Manejo de la vía aérea ante un caso de paro respiratorio en un escenario clínico simulado. Experiencia en una residencia de pediatría / Airway management during a respiratory arrest in a clinical simulation scenario. Experience at a pediatric residency program

Introducción. La insuficiencia respiratoria es la causa más común de paro cardíaco en pediatría; su reconocimiento y el manejo adecuado son cruciales. La simulación se utiliza para mejorar las habilidades médicas. El objetivo del trabajo fue determinar la proporción de residentes de pediatría que reconocieron un paro respiratorio (PR) pediátrico en un centro de simulación. Métodos. Se realizó un estudio observacional con 77 médicos residentes. Se utilizó un caso simulado de un paciente con dificultad respiratoria que progresa a PR. Resultados. De los 77 participantes, 48 reconocieron el paro respiratorio (62,3 %). El tiempo medio para reconocer el PR fue de 34,43 segundos. Conclusión. El 62,3 % de los participantes logró reconocer el paro respiratorio. Entre aquellos que lo identificaron, el tiempo promedio fue de 34,43 segundos. Se observaron graves deficiencias en algunas de las intervenciones esperadas.

Introduction. Respiratory failure is the most common cause of cardiac arrest in pediatrics. Recognizing and managing it adequately is critical. Simulation is used to improve medical skills. The objective of this study was to establish the proportion of pediatric residents who recognized a respiratory arrest in a child at a simulation center. Methods. This was an observational study in 77 residents. A simulation of a patient with respiratory distress that progressed to respiratory arrest was used. Results. Among the 77 participants, 48 recognized respiratory arrest (62.3%). The mean time to recognize respiratory arrest was 34.43 seconds. Conclusion. Respiratory arrest was recognized by 62.3% of participants. Among those who did so, the average time was 34.43 seconds. Severe failures were noted in some of the expected interventions.

Cánula nasal de alto flujo en pacientes críticos: una revisión narrativa / High Flow Nasal Cannula in Critically Ill Patients: a Narrative Review

La cánula nasal de alto flujo se ha convertido en una de las principales estrategias de soporte ventilatorio no invasivo en la insuficiencia respiratoria aguda hipoxémica, principalmente después de la pandemia de COVID-19. Sin embargo, su uso se extiende más allá de este escenario y abarca diferentes condiciones clínicas como el período postextubación, período postquirúrgico, insuficiencia respiratoria hipercápnica y soporte vital en pacientes inmunodeprimidos, trasplantados u oncológicos. Los manuscritos que avalan su aplicación han sido ampliamente difundidos y el grado de evidencia es lo suficientemente alto como para recomendar su uso. Por tanto, es necesario destacar sus efectos fisiológicos como el confort, una fracción inspirada de oxígeno precisa, el lavado de CO2 o la optimización del volumen pulmonar de fin de espiración para comprender su mecanismo de acción y mejorar los resultados de los pacientes. El objetivo de esta revisión narrativa es ofrecer un resumen breve y conciso de los efectos y beneficios de aplicar esta terapia en diferentes escenarios clínicos sin la estructura rígida de una revisión sistemática. Con base en estas líneas, el lector curioso puede ampliar la evidencia científica que avala el empleo de la cánula nasal de alto flujo en cada escenario particular. (AU);

High-flow nasal cannula has become one of the main strategies for non-invasive ventilatory support in hypoxemic acute respiratory failure, mainly after the COVID-19 pandemic. However, its use extends beyond this scenario and covers different clinical conditions such as the post-extubation period, post-surgical period, hypercapnic respiratory failure and life support in immunosuppressed, trasplant or cancer patients. Manuscripts that support its application have been widely disseminated and the degree of evidence is high enough to recommend its use. Therefore, it is necessary to highlight its physiological effects such as comfort, precise fraction of inspiratory oxygen, CO2 lavage or optimize end-expiratory lung volume to understand its mechanism of action and improve patients' outcomes. The objective of this narrative review is to offer a brief and concise summary of the benefits of applying this therapy in different clinical scenarios without the rigid structure of a systematic review. Based on these lines, the curious reader can expand the scientific evidence that supports the use of the high-flow nasal cannula in each particular scenario. (AU);

Design and application of decompression fixator to prevent HFNC facial pressure injury / 中华危重病急救医学

As a new respiratory support technique, high-flow nasal cannula oxygen therapy (HFNC) has been widely used in clinical practice in recent years. During HFNC treatment, due to the long time and continuous wearing of nasal stopper and fasteners on the patient face, it is easy to cause medical device-related pressure injury on multiple facial skin. Moreover, when the patient's position changes greatly, because there is no good fixed design at the HFNC nasal stopper, it is easy to shift or turn the nasal stopper outward, causing abnormal ventilation and failure to achieve the purpose of clinical oxygen therapy. To overcome above problems, medical staff in the intensive care unit of department of infectious diseases, Tongji Hospital Tongji Medical College of HUST designed a new type of decompression fixator to prevent HFNC face pressure injury, and obtained national utility model patent (ZL 2022 2 0754626.1). The integrated design structure of the device has the functions of decompression of facial skin and fixation of nasal stopper, which can ensure the effect of oxygen therapy and improve the oxygen therapy experience and patient comfort, which is suitable for clinical promotion.

