Comparison of the effectiveness of different high-flow devices in neonatal care

Abstract Objective: To evaluate the success rate of high-flow nasal cannula (HFNC) therapy using an adapted obsolete mechanical ventilator (MV), Optiflow™ and Vapotherm™ in newborns (NBs). Method: This was a retrospective observational study conducted in the neonatal intensive care unit (NICU). The sample comprised NBs who underwent HFNC therapy due to ventilatory dysfunction, for weaning from non-invasive ventilation (NIV), or post-extubation. The three groups, stratified according to gestational age (GA) and birth weight, and corrected GA and weight at the beginning of HFNC use, were as follows: Optiflow ™, Vapotherm ™, and obsolete Mechanical Ventilator (MV) adapted for high flow therapy. Subsequently, the NBs were divided into a success group (SG) and a failure group (FG). HFNC success was defined as a therapy duration exceeding 72 h. Results: A total of 209 NBs were evaluated, with 31.1 % using HFNC due to ventilatory dysfunction, 2.4 % after extubation, and 66.5 % after NIV weaning. HFNC success rate was observed in 90.9 % of the NBs, with no difference between equipment types (Vapotherm ™, Optiflow ™, and adapted VM). Conclusion: Different types of HFNC equipment are equally effective when used in neonatology for respiratory dysfunction, as a method of weaning from NIV and post-extubation. Adapted obsolete MV can be an alternative for HFCN therapy in resource-constrained settings.

Correlation between nasal anatomical characteristics in newborns and short binasal prong dimensions

Abstract Objective: To correlate the nasal anatomical characteristics of newborns with the dimensions of short binasal prongs. Method: Observational, cross-sectional study carried out in two hospitals in southern Brazil. The authors evaluated 1620 newborns with neonatal data and nasal dimensions. To measure the dimensions of the nasal region, the authors considered the width of the medial columella, the right nostril diameter, and the left nostril diameter. These data were correlated with the dimensions of two models of short binasal prongs. Results: Of the total newborns evaluated, 807 were female (49.8%), and 813 were male (50.2%). The majority were white (96.2%). The mean gestational age was 37.4 ± 2.9 weeks, ranging from 22 to 42 weeks. The birth weight was 2946.8 ± 699.3 g, ranging from 490.0 to 4740.0 g. Most of the nasal measures were significantly larger than both prong model measurements. Conclusion: The sizes of short binasal prongs available on the Brazilian market do not match the nasal anatomical characteristics of newborns.

Caracterización de los pacientes con edema agudo del pulmón en el servicio de urgencias

Introducción: El edema agudo del pulmón es una enfermedad frecuente en los pacientes que se presentan en los servicios de urgencias. Objetivo: Caracterizar a los pacientes con edema agudo del pulmón en el servicio de urgencias. Método: Se realizó un estudio descriptivo y transversal en 37 pacientes con edema agudo del pulmón, que asistieron al cuerpo de guardia del Hospital Clinicoquirúrgico Docente Dr. Joaquín Castillo Duany de Santiago de Cuba, desde enero a noviembre de 2019. Las variables estudiadas fueron edad, sexo, estado al egreso y uso de la ventilación no invasiva. Resultados: No hubo diferencias entre ambos sexos, predominaron los mayores de 60 años, que padecían de hipertensión arterial. Se comprobó el poco uso de la ventilación no invasiva o invasiva. Conclusiones: El edema agudo del pulmón es más frecuente en pacientes mayores de 60 años, sin distinción de sexo. La mayoría lo presenta relacionado con la hipertensión arterial y existe un escaso uso de la ventilación no invasiva en estos casos.

Introduction: Acute pulmonary edema is a frequent disease among patients in emergency services. Objective: To characterize patients with acute pulmonary edema who attended the emergency services. Methods: A descriptive and cross-sectional study of 37 patients with acute pulmonary edema who attended the emergency services of Dr. Joaquín Castillo Duany Teaching Clinical Surgical Hospital in Santiago de Cuba was carried out, from January to November 2019. The studied variables were age, sex, alive or dead when discharged, noninvasive ventilation usage. Results: There were no differences between the sexes; there was a prevalence of patients older than 60 years of age, who suffered from hypertension. It was demonstrated low noninvasive or invasive ventilation usage. Conclusions: Acute pulmonary edema is more frequent among patients older than 60 years of age in both sexes. Most of the patients suffered from hypertension and there was a deficit in the implementation of noninvasive ventilation in these cases.

