pulmonary function were having had culture-positive pulmonary tuberculosis in the past, being over 50 years of age, having recurrent tuberculosis, and having a lower level of education. Conclusions: Nearly half of all tuberculosis patients evolve to impaired pulmonary function. That underscores the need for pulmonary function testing after the end of treatment.

RESUMO Objetivo: Avaliar a prevalência de alterações da função pulmonar e investigar os fatores que afetam a função pulmonar em pacientes tratados para tuberculose pulmonar. Métodos: Um total de 214 pacientes consecutivos (132 homens e 82 mulheres; 20-82 anos de idade), tratados para tuberculose pulmonar e acompanhados em um dispensário local, foi submetido a espirometria e pletismografia pelo menos um ano após o tratamento. Resultados: O comprometimento pulmonar estava presente em 102 (47,7%) dos 214 pacientes avaliados. A alteração funcional mais comum foi o distúrbio ventilatório obstrutivo (observado em 34,6%). Dos 214 pacientes, 60 (28,0%) apresentaram função pulmonar reduzida (VEF1 abaixo do limite inferior de normalidade). Os fatores de risco para função pulmonar reduzida foram tuberculose pulmonar com cultura positiva no passado, idade acima de 50 anos, recidiva de tuberculose e menor nível de escolaridade. Conclusões: Quase metade de todos os pacientes com tuberculose evolui com comprometimento da função pulmonar. Isso reforça a necessidade de testes de função pulmonar após o término do tratamento.

Current issues in the respiratory care of patients with amyotrophic lateral sclerosis / Tópicos atuais no tratamento respiratório de pacientes com esclerose lateral amiotrófica

Amyotrophic lateral sclerosis is a progressive neuromuscular disease, resulting in respiratory muscle weakness, reduced pulmonary volumes, ineffective cough, secretion retention, and respiratory failure. Measures as vital capacity, maximal inspiratory and expiratory pressures, sniff nasal inspiratory pressure, cough peak flow and pulse oximetry are recommended to monitor the respiratory function. The patients should be followed up by a multidisciplinary team, focused in improving the quality of life and deal with the respiratory symptoms. The respiratory care approach includes airway clearance techniques, mechanically assisted cough and noninvasive mechanical ventilation. Vaccination and respiratory pharmacological support are also recommended. To date, there is no enough evidence supporting the inspiratory muscle training and diaphragmatic pacing.

Esclerose lateral amiotrófica é uma doença neuromuscular progressiva que resulta em fraqueza muscular, redução dos volumes pulmonares, tosse ineficaz, retenção de secreção e insuficiência respiratória. Medidas como a capacidade vital, pressão inspiratória e pressão expiratória máximas, pressão inspiratória máxima nasal, pico de fluxo de tosse e oximetria de pulso são recomendados para monitorar a função respiratória. Os pacientes devem ser acompanhados por uma equipe multidisciplinar, buscando melhorias na qualidade de vida e melhores estratégias para lidar com os sintomas respiratórios. A abordagem de cuidados respiratórios inclui técnicas de desobstrução das vias respiratórias, tosse assistida mecanicamente e ventilação mecânica não invasiva. Vacinação e suporte farmacológico também são recomendados. Até o momento, não existem provas suficientes que suportam o treinamento muscular inspiratório e a estimulação diafragmática.

Entendendo melhor a insuficiência respiratória aguda / A better understanding of acute respiratory failure

A insuficiência respiratória aguda (IRpA) é uma síndrome potencialmente grave, constituindo uma das principais indicações de internação em unidades de terapia intensiva. Embora diferentes condições clínicas possam evoluir com IRpA, todas apresentarão comprometimento nas trocas gasosas que caracterizarão a síndrome.O conhecimento da fisiologia das trocas gasosas e os mecanismos pelos quais elas podem ser alteradas permite compreender a fisiopatologia da IRpA e as repercussões dos diferentes distúrbios sobre os gases arteriais. Este conhecimento permite a interpretação adequada da gasometria arterial e de indicadores derivados da mesma, facilitando a condução dos pacientes com IRpA, tanto em relação ao diagnóstico etiológico, quanto ao tratamento de suporte.Estes conceitos da fisiologia das troas gasosas e da fisiopatologia da IRpA e suas aplicações clínicas serão revisados neste artigo...