Oxigenoterapia em pacientes com deficiência do sistema respiratório por obstrução crônica aos fluxos aéreos com ou sem hipercapnia: revisão sistemática / Oxygenotherapy in patients with disability of the respiratory system by chronic obstruction to air flows with or without hypercapnia: systematic review

Introdução: a deficiência no sistema por obstrução crônica aos fluxos aéreos é uma doença caracterizada por inflamação, associada a alterações anatômicas e fisiológicas, podendo ocasionar exacerbações respiratórias. A oxigenoterapia tem sido uma alternativa usada em pacientes que possuem insuficiência respiratória decorrente da obstrução crônica, como tentativa de diminuir os sintomas e as complicações geradas. Objetivo: avaliar os efeitos da oxigenoterapia em pacientes com deficiência do sistema respiratório por obstrução crônica, com e sem hipercapnia, quanto aos desfechos pressão parcial de oxigênio, frequência respiratória, tempo de internamento e qualidade de vida.Metodologia: revisão de ensaios clínicos controlados e randomizados (ECR) nas bases de dados PubMed, Cochrane e PEDro. Incluídos estudos originais que utilizaram a oxigenoterapia como intervenção em pacientes com deficiência do sistema respiratório por obstrução crônica aos fluxos aéreos ou que outras síndromes. Resultados: na busca realizada nas bases de dados foram identificados um total de 387 estudos, reduzindo para 87 quando aplicado o descritor "ensaio clínico" e 7 estudos foram incluídos publicados entre os anos de 2004 e 2019. Conclusão: A oxigenoterapia mostrou-se incremento da pressão parcial de oxigênio, frequência respiratória e redução do tempo de internamento com impactos na melhora da qualidade de vida.

Introduction: system deficiency due to chronic airflow obstruction is a disease characterized by inflammation, associated with anatomical and physiological changes, which can cause respiratory exacerbations. Oxygen therapy has been an alternative used in patients who have respiratory failure due to obstruction of the obstruction as an attempt to reduce symptoms and as complications generated. Objective: to evaluate the effects of oxygen therapy in patients with respiratory system deficiency due to chronic obstruction, with and without hypercapnia, in terms of partial oxygen pressure, respiratory rate, length of stay and quality of life. Methodology: review of controlled clinical trials and (RCT) in the PubMed, Cochrane and PEDro databases. Included original studies that used oxygen therapy as an intervention in patients with respiratory system deficiency due to obstruction to flow flows or other syndromes. Results: in the search carried out in the databases, a total of 387 studies were identified, for 87 when the descriptor "clinical trial" was projected and 7 studies were included between the years 2004 and 2019. Conclusion: oxygen therapy showed an increase in pressure partial oxygen, respiratory rate and reduction in hospital stay with impacts on improving the quality due.

Posición prono en embarazada con neumonía grave por COVID-19 / Prone position in pregnant woman with severe COVID-19 pneumonia

Resumen Se han comunicado buenos resultados clínicos al poner en posición prono a pacientes con Síndrome de Distrés Respiratorio Agudo por COVID-19. Objetivo: Describir la maniobra prono, sus resultados clínicos y cuidados asociados, en una mujer de 34 años de edad con 26 semanas de embarazo, que estaba en ventilación mecánica, por un cuadro clínico de neumonía multifocal por COVID-19. Se realizó maniobra prono lateralizada hacia izquierda, en tres etapas, preparación, ejecución y evaluación. Luego de 62 h de prono, se observó una recuperación favorable de la gestante: la relación PaO2/FiO2 aumentó de 151 a 368 mmHg, y disminuyó el compromiso radiológico pulmonar, sin que se detectaran complicaciones fetales. Conclusiones: Esta maniobra que puede beneficiar a pacientes con insuficiencia respiratoria grave, en embarazadas debe ser una técnica protocolizada, con equipos de trabajo experimentados e implementación adecuada.

Good clinical results have been reported when placing patients with acute respiratory distress syndrome due to COVID-19 in a prone position. Objective: To describe the prone maneuver, its clinical results and associated care in a 34-year-old woman with 26 weeks of pregnancy, who was on mechanical ventilation, due to a clinical picture of COVID-19 multifocal pneumonia. Lateralized prone maneuver was carried out to the left, in three stages, preparation, execution and evaluation. After 62 hours of prone, a favorable recovery of the pregnant woman was observed: PaO2/FiO2 ratio increased from 151 to 368 mmHg, and the pulmonary radiological compromise decreased, without fetal complications being detected. Conclusions: This maneuver that might benefit patients with severe respiratory failure, in pregnant women should be a protocolized technique, with experienced work teams and adequate implementation.