Cambios en Mecánica Respiratoria en Usuarios Pediátricos en Ventilación Mecánica Post Cirugía de Cardiopatía Congénita Sometidos a Kinesiología Respiratoria versus Succión Endotraqueal. Revisión Estructurada / Changes in Respiratory Mechanics in Pediatric Users on Mechanical Ventilation Post Congenital Heart Disease Surgery Undergoing Respiratory Kinesiology versus Endotracheal Suction. Structured Review

Introducción. Las cardiopatías congénitas (CC) en Chile corresponden a la segunda causa de muerte en menores de 1 año, requiriendo cirugías paliativas y/o correctivas el 65% de estas. En el post operatorio frecuentemente se utiliza ventilación mecánica invasiva (VM) y succión endotraqueal (SET) para remover secreciones. Sin embargo, la kinesiología respiratoria (KTR) ha mostrado mejoras significativas en la distensibilidad toracopulmonar (Cest) y resistencia de vía aérea (Rva) en otros grupos de usuarios pediátricos y adultos en VM. Objetivo. Comparar los cambios en la Cest y Rva en usuarios pediátricos en VM post cirugía de cardiopatía congénita (CCC) sometidos a KTR versus SET exclusiva. Métodos. Revisión sistemática de estudios publicados en bases de datos PUBMED, PeDro, Scielo y Google Scholar que comparan el uso de KTR ó SET sobre los cambios en mecánica ventilatoria en usuarios pediátricos en VM post cirugía de cardiopatía congénita, limitados a inglés, español y portugués, excluyendo a sujetos con traqueostomía o con oxigenación por membrana extracorpórea. Se utilizó guía PRISMA para la selección de artículos. Se revisaron 397 artículos y se seleccionó 1 artículo extra de los artículos sugeridos. Se eliminó 1 artículo por duplicidad. Por títulos y resúmenes se seleccionaron 2 artículos, los cuales al leer el texto completo fueron retirados debido a que la población no correspondía a cardiópatas. Resultados. El final de artículos seleccionados fue de 0 artículos, debido a lo cual se removió el operador Booleano "NOT", y se removió la población de cardiopatías. De este modo quedaron 2 artículos seleccionados para la revisión cualitativa final donde se compara KTR versus SET, y KTR en kinesiólogos especialistas y no especialistas, mostrando ambos aumento en la Cest y disminución de la Rva a favor de la KTR, hasta los 30 minutos post intervención. Conclusiones. No se encontraron artículos que demuestren cambios en Cest y Rva con el uso de KTR + SET versus SET exclusiva, en usuarios pediátricos ventilados posterior a CCC. Con la remoción de filtros seleccionamos 2 artículos que demuestran aumento de Cest y disminución de Rva en sujetos pediátricos en VM, uno comparando con SET, y por grupos de especialistas y no especialistas en respiratorio. Se sugieren estudios primarios para evaluar los efectos de esta intervención en esta población.