Acute respiratory failure (ARF) is a potentially severe syndrome, which is a common indication for admission to an intensive care unit. Although the ARF can be caused by different clinical conditions, all of them will present gas exchange impairments that will characterize the syndrome.By knowing the gas exchanges physiology and the mechanisms by which they can be impaired, one can understand the physiopathology of the ARF and how it can compromise the arterial gases. This knowledge allows the correct interpretation of arterial blood gases and other useful indicators, such as the alveolar-arterial oxygen gradient, which help us to manage patients with ARF, both in their diagnosis, and in their supportive treatment.These concepts about the gas exchange physiology and the ARF physiopathology, and their clinical relevance, will be discussed in this article...

Insuficiência respiratória aguda na criança / Respiratory failure in children

Este texto apresenta uma revisão da definição, da fisiopatologia e do manejo das emergências respiratórias e da insuficiência respiratória aguda na criança, enfatizando os dispositivos mais adequados de liberação de oxigênio. As crianças são mais suscetíveis aos problemas respiratórios graves, sendo estes, causas importantes de procura pela sala de emergência em pediatria. O reconhecimento precoce e o início rápido de tratamento são pontos fundamentais para o melhor desfecho desses pacientes.

This paper presents a review of the definition, pathophysiology and management of respiratory distress and failure in children, and emphasizes the most appropriate devices for oxygen delivery. Children are more susceptible to severe respiratory problems, which are leading causes of pediatric emergency room demand. Prompt recognition and effective management of respiratory problems are essential to improve outcome of these patients.

Success rate and neonatal morbidities associated with early extubation in extremely low birth weight infants

Mechanical ventilation improves survival of preterm infants with respiratory failure. The aim of this study was to determine the success rate and short-term neonatal morbidities of early extubation in extremely low birth weight [ELBW] infants in a tertiary care neonatal intensive care unit [NICU]. Retrospective cohort study of ELBW infants admitted to a tertiary, neonatal intensive care referral unit from January 1st to December 31[st], 2005. The primary outcome was the success rate of early extubation in ELBW infants who were intubated at delivery, extubated in the first 48 hours of life, and did not require reintubation within 72 hours following extubation. Thirty of the 95 eligible infants were extubated early; of these 30 infants, 24 [80%] had a successful extubation. Infants extubated early had a higher mean birth weight [855 vs 745 g; P<.0001] and gestational age [27.3 vs 25.6 weeks; P<.0001]. ELBW infants who were extubated early had lower rates of death [relative risk [RR], 0.05; 95% Cl, [0.0, 0.79]; P=.003], intraventricular hemorrhage [IVH] [RR, 0.23; 95% Cl, 0.08, 0.70; P=.008], and patent ductus arteriosus [PDA] [RR, 0.76; 95% Cl, 0.60, 0.98; P=.03] compared with those who remained ventilated beyond the first 48 hours of life. The rate of successful early extubation in our unit exceeded the sole previously reported rate. Successful early extubation was associated with lower rates of death, IVH, and PDA in ELBW infants

Dimensión respiratoria de la escala ALSFRS-R y la función respiratoria en la esclerosis lateral amiotrófica / Respiratory domain of revised amyotrophic lateral sclerosis: Functional Rating Scale

Virtualmente todos los pacientes con esclerosis lateral amiotrófica tendrán disnea, que es quizá el síntoma más penoso de esta devastadora enfermedad. El objetivo de este estudio fue correlacionar la dimensión respiratoria de la escala ALSFRS-R, la capacidad vital forzada y las presiones estáticas máximas bucales. Se estudiaron prospectivamente 20 pacientes consecutivos sin disnea durante 24 meses. El puntaje total de la escala ALSFRS-R disminuyó de 34.3 ± 10.3 a 22.1 ± 8.0 (p = 0.0325); la contribución de la dimensión respiratoria fue insignificante. En quienes refirieron disnea (n: 12), la capacidad vital forzada cayó un 41 ± 21 % del valor inicial pero con similar caída (46 ± 23%), 8 pacientes no refirieron disnea. La correlación entre la escala ALSFRS-R con la capacidad vital forzada (litros) fue r: 0.73, (p = 0.0016) y con la presión inspiratoria máxima (cm H2O), r: 0.84, p = 0.0038. La correlación entre la capacidad vital forzada (%) con la disnea fue r s: 0.23, p = 0.1400. La correlación de la disnea con la presión inspiratoria máxima (%) fue r s: 0.58, p = 0.0300 y con la presión espiratoria máxima (%), r s: 0.49, p = 0.0400. La dimensión respiratoria de la escala ALSFRS-R no permitió predecir el grado de deterioro funcional respiratorio. Esto sugiere que dicha dimensión no reemplaza a las mediciones funcionales respiratorias y, debido a que la insuficiencia respiratoria puede no ser evidente, la realización de dichas pruebas provee una base objetiva de seguimiento y permite planear medidas con anticipación.