Clinical analysis of 6 critically ill children with acute chlorine poisoning / 中华儿科杂志

Objective: To analyze the clinical characteristics and treatment of critically ill children with acute chlorine poisoning and explore the risk factors and effective strategies. Methods: This retrospective study collected the clinical data, including general state, clinical characteristics, treatment and follow-up(till 1 year and 6 months after discharge), of 6 critically ill children who were hospitalized in the Pediatric Intensive Care Unit of Beijing Children's Hospital due to acute chlorine poisoning in August 2019. Results: There were 6 children characterized by severe dyspnea in this accident, among whom 4 were boys and two girls, aged 4-12 years. When the accident occurred, they were within 5 m of the chlorine source. These patients underwent tracheal intubation and mechanical ventilation in 3.5-7.0 h after poisoning. The child who was the closest to the chlorine source (1.5 m) and took the longest time (5 min) to evacuate was the most severe one. He suffered hypoxia which could not be corrected by conventional mechanical ventilation and severe shock, then had veno-arterial extracorporeal membrane oxygenation(ECMO) treatment started 10 h after the accident. All the 6 children in this study survived. Following-up found no growth and developmental abnormality. The pulmonary function tests were normal except for one case with increased small airway resistance due to previous suspected asthma, and the lung CT, electhoencephalogram, and brain magnetic resonance imaging were all normal. Conclusions: Severe chlorine poisoning is mainly characterized by respiratory failure. Mechanical ventilation is often required within a few hours after poisoning. When conventional mechanical ventilation is ineffective, ECMO could save live. Timely treatment could improve prognosis.

Oxigenoterapia con cánula nasal de alto flujo: experiencia en un servicio de urgencias de la ciudad de Bogotá / Oxygen therapy with a high-flow nasal cannula: experience in emergency service in the city of Bogotá

El objetivo de este estudio es analizar desenlaces clínicos de oxigenoterapia con cánula nasal de alto flujo (CNAF) en niños con dificultad respiratoria aguda en un servicio de urgencias. Estudio longitudinal, retrospectivo de datos panel en niños con diagnóstico de dificultad respiratoria moderada- severa. El resultado primario de interés fue ingreso a unidad de cuidados intensivos pediátricos (UCIP) o requerir intubación 24 horas posteriores al inicio de la terapia. Se calcularon medidas de frecuencia y tendencia central. Los grupos se compararon con las pruebas Chi2, Fisher, Wilcoxon y Kruskal-Wallis. El análisis de datos panel balanceados identificó puntos de inflexión en las curvas de normalización de respuesta respiratoria. Un total de 339 niños de 0 a 16 años cumplieron los criterios de inclusión. Mayoría hombres (62,24%), mediana de edad 2 años (RIQ= 0,75-3) y neumonía como principal causa de dificultad respiratoria (33,92%). El ingreso a UCIP (14,5%) y la intubación (0,9%) fue baja en la cohorte. En las primeras tres horas con CNAF se evidenció mejoría en los parámetros respiratorios, sin diferencias significativas entre pacientes con y sin respuesta clínica (frecuencia cardiaca p=0,317; frecuencia respiratoria p=0,423; SatO2 p=0,297; FiO2 p=0,116). No se presentaron eventos adversos ni casos de mortalidad. Los resultados sugieren que la oxigenoterapia con CNAF puede ser una alternativa de soporte respiratorio inicial en niños ≤16 años con dificultad respiratoria moderada a severa. La incidencia de intubación e ingreso a UCIP fue baja. La CNAF fue bien tolerada en los diferentes grupos de edad.

Objective: To analyze clinical outcomes of oxygen therapy with a high-flow nasal cannula (HFNC) in children with acute respiratory distress in an emergency department. We design a longitudinal retrospective study of panel data in children with a diagnosis of moderate-severe respiratory distress. The primary outcome of interest was admission to the pediatric intensive care unit (PICU) or requiring intubation 24 hours after initiation of therapy.We calculated the statistics of frequency and central tendency. Finally, the Chi2, Fisher, Wilcoxon and Kruskal-Wallis tests were used to compare groups. Balanced panel data analysis identified inflexion points in the respiratory response normalization curves. Children (n = 339) from zero to 16 years old met the inclusion criteria. Most men (62.24%), median age= 2 years (IQR = 0.75-3) and pneumonia as the main cause of respiratory distress (33.92%). Admission to the PICU (14.5%) and intubation (0.9%) was low in the cohort. In the first three hours with HFNC, improvement in respiratory parameters was evidenced, with no significant differences between patients with and without clinical response (heart rate p = 0.317; respiratory rate p = 0.423; SatO2 p = 0.297; FiO2 p = 0.116). There were no adverse events or mortality cases. The results suggest that oxygen therapy with HFNC can be an alternative for initial respiratory support in children ≤16 years of age with moderate to severe respiratory distress. The incidence of intubation and admission to the PICU was low. The HFNC was well tolerated in the different age groups.