Introduction. Congenital heart diseases (CHD) are the second general cause for children death under 1 year. In Chile, approximately 65% CHD need surgery, could was palliative or corrective. In the postoperative period, invasive mechanical ventilation (MV) is frequently used as a life support method, but it is associated with complications. Tracheal suction (SET) is regularly used to remove secretions; however, respiratory chest physiotherapy (KTR) has shown significant improvements in thoraco-pulmonary compliance and airway resistance in other groups of pediatrics and adult's users in MV. Objetive. to compare changes in thoraco-pulmonary compliance and airway resistance in pediatric subjects under mechanical ventilation after congenital heart disease surgery comparing chest physiotherapy and exclusive tracheal suction. Methods. systematic review of studies published in PUBMED, PeDro, Scielo and Google Scholar databases who compares KTR or SET use on changes in ventilatory mechanics in pediatric users under MV after congenital heart disease surgery, limited to English, Spanish and Portuguese languages, excluding user with tracheostomy or extracorporeal membrane of oxygenation. It was use the PRISMA guide to articles selection. A search was carried out, with a total of 397 articles reviewed (English: PubMed = 3, PeDro = 8, Scholar = 383; Spanish: Scholar = 3, Scielo = 0; and Portuguese: Scielo = 0). One extra article was selected from the suggested articles, and 1 article was eliminated due to duplication. By titles and abstracts, 2 articles were selected, but the population did not correspond to heart disease. Results. the final selected articles were 0 articles. By this reason, it were removed: Boolean operator "NOT", and congenital heart disease population. Thus, 2 articles were selected for the final qualitative review where it was compares KTR versus SET, and KTR by specialist and non-specialist. Both articles shown improvement in compliance and resistance until 30 minutes post intervention. The CC population was in a 40 to 60% range in both studies. Conclusions. it was no found articles that demonstrate changes in compliance and resistance in the airway with the use of KTR + SET versus exclusive SET in pediatric users after CCC connected to MV. After filter remotion, we found 2 studies shown improves in increase compliance and reduce resistance in pediatric user in MV, ones comparing with SET, and the other one comparing between specialists in respiratory pediatric physiotherapy and not specialists. It suggests to made primary clinical studies about this intervention in CC population.

Real-time changes in rib cage expansion and use of abdominal mechanical stimulation in newborns: a quasi-experimental study / Mudanças na expansibilidade torácica com o uso de estímulo mecânico na região abdominal em recém-nascidos: um estudo quase-experimental

ABSTRACT Objective: To assess the rib cage expansion and respiratory rate in newborns using an abdominal stabilization band. Methods: The study included 32 newborns of both genders, with gestational age between 35 and 41 weeks. The abdominal stabilization band was used for 15 minutes between the xiphoid process and the anterosuperior iliac crest, with an abdominal contention 0.5cm smaller than the abdominal circumference. The rib cage expansion was evaluated by a breathing transducer (Pneumotrace II™) three minutes before using the band, during the use (15 minutes), and ten minutes after removing the band. The Shapiro-Wilk test verified data normality, and the Wilcoxon test compared the variables considering rib cage expansion and respiratory rate. Significance was set to p<0.05. Results: There was an increase in respiratory rate when comparing before and ten minutes after removing (p=0.008) the abdominal stabilization band, as well as when comparing during its use and ten minutes after its removal (p=0.001). There was also an increase in rib cage expansion when comparing before and during the use of the abdominal stabilization band (p=0.005). Conclusions: The use of the abdominal stabilization band promoted an increase in the rib cage expansion and respiratory rate in the assessed newborns and may be a viable option to improve the respiratory kinematics of this population.

RESUMO Objetivo: Avaliar a expansibilidade torácica e a frequência respiratória em recém-nascidos que fizeram uso de uma faixa de estabilização abdominal. Métodos: O estudo incluiu 32 recém-nascidos de ambos os sexos, com idade gestacional entre 35 e 41 semanas. A faixa de estabilização abdominal foi mantida por 15 minutos entre o processo xifoide e a espinha ilíaca anterossuperior, com contenção abdominal 0,5 cm menor do que a circunferência abdominal. A expansibilidade torácica foi avaliada por um transdutor piezoelétrico (Pneumotrace II™) 3 minutos antes do uso da faixa, durante 15 minutos, e 10 minutos após sua retirada. A normalidade das variáveis foi testada pelo teste de Shapiro-Wilk e a análise comparativa da expansibilidade torácica e da frequência respiratória foi realizada por meio do teste t pareado, considerando-se p<0,05. Resultados: Houve aumento da frequência respiratória quando comparados os tempos antes do uso da faixa e 10 minutos após a retirada (p=0,008), bem como quando comparados os tempos durante o uso e 10 minutos após a retirada da faixa (p=0,001). Houve aumento da expansibilidade torácica quando comparados os tempos antes e durante o uso da faixa (p=0,005). Conclusões: O uso da faixa de estabilização abdominal conferiu aumento da expansibilidade torácica e da frequência respiratória nos recém-nascidos estudados, podendo ser uma opção viável para a melhora da cinemática respiratória dessa população.