Virtually all patients with amyotrophic lateral sclerosis will complain of dyspnea, which is perhaps the most distressing symptom of this devastating disease. The objective was to correlate respiratory domain of ALSFRS-R with forced vital capacity and maximal static pressures in the mouth. We designed a prospective study in 20 consecutive patients without dyspnea during 24 months. The global decline of ALSFRS-R was from 34.3 ± 10.3 to 22.1 ± 8.0 (p = 0.0325), the contribution of respiratory domain was irrelevant. Those who referred dyspnea (n: 12), forced vital capacity fell 41 ± 21% of the initial value but with similar value of fall (46 ± 23%) 8 patients did not referred dyspnea. Total score of ALSFRS-R correlated with forced vital capacity (litres), r: 0.73, p = 0.0016 and maximal inspiratory pressure (cm H2O), r: 0.84, p = 0.0038, but the fall of the forced vital capacity (%) did not correlate with dyspnea (r s: 0.23, p = 0.1400). There was a moderate correlation between dyspnea and maximal inspiratory pressure (%), r s: 0.58, p = 0.0300 and between dyspnea and maximal expiratory pressure (%), r s: 0.49, p = 0.0400. We concluded that the respiratory functional deterioration could not be predicted using respiratory domain of ALSFRS-R. This suggests that respiratory domain of this scale does not replace to respiratory function testing measurements and, due to the respiratory insufficiency could not be clinically evident; performing pulmonary function tests provides an objective view and permit to make anticipatory actions.

Ventilación no invasiva en insuficiencia respiratoria aguda / Non-invasive ventilation in acute respiratory failure

Background: Non-invasive ventilation (NIV) has become a therapeutic tool for acute respiratory failure in pediatric patients. Objective: To describe NIV experience at a Pediatric Intensive Care Unit, identifying factors associated to modality failure. Methods: Patients cohort who received NIV in acute respiratory failure during 2005-2007. Recolection of clinical and gasometrical variables previous and subsequent to connection to NIV. Descriptive statistic and logistic regression analysis were performed. Results: 51 events of NIV, where 55 percent) cases were congenital cardiopathies. NIV main indication was respiratory distress post-extubation (31.4 percent). 15 patients (29.4 percent) required CMV. In univariate logistic regression for variables, an independent association was found between Fi02 pre-connection and Fi02 subsequent to NIV connection, with necessity of CMV. 9 percent> presented complications and mortality was not related to ventilatory modality. Conclusions: NIV is useful in pediatric patients with acute respiratory insufficiency, with low risk of complications. The variables associated with failure are easy to obtain and interpretate.

Introducción: La ventilación no invasiva (VNI) se ha convertido en una herramienta terapéutica en insuficiencia respiratoria aguda en pediatría. Objetivo: Describir la experiencia con VNI en una unidad de paciente crítico pediátrico, e identificar factores asociados con fracaso de la modalidad. Pacientes y Método: Cohorte de pacientes que recibieron VNI en contexto de insuficiencia respiratoria aguda durante el período 2005-2007. Registro de variables clínicas y gasométricas previo y posterior a la conexión a VNI. Se realizó estadística descriptiva y análisis de regresión logística. Resultados: Analizamos 51 eventos de VNI, 55 por ciento en postoperatorio de cardiopatías congénitas. La principal indicación de VNI fue dificultad respiratoria post extubación (31,4 por ciento). Quince pacientes (29,4 por ciento) fracasaron, requiriendo VMC. Al realizar regresión logística univariada se encontró asociación independiente entre la Fi0(2) pre conexión y Fi0(2) posterior a la conexión a VNI, con la necesidad de VMC. Nueve por ciento presentaron complicaciones. No se observó mortalidad asociada a la modalidad ventilatoria. Conclusiones: La VNI es útil en pacientes pediátricos insuficiencia respiratoria aguda y tiene un bajo riesgo de complicaciones. Las variables asociadas con fracaso de VNI son de fácil obtención e interpretación.