ELMO, a new helmet interface for CPAP to treat COVID-19-related acute hypoxemic respiratory failure outside the ICU: a feasibility study / ELMO, uma nova interface do tipo capacete para CPAP no tratamento da insuficiência respiratória aguda hipoxêmica por COVID-19 fora da UTI: estudo de viabilidade

ABSTRACT Objective: To assess the feasibility of using a new helmet interface for CPAP, designated ELMO, to treat COVID-19-related acute hypoxemic respiratory failure (AHRF) outside the ICU. Methods: This was a proof-of-concept study involving patients with moderate to severe AHRF secondary to COVID-19 admitted to the general ward of a public hospital. The intervention consisted of applying CPAP via the ELMO interface integrated with oxygen and compressed air flow meters (30 L/min each) and a PEEP valve (CPAP levels = 8-10 cmH2O), forming the ELMOcpap system. The patients were monitored for cardiorespiratory parameters, adverse events, and comfort. Results: Ten patients completed the study protocol. The ELMOcpap system was well tolerated, with no relevant adverse effects. Its use was feasible outside the ICU for a prolonged amount of time and was shown to be successful in 60% of the patients. A CPAP of 10 cmH2O with a total gas flow of 56-60 L/min improved oxygenation after 30-to 60-min ELMOcpap sessions, allowing a significant decrease in estimated FIO2 (p = 0.014) and an increase in estimated PaO2/FIO2 ratio (p = 0.008) within the first hour without CO2 rebreathing. Conclusions: The use of ELMOcpap has proven to be feasible and effective in delivering high-flow CPAP to patients with COVID-19-related AHRF outside the ICU. There were no major adverse effects, and ELMO was considered comfortable. ELMOcpap sessions significantly improved oxygenation, reducing FIO2 without CO2 rebreathing. The overall success rate was 60% in this pilot study, and further clinical trials should be carried out in the future. (ClinicalTrials.gov identifier: NCT04470258 [http://www.clinicaltrials.gov/])

RESUMO Objetivo: Avaliar a viabilidade do uso de uma nova interface do tipo capacete para CPAP, denominada ELMO, para o tratamento da insuficiência respiratória aguda (IRpA) hipoxêmica por COVID-19 fora da UTI. Métodos: Estudo de prova de conceito envolvendo pacientes com IRpA hipoxêmica moderada a grave secundária à COVID-19, internados na enfermaria geral de um hospital público. A intervenção consistiu na aplicação de CPAP por meio da interface ELMO integrada a fluxômetros de oxigênio e ar comprimido (30 L/min cada) e a uma válvula de PEEP (níveis de CPAP = 8-10 cmH2O), formando o sistema ELMOcpap. Os pacientes foram monitorados quanto a parâmetros cardiorrespiratórios, eventos adversos e conforto. Resultados: Dez pacientes completaram o protocolo do estudo. O sistema ELMOcpap foi bem tolerado, sem efeitos adversos relevantes. Seu uso foi viável fora da UTI por tempo prolongado e mostrou-se bem-sucedido em 60% dos pacientes. Uma CPAP de 10 cmH2O com fluxo total de gás de 56-60 L/min melhorou a oxigenação após sessões de ELMOcpap de 30-60 min, permitindo redução significativa da FIO2 estimada (p = 0,014) e aumento da PaO2/FIO2 estimada (p = 0,008) na primeira hora, sem reinalação de CO2. Conclusões: O uso do ELMOcpap mostrou-se viável e eficaz no fornecimento de CPAP de alto fluxo a pacientes com IRpA hipoxêmica por COVID-19 fora da UTI. Não houve nenhum efeito adverso importante, e o ELMO foi considerado confortável. As sessões de ELMOcpap melhoraram significativamente a oxigenação, reduzindo a FIO2 sem reinalação de CO2. A taxa global de sucesso foi de 60% neste estudo piloto, e novos ensaios clínicos devem ser realizados. (ClinicalTrials.gov identifier: NCT04470258 [http://www.clinicaltrials.gov/])

Oxigenação por membrana extracorpórea na insuficiência respiratória em crianças: os anos antes e depois da pandemia de H1N1 de 2009 / Extracorporeal membrane oxygenation for respiratory failure in children: the years before and after the 2009 H1N1 pandemic