Contamination of equipment and surfaces in the operating room anesthesia workspace: a cross-sectional study

ABSTRACT BACKGROUND: Contamination of the breathing circuit and medication preparation surface of an anesthesia machine can increase the risk of cross-infection. OBJECTIVE: To evaluate the contamination of the anesthetic medication preparation surface, respiratory circuits, and devices used in general anesthesia with assisted mechanical ventilation. DESIGN AND SETTING: Cross-sectional, quantitative study conducted at the surgical center of a philanthropic hospital, of medium complexity located in the municipality of Três Lagoas, in the eastern region of the State of Mato Grosso do Sul. METHODS: Eighty-two microbiological samples were collected from the breathing circuits. After repeating the samples in different culture media, 328 analyses were performed. RESULTS: A higher occurrence of E. coli, Enterobacter spp., Pseudomonas spp., Staphylococcus aureus, and Streptococcus pneumoniae (P < 0.001) were observed. Variations were observed depending on the culture medium and sample collection site. CONCLUSION: The study findings underscore the inadequate disinfection of the inspiratory and expiratory branches, highlighting the importance of stringent cleaning and disinfection of high-touch surfaces.

Noninvasive mechanical ventilation assistance in amyotrophic lateral sclerosis: a systematic review

ABSTRACT BACKGROUND: Respiratory failure is the most common cause of death in patients with amyotrophic lateral sclerosis (ALS), and morbidity is related to poor quality of life (QOL). Non-invasive ventilation (NIV) may be associated with prolonged survival and QOL in patients with ALS. OBJECTIVES: To assess whether NIV is effective and safe for patients with ALS in terms of survival and QOL, alerting the health system. DESIGN AND SETTING: Systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting standards using population, intervention, comparison, and outcome strategies. METHODS: The Cochrane Library, CENTRAL, MEDLINE, LILACS, EMBASE, and CRD databases were searched based on the eligibility criteria for all types of studies on NIV use in patients with ALS published up to January 2022. Data were extracted from the included studies, and the findings were presented using a narrative synthesis. RESULTS: Of the 120 papers identified, only 14 were related to systematic reviews. After thorough reading, only one meta-analysis was considered eligible. In the second stage, 248 studies were included; however, only one systematic review was included. The results demonstrated that NIV provided relief from the symptoms of chronic hypoventilation, increased survival, and improved QOL compared to standard care. These results varied according to clinical phenotype. CONCLUSIONS: NIV in patients with ALS improves the outcome and can delay the indication for tracheostomy, reducing expenditure on hospitalization and occupancy of intensive care unit beds. SYSTEMATIC REVIEW REGISTRATION: PROSPERO database: CRD42021279910 — https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=279910.

A Simplified Protocol for Tracheostomy Decannulation in Patients Weaned off Prolonged Mechanical Ventilation

Abstract Introduction The criteria for the removal of the tracheostomy tube (decannulation) vary from center to center. Some perform an endoscopic evaluation under anesthesia or computed tomography, which adds to the cost and discomfort. We use a simple two-part protocol to determine the eligibility and carry out the decannulation: part I consists of airway and swallowing assessment through an office-based flexible laryngotracheoscopy, and part II involves a tracheostomy capping trial. Objective The primary objective was to determine the safety and efficacy of the simplified decannulation protocol followed at our center among the patients who were weaned off the mechanical ventilator and exhibited good swallowing function clinically. Methods Of the patients considered for decannulation between November 1st, 2018, and October 31st, 2020, those who had undergone tracheostomy for prolonged mechanical ventilation were included. The efficacy to predict successful decannulation was calculated by the decannulation rate among patients who had been deemed eligible for decannulation in part I of the protocol, and the safety profile was defined by the protocol's ability to correctly predict the chances of risk-free decannulation among those submitted to part II of the protocol. Results Among the 48 patients included (mean age: 46.5 years; male-to-female ratio: 3:1), the efficacy of our protocol in predicting the successful decannulation was of 87.5%, and it was was safe or reliable in 95.45%. Also, in our cohort, the decannulation success and the duration of tracheotomy dependence were significantly affected by the neurological status of the patients. Conclusion The decannulation protocol consisting of office-based flexible laryngotracheoscopy and capping trial of the tracheostomy tube can safely and effectively aid the decannulation process.