Fisiopatología y soporte ventilatorio no invasivo en la falla respiratoria aguda de los pacientes con obesidad / Pathophysiology and noninvasive ventilatory support in acute respiratory failure of obese patients

La obesidad en sus distintas expresiones es una enfermedad que está en aumento en varias regiones del mundo, incluido nuestro país. Más allá del mayor riesgo de diabetes y compromiso cardiovascular, también hay mayor frecuencia de problemas respiratorios que incluye trastornos restrictivos, obstructivos, apnea obstructiva del sueño y síndrome de hipoventilación-obesidad. Todas estas manifestaciones respiratorias pueden expresarse o agravarse ante un cuadro crítico o ante una situación de cirugía programada poniendo al paciente obeso en riesgo de insuficiencia respiratoria. En esta revisión efectuaremos un análisis de las distintas alteraciones fisiopatológicas que determinan disfunción respiratoria aguda en el paciente obeso y una revisión de la utilización de la ventilación mecánica no invasiva en el tratamiento de la misma.

The frequency of obesity, in its various manifestations, is increasing in many parts of the world, including our country. Apart from the higher risk of diabetes and cardiovascular complications, obesity also conveys a high rate of respiratory problems including restrictive and obstructive disorders, obstructive sleep apnea and obesity-hypoventilation syndrome. All these respiratory manifestations can appear or worsen on occasion of a critical situation, or when a non-urgent surgery is planned. In this review we present an analysis of the different physiopathologic alterations that can lead to acute respiratory failure in an obese patient and a review of the use of non invasive ventilation treatment.

Fisiopatología y soporte ventilatorio no invasivo en la falla respiratoria aguda de los pacientes con obesidad / Pathophysiology and noninvasive ventilatory support in acute respiratory failure in patients with obesity

La obesidad en sus distintas expresiones es una enfermedad que está en aumento en varias regiones del mundo, incluido nuestro país. Mas alla del mayor riesgo de diabetes y compromiso cardiovascular, también hay mayor frecuencia de problemas respiratorios que incluye trastornos restrictivos, obstructivos, apnea obstructiva del sueño y síndrome de hipoventilación-obesidad. Todas estas manifestaciones respiratorias pueden expresarse o agravarse ante un cuadro crítico o ante una situación de cirugía programada poniendo al paciente obeso en riesgo de insuficiencia respiratoria. En esta revisión efectuaremos un análisis de las distintas alteraciones fisiopatológicas que determinan disfunción respiratoria aguda en el paciente obeso y una revisión de la utilización de la ventilación mecánica no invasiva en el tratamiento de la misma.

Fisiología e indicaciones de la asistencia ventilatoria no invasiva / Noninvasive ventilation: indications and physiology

El presente capítulo aborda los aspectos fisiológicos y fisiopatológicos que condicionan la claudicación de la bomba respiratoria y sustentan la aplicación clínica de la ventilación mecánica no invasiva en el escenario pediátrico, tanto como estrategia ventilatoria domiciliaria en aquellos que requieren ventilación mecánica prolongada, como en el manejo de la insuficiencia respiratoria aguda en unidades de paciente crítico. Asimismo se exponen brevemente sus principales indicaciones en la práctica clínica.

Asistencia ventilatoria no invasiva en el paciente crónico: criterios de selección / Noninvasive ventilation in chronic patient: selection criteria

En el tratamiento de los pacientes con insuficiencia respiratoria crónica, ya sea esta por una condición progresiva o estable, se ha incorporado en los últimos años la Ventilación Mecánica no Invasiva (VNI) como una alternativa eficiente en el manejo domiciliario. Su uso protocolizado ha logrado mejorarla evolución y sobrevida de estos pacientes, disminuyendo la morbilidad relacionada a exacerbaciones y mejorando la calidad de vida del paciente y su familia. Esto ha requerido establecer criterios estrictos de selección y revisar las contraindicaciones según consideraciones técnicas y éticas. Estas decisiones tienen implicancias económicas, tecnológicas y en la organización de una red de apoyo en que participe en forma fluida todo el equipo de salud. Se mencionan las recomendaciones existentes parainiciar la VNI y los criterios de selección considerados en el Programa Chileno de Asistencia Ventilatoria no Invasiva en Domicilio.