RESUMO Objetivo: Avaliar o impacto no número de casos de oxigenação por membrana extracorpórea e as taxas de sobrevivência nos anos seguintes à pandemia de H1N1 de 2009. Métodos: Avaliaram-se dois períodos distintos de utilização de oxigenação por membrana extracorpórea como suporte para insuficiência respiratória em crianças, por meio da análise de conjuntos de dados da Extracorporeal Life Support Organization. Foram construídos modelos autorregressivos integrados de médias móveis para estimar os efeitos da pandemia. O ano de 2009 foi o ano de intervenção (epidemia de H1N1) em um modelo de séries temporais interrompidas. Os dados colhidos entre 2001 e 2010 foram considerados pré-intervenção e os obtidos entre 2010 e 2017 como pós-intervenção. Resultados: Em comparação com o período entre 2001 e 2010, o período entre 2010 e 2017 mostrou aumento das taxas de sobrevivência (p < 0,0001), com melhora significante da sobrevivência quando se realizou oxigenação por membrana extracorpórea nos casos de insuficiência aguda por pneumonia viral. Antes do ponto de nível de efeito (2009), o modelo autorregressivo integrado de médias móveis mostrou aumento de 23 casos de oxigenação por membrana extracorpórea ao ano. Em termos de sobrevivência, a curva mostra que não houve aumento significante das taxas de sobrevivência antes de 2009 (p = 0,41), porém o nível de efeito foi próximo à significância após 2 anos (p = 0,05), com aumento de 6% na sobrevivência. Em 4 anos, ocorreu aumento de 8% (p = 0,03) na sobrevivência, e, 6 anos após 2009, a sobrevivência mostrou aumento de até 10% (p = 0,026). Conclusão: Nos anos após 2009, ocorreu significante e progressivo aumento global das taxas de sobrevivência com oxigenação por membrana extracorpórea para todos os casos, principalmente em razão de melhoras tecnológicas e dos protocolos de tratamento para insuficiência respiratória aguda relacionada à pneumonia viral e a outras condições respiratórias.

ABSTRACT Objective: To evaluate whether there was any impact on the number of pediatric extracorporeal membrane oxygenation runs and survival rates in the years subsequent to the 2009 pandemic. Methods: We studied two different periods of extracorporeal membrane oxygenation support for respiratory failure in children by analyzing datasets from the Extracorporeal Life Support Organization. Autoregressive integrated moving average models were constructed to estimate the effect of the pandemic. The year 2009 was the year of intervention (the H1N1 epidemic) in an interrupted time series model. Data collected from 2001 - 2010 were considered preintervention, and data collected from 2010 - 2017 were considered postintervention. Results: There was an increase in survival rates in the period 2010 - 2017 compared to 2001 - 2010 (p < 0.0001), with a significant improvement in survival when extracorporeal membrane oxygenation was performed for acute respiratory failure due to viral pneumonia. The autoregressive integrated moving average model shows an increase of 23 extracorporeal membrane oxygenation runs per year, prior to the point of the level effect (2009). In terms of survival, the preslope shows that there was no significant increase in survival rates before 2009 (p = 0.41), but the level effect was nearly significant after two years (p = 0.05), with a 6% increase in survival. In four years, there was an 8% (p = 0.03) increase in survival, and six years after 2009, there was up to a 10% (p = 0.026) increase in survival. Conclusion: In the years following 2009, there was a significant, global incremental increase in the extracorporeal membrane oxygenation survival rates for all runs, mainly due to improvements in the technology and treatment protocols for acute respiratory failure related to viral pneumonia and other respiratory conditions.

Neumonitis química grave secundaria a la inhalación de talco. A propósito de un caso pediátrico / Severe chemical pneumonitis secondary to talc inhalation. A pediatric case

El talco, un silicato de magnesio hidratado, formó parte durante décadas del cuidado tradicional de lactantes y niños pequeños. Si bien en los niños su inhalación aguda, que suele ser accidental durante el cambio de pañales, no es frecuente, es una condición potencialmente peligrosa, que puede provocar dificultad respiratoria grave e incluso cuadros mortales. Se describe el grave compromiso respiratorio por neumonitis química asociado con la inhalación accidental de talco en un lactante de 14 meses. El niño presentó un cuadro de dificultad respiratoria con requerimiento de asistencia respiratoria mecánica (ARM) durante una semana. En cuanto al tratamiento, no existe un estándar, se utilizaron antibióticos y corticoides sistémicos y aerosolterapia. No presentó complicaciones en otros órganos o sistemas. Su evolución fue favorable, se pudo externar al décimo día de internación y presentó posteriormente episodios aislados de hiperreactividad bronquial.

Talc is a hydrated magnesium silicate. It was part of traditional infant and young child care for decades. In children, its acute inhalation, generally accidental during diaper changes, although not frequent, is a potentially dangerous condition, and can cause severe respiratory distress and even death. We describe the case of a 14-month child who had an accidental inhalation of talc, chemical pneumonitis and severe respiratory compromise. The patient had acute respiratory distress syndrome requiring mechanical ventilation for one week. There is no standard treatment, we used systemic antibiotics and corticosteroids and aerosol therapy. He did not have complications in other organs or systems. He was hospitalized for ten days. In the follow up, he had isolated episodes of bronchial hyperresponsiveness.

Renal replacement therapy by the popliteal vein in a critical patient with COVID-19 in the prone position / Terapia renal substitutiva pela veia poplítea em paciente crítico com COVID-19 na posição de pronação

Abstract This patient was a 73-year-old man who initially came to our service with acute respiratory failure secondary to COVID-19. Soon after hospitalization, he was submitted to orotracheal intubation and placed in the prone position to improve hypoxia, due to severe acute respiratory syndrome (SARS). On the third day of hospitalization, he developed acute oliguric kidney injury and volume overload. The nephrology service was activated to obtain deep venous access for renal replacement therapy (RRT). The patient could not be placed in the supine position due to significant hypoxemia. A 50-cm Permcath (MAHURKARTM, Covidien, Massachusetts, USA) was inserted through the left popliteal vein. This case report describes a possible challenging scenario that the interventional nephrologist may encounter when dealing with patients with COVID-19 with respiratory impairment in the prone position.