Is Incentive Spirometry Superior to Standard Care in Postoperative Cardiac Surgery on Clinical Outcomes and Length of Hospital and Intensive Care Unit Stay? A Systematic Review with Meta-Analysis

ABSTRACT Introduction: Cardiac surgery is a frequent surgical procedure and may present a high risk of complications. Among the prophylactic strategies studied to decrease the rates of negative outcomes, respiratory care seems to reduce pulmonary complications. Incentive spirometry (IS) is a low-cost, respiratory exercise technique, used for the prevention and treatment of postoperative pulmonary complications (PPC). The aim of this review was to evaluate whether IS is superior to respiratory care, mobilization exercises, and noninvasive ventilation on PPC, and clinical outcomes. Methods: Systematic review. Medical Literature Analysis and Retrieval System Online (or MEDLINE®), Embase®, Cochrane Central Register of Controlled Trials (or CENTRAL), Physiotherapy Evidence Database (or PEDro), Cumulative Index of Nursing and Allied Health (or CINAHL®), Latin American and Caribbean Health Sciences Literature (or LILACS), Scientific Electronic Library Online (or SciELO), Allied, Scopus®, and OpenGrey databases, clinical trial registration sites, conferences, congresses, and symposiums were searched. Results: Twenty-one randomized trials and one quasi-randomized trial (1,677 participants) were included. For partial pressure of oxygen (PaO2), IS was inferior to respiratory care (mean difference [MD] -4.48; 95% confidence interval [CI] -8.32 to -0.63). Flow-oriented IS was inferior to respiratory care on PaO2 (MD -4.53; 95% CI -8.88 to -0.18). However, compared to respiratory care, flow-oriented IS was superior on recovery vital capacity. Conclusions: This meta-analysis revealed that IS was not superior to standard respiratory care for PPCs and clinical outcomes, therefore its use should not be widely recommended until further studies with high quality be performed to ensure this clinical guidance.

Single-Lung Ventilation in Infants for Surgical Repair of Coarctation of The Aorta Without Cardiopulmonary Bypass

ABSTRACT Objective: To investigate the effect of improving the operative field and postoperative atelectasis of single-lung ventilation (SLV) in the surgical repair of coarctation of the aorta (CoA) in infants without the use of cardiopulmonary bypass (CPB). Methods: This was a retrospective cohort study. The clinical data of 28 infants (aged 1 to 4 months, weighing between 4.2 and 6 kg) who underwent surgical repair of CoA without CPB from January 2019 to May 2022 were analyzed. Fourteen infants received SLV with a bronchial blocker (Group S), and the other 14 infants received routine endotracheal intubation and bilateral lung ventilation (Group R). Results: In comparison to Group R, Group S exhibited improved exposure of the operative field, a lower postoperative atelectasis score (P<0.001), reduced prevalence of hypoxemia (P=0.01), and shorter durations of operation, mechanical ventilation, and ICU stay (P=0.01, P<0.001, P=0.03). There was no difference in preoperative information or perioperative respiratory and circulatory indicators before SLV, 10 minutes after SLV, and 10 minutes after the end of SLV between the two groups (P>0.05). Intraoperative bleeding, intraoperative positive end-expiratory pressure (PEEP), and systolic pressure gradient across the coarctation after operation were also not different between the two groups (P>0.05). Conclusion: This study demonstrates that employing SLV with a bronchial blocker is consistent with enhanced operative field, reduced operation duration, lower prevalence of intraoperative hypoxemia, and fewer postoperative complications during the surgical repair of CoA in infants without the use of CPB.