Resumo O paciente era um homem de 73 anos de idade que inicialmente veio ao nosso serviço com insuficiência respiratória aguda secundária à COVID-19. Logo após a internação, ele foi submetido à intubação orotraqueal e pronado para melhorar a hipóxia devido à síndrome respiratória aguda grave (SARS - do inglês "severe acute respiratory syndrome"). No terceiro dia de internação, o mesmo desenvolveu lesão renal aguda oligúrica e sobrecarga de volume. O serviço de nefrologia foi acionado para realizar acesso venoso profundo para terapia renal substitutiva (TRS). O paciente não pôde ser colocado na posição de decúbito dorsal devido a uma hipoxemia significativa. Um Permcath de 50 cm (MAHURKARTM, Covidien, Massachusetts, EUA) foi inserido através da veia poplítea esquerda. Este relato de caso descreve um possível cenário desafiador com o qual o nefrologista intervencionista pode se deparar ao lidar com pacientes com COVID-19 com problemas respiratórios e colocados em pronação.

Contributing factors for the withdrawal from treatment in neonates with respiratory failure / 中国当代儿科杂志

OBJECTIVE@#To investigate the factors contributing to the withdrawal from treatment in neonates with respiratory failure.@*METHODS@#The medical data of 2 525 neonates with respiratory failure were retrospectively studied, who were reported in 30 hospitals of Jiangsu Province from January to December, 2019. According to whether a complete treatment was given, they were divided into a complete treatment group with 2 162 neonates and a withdrawal group with 363 neonates. A multivariate logistic regression analysis was used to investigate the factors contributing to the withdrawal from treatment in neonates with respiratory failure.@*RESULTS@#The multivariate logistic regression analysis showed that small-for-gestational-age birth, congenital abnormality, gestational age < 28 weeks, living in the rural area or county-level city, and maternal age < 25 years were risk factors for the withdrawal from treatment in neonates with respiratory failure (@*CONCLUSIONS@#Small-for-gestational-age birth, congenital abnormality, gestational age, living area, maternal age, Apgar score at birth, and method of birth are contributing factors for the withdrawal from treatment in neonates with respiratory failure. A poor prognosis and a low quality of life in future might be major immediate causes of withdrawal from treatment in neonates with respiratory failure, which needs to be confirmed by further studies.

Predictors and outcomes of high-flow nasal cannula failure following extubation: A multicentre observational study

INTRODUCTION@#Despite adhering to criteria for extubation, up to 20% of intensive care patients require re-intubation, even with use of post-extubation high-flow nasal cannula (HFNC). This study aims to identify independent predictors and outcomes of extubation failure in patients who failed post-extubation HFNC.@*METHODS@#We conducted a multicentre observational study involving 9 adult intensive care units (ICUs) across 5 public hospitals in Singapore. We included patients extubated to HFNC following spontaneous breathing trials. We compared patients who were successfully weaned off HFNC with those who failed HFNC (defined as re-intubation ≤7 days following extubation). Generalised additive logistic regression analysis was used to identify independent risk factors for failed HFNC.@*RESULTS@#Among 244 patients (mean age: 63.92±15.51 years, 65.2% male, median APACHE II score 23.55±7.35), 41 (16.8%) failed HFNC; hypoxia, hypercapnia and excessive secretions were primary reasons. Stroke was an independent predictor of HFNC failure (odds ratio 2.48, 95% confidence interval 1.83-3.37). Failed HFNC, as compared to successful HFNC, was associated with increased median ICU length of stay (14 versus 7 days, @*CONCLUSION@#Post-extubation HFNC failure, especially in patients with stroke as a comorbidity, remains a clinical challenge and predicts poorer clinical outcomes. Our observational study highlights the need for future prospective trials to better identify patients at high risk of post-extubation HFNC failure.

Effect of acupuncture on diaphragmatic function in patients with AECOPD typeⅡ respiratory failure evaluated by ultrasound detection / 中国针灸

OBJECTIVE@#To observe the therapeutic effect of acupuncture combined with western conventional therapy on type Ⅱ respiratory failure of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and evaluate the effect of acupuncture on diaphragmatic function and prognosis by bedside ultrasound.@*METHODS@#A total of 111 patients with AECOPD type Ⅱ respiratory failure were randomized into an acupuncture group, a conventional treatment group and a non-acupoint acupuncture group, 37 cases in each one. The routine AECOPD nursing care and treatment with western medicine were provided in the 3 groups. Additionally, in the acupuncture group, acupuncture was applied at Dingchuan (EX-B 1), Feishu (BL 13), Taiyuan (LU 9), Danzhong (CV 17) and Zhongwan (CV 12), etc. In the non-acupoint acupuncture group, acupuncture was given at the points 5 to 10 mm lateral to each of the acupoints selected in the acupuncture group. Acupuncture was given once every day, 30 min each time, consecutively for 10 days in the above two groups. Separately, before treatment, on day 3, 7 and 10 of treatment, arterial partial pressure of oxygen (PaO@*RESULTS@#On day 3, 7 and 10 of treatment, PaO@*CONCLUSION@#Acupuncture as adjunctive therapy achieves significant therapeutic effect on AECOPD type Ⅱ respiratory failure. It improves diaphragmatic function, promotes oxygenation and relieves carbon dioxide retention of artery, alleviates clinical symptoms and reduces the time of mechanic ventilation and hospitalization. Besides, the bedside ultrasound detection can objectively reflect the effect of acupuncture on diaphragmatic function in the patients with AECOPD complicated with typeⅡrespiratory failure.

Risk factors for intracranial hemorrhage and mortality in adult patients with severe respiratory failure managed using veno-venous extracorporeal membrane oxygenation / 中华医学杂志(英文版)

BACKGROUND@#Intracerebral hemorrhage (ICH) is one of the most severe complications during veno-venous extracorporeal membrane oxygenation (VV-ECMO). This study aimed to determine the risk factors for ICH and mortality in such patients.@*METHODS@#We analyzed the clinical data of 77 patients who received VV-ECMO due to severe respiratory failure from July 2013 to May 2019 at China-Japan Friendship Hospital. Demographical data, laboratory indices, imaging characteristics, and other clinical information were collected. Multivariable logistic regression analyses were performed to identify risk factors for ICH and mortality.@*RESULTS@#Of 77 patients, 11 (14.3%) suffered from ICH, and 36 (46.8%) survived. The survival rate was significantly lower (18.2% [2/11] vs. 51.5% [34/66], P = 0.040) in patients with ICH than in those without ICH. Multivariable analysis revealed that factors independently associated with ICH were diabetes mellitus (adjusted odds ratio [aOR]: 12.848, 95% confidence interval [CI]: 1.129-146.188, P = 0.040) and minimum fibrinogen during ECMO (aOR: 2.557, 95% CI: 1.244-5.252, P = 0.011). Multivariable analysis showed that factors independently associated with mortality were acute hepatic failure during ECMO (aOR: 9.205, 95% CI: 1.375-61.604, P = 0.022), CO2 retention before ECMO (aOR: 7.602, 95% CI: 1.514-38.188, P = 0.014), and minimum platelet concentration during ECMO (aOR: 0.130, 95% CI: 0.029-0.577, P = 0.007).@*CONCLUSIONS@#Diabetes mellitus and minimum fibrinogen concentration during ECMO are risk factors for ICH in patients with severe respiratory failure managed using VV-ECMO. This indicated that anticoagulants use and nervous system monitoring should be performed more carefully in patients with diabetes when treated with VV-ECMO due to severe respiratory failure.

Response of patients with acute respiratory failure caused by COVID-19 to awake-prone position outside the intensive care unit based on pulmonary involvement

OBJECTIVES: Since there are difficulties in establishing effective treatments for COVID-19, a vital way to reduce mortality is an early intervention to prevent disease progression. This study aimed to evaluate the performance of patients with COVID-19 with acute hypoxic respiratory failure according to pulmonary impairment in the awake-prone position, outside of the intensive care unit (ICU). METHODS: A prospective observational cohort study was conducted on COVID-19 patients under noninvasive respiratory support. Clinical and laboratory data were obtained for each patient before the treatment and after they were placed in the awake-prone position. To identify responders and non-responders after the first prone maneuver, receiver operating characteristic curves with sensitivity and specificity of the PaO2/FiO2 and SpO2/FiO2 indices were analyzed. The maneuver was considered positive if the patient did not require endotracheal intubation for ventilatory assistance. RESULTS: Forty-eight patients were included, and 64.6% were categorized as responders. The SpO2/FiO2 index was effective for predicting endotracheal intubation in COVID-19 patients regardless of lung parenchymal damage (area under the curve 0.84, cutoff point 165, sensitivity 85%, specificity 75%). Responders had better outcomes with lower hospital mortality (hazard ratio [HR]=0.107, 95% confidence interval [CI]: 0.012-0.93) and a shorter length of stay (median difference 6 days, HR=0.30, 95% CI: 0.13-0.66) after adjusting for age, body mass index, sex, and comorbidities. CONCLUSIONS: The awake-prone position for COVID-19 patients outside the ICU can improve oxygenation and clinical outcomes regardless of the extent of pulmonary impairment. Furthermore, the SpO2/FiO2 index discriminates responders from non-responders to the prone maneuver predicting endotracheal intubation with a cutoff under or below 165.