Prediction of Vasoactive-Inotropic Score on Prolonged Mechanical Ventilation in Adult Congenital Heart Disease Patients After Surgical Treatment Combined with Coronary Artery Bypass Grafting

ABSTRACT Introduction: This study aimed to investigate the predictive value of the vasoactive-inotropic score (VIS) at different time points for postoperative prolonged mechanical ventilation (PMV) in adult congenital heart disease patients undergoing surgical treatment combined with coronary artery bypass grafting. Methods: Patients were divided into two groups that developed PMV or not. The propensity score matching method was applied to reduce the effects of confounding factors between the two groups. VIS at different time points (VIS at the end of surgery, VIS6h, VIS12h, and VIS12h max) after surgery were recorded and calculated. The value of VIS in predicting PMV was analyzed by the receiver operating characteristic (ROC) curve, and multivariate logistic regression was used to analyze independent risk factors. Results: Among 250 patients, 52 were in the PMV group, and 198 were in the non-PMV group. PMV rate was 20.8%. After propensity score matching, 94 patients were matched in pairs. At each time point, the area under the ROC curve predicted by VIS for PMV was > 0.500, among which VIS at the end of surgery was the largest (0.805). The optimal cutoff point for VIS of 6.5 could predict PMV with 78.7% sensitivity and 72.3% specificity. VIS at the end of surgery was an independent risk factor for PMV (odds ratio=1.301, 95% confidence interval 1.091~1.551, P<0.01). Conclusion: VIS at the end of surgery is an independent predictor for PMV in patients with adult congenital heart disease surgical treatment combined with coronary artery bypass grafting.

Critical speed, thresholds for vo2max and boundaries of the severe exercise intensity domain / Velocidad crítica, vo2máx y límites de el dominio de la intensidad del ejercicio severo / Velocidade crítica, vo2max e limites de o domínio de intensidade de exercício severo

ABSTRACT Introduction: The severe exercise intensity domain can be defined as the range of work rates or speeds over which VO2max can be elicited. Objectives: Our purpose was to determine if critical speed (running analog of critical power) identifies the lower boundary of the severe domain and to identify the upper boundary of the domain. Methods: Twenty-five individuals performed five running tests to exhaustion, each lasting > 2.5 min and < 16 min. The two-parameter speed vs time-to-exhaustion relationship generated values for critical speed and the three-parameter speed vs time-to-reach-VO2max relationship generated values for the threshold speed above which VO2max can be elicited. The relationships were solved to calculate the minimum time needed to elicit VO2max. Results: Critical speed (3.00 ± 0.38 m·s−1) and the threshold speed above which VO2max can be elicited (2.99 ± 0.37 m·s−1) were correlated (r = 0.83, p < 0.01) and did not differ (p = 0.70), confirming critical speed as the lower boundary of the severe domain. The minimum time needed to elicit VO2max (103 ± 7 s) and the associated highest speed at which VO2max can be elicited (4.98 ± 0.52 m·s−1) identified the upper boundary of the severe domain for these participants. Conclusion: The critical power concept, which requires no metabolic measurements, can be used to identify the lowest speed at which VO2max can be elicited. With addition of metabolic measurements, mathematical modeling can also identify the highest speed and shortest exercise duration at which VO2max can be elicited. Evidence Level I; Validating cohort study with good reference standards.

RESUMEN Introducción: El dominio de la intensidad del ejercicio severo se puede definir como el rango de ritmos o velocidades de trabajo sobre las que se puede obtener el VO2max. Objetivos: Nuestro propósito fue determinar si la velocidad crítica (funcionamiento analógico de potencia crítica) identifica el límite inferior del dominio severo e identificar el límite superior del dominio. Métodos: Veinticinco personas realizaron cinco pruebas de carrera hasta el agotamiento, cada una con una duración de > 2,5 min y <16 min. La relación de dos parámetros de velocidad frente a tiempo de agotamiento generó valores para la velocidad crítica y la relación de tres parámetros de velocidad frente a tiempo de alcance de VO2max generó valores para la velocidad umbral por encima del cual se puede obtener el VO2max. Las relaciones se resolvieron para calcular el tiempo mínimo necesario para obtener el VO2max. Resultados: La velocidad crítica (3,00 ± 0,38 m·s−1) y la velocidad umbral por encima de la cual se puede obtener el VO2max (2,99 ± 0,37 m·s−1) se correlacionaron (r = 0,83, p < 0,01) y no difirieron (p = 0,70), lo que confirma la