Soporte ventilatorio no invasivo como puente hacia el trasplante pulmonar: reporte de un caso / Bridging to lung transplant using noninvasive ventilatory support: a case report

El soporte ventilatorio no invasivo es una herramienta que ha demostrado mejorar la sobrevida de pacientes con falla muscular de la bomba respiratoria y el manejo de enfermedades pulmonares crónicas, incluso la ventilación no invasiva nocturna ha servido de puente hacia el trasplante pulmonar. Se presenta el caso de una adolescente de 14 años con enfermedad pulmonar crónica hipoxémica severa y falla ventilatoria secundaria, que requirió ventilación prolongada y traqueostomía en espera de trasplante pulmonar. Luego de reevaluar indemnidad de la vía aérea fue decanulada a soporte ventilatorio no invasivo, con uso alternado de mascarilla nasal nocturna y pieza bucal diurna, permitiendo descanso muscular respiratorio eficiente, y mejoría de flujo de tos con técnicas de apilamiento de aire. Este plan permitió una decanulación segura y realizar soporte continuo ventilatorio no invasivo con un programa de rehabilitación cardiorrespiratorio. Generalmente, el soporte ventilatorio no invasivo se utiliza en trastornos primarios de la bomba respiratoria. En este caso, se indicó para enfermedad pulmonar crónica hipoxémica, mostrando claros beneficios con oxigenación adecuada, buen rendimiento cardiovascular con mejor tolerancia al ejercicio y entrenamiento en el escenario de preparación al trasplante pulmonar.

Noninvasive Ventilatory Support has demonstrated to improve survival of patients with ventilatory pump muscle failure and nocturnal noninvasive ventilation is useful in chronic lung disease, even bridging to lung transplant. We present a 14 years old girl with severe hypoxemic chronic lung disease and secondary ventilatory failure, who required continuous long-term ventilation and underwent a tracheostomy waiting for lung transplant. After reevaluated the airway patency the patient was decannulated to Noninvasive Ventilation Support, alternating nocturnal nasal mask with diurnal mouth piece in order to provide efficient respiratory muscle rest, made air stacking and improved cough flow. This plan allows safe decannulation to continuous Noninvasive Ventilatory Support tailoring a rehabilitation cardiorespiratory program. Usually, Noninvasive Ventilation Support is prescribed for primary respiratory pump muscles failure, but in this case, it was applied for a hypoxemic chronic lung disease. Clear benefits were observed leading to appropriate oxygenation, good cardiovascular performance with better tolerance to exercise for training in the preparatory scenario of a lung transplant.

Características clínicas e preditores de ventilação mecânica em pacientes com COVID-19 hospitalizados no sul do país / Clinical characteristics and predictors of mechanical ventilation in patients with COVID-19 hospitalized in Southern Brazil

RESUMO Objetivo: Descrever as características clínicas e os preditores de ventilação mecânica em pacientes adultos internados com COVID-19. Métodos: Conduziu-se um estudo de coorte retrospectiva com inclusão de pacientes hospitalizados entre 17 de março e 3 de maio de 2020, que tiveram o diagnóstico de infecção pelo SARS-CoV-2. As características clínicas e demográficas foram extraídas de registros em prontuário eletrônico. Resultados: Incluíram-se no estudo 88 pacientes consecutivos. A mediana da idade dos pacientes foi de 63 anos (IQR: 49 - 71); 59 (67%) pacientes eram do sexo masculino, 65 (86%) tinham educação universitária e 67 (76%) tinham, no mínimo, uma comorbidade. Dentre eles, 29 (33%) pacientes foram admitidos à unidade de terapia intensiva, 18 (20%) necessitaram de ventilação mecânica e nove (10,2%) morreram durante a hospitalização. O tempo mediano de permanência na unidade de terapia intensiva e o tempo mediano de ventilação mecânica foram, respectivamente, de 23 e 29,5 dias. Idade acima ou igual a 65 anos foi fator de risco independente para ventilação mecânica (RC: 8,4; IC95% de 1,3 - 55,6; valor de p = 0,02). Conclusão: Nossos achados descrevem a primeira onda de pacientes brasileiros hospitalizados por COVID-19. Em nossa população, idade foi o maior preditor de insuficiência respiratória e necessidade de ventilação mecânica.

Abstract Objective: This study aims to describe the clinical characteristics and predictors of mechanical ventilation of adult inpatients with COVID-19 in a single center. Methods: A retrospective cohort study was performed and included adult inpatients hospitalized from March 17th to May 3rd, 2020, who were diagnosed with SARS-CoV-2 infection. Clinical and demographic characteristics were extracted from electronic medical records. Results: Overall, 88 consecutive patients were included in this study. The median age of the patients was 63 years (IQR 49 - 71); 59 (67%) were male, 65 (86%) had a college degree and 67 (76%) had at least one comorbidity. Twenty-nine (33%) patients were admitted to the intensive care unit, 18 (20%) patients needed mechanical ventilation, and 9 (10.2%) died during hospitalization. The median length of stay in the intensive care unit and the median duration of mechanical ventilation was 23 and 29.5 days, respectively. An age ≥ 65 years was an independent risk factor for mechanical ventilation (OR 8.4 95%CI 1.3 - 55.6 p = 0.02). Conclusion: Our findings describe the first wave of Brazilian patients hospitalized for COVID-19. Age was the strongest predictor of respiratory insufficiency and the need for mechanical ventilation in our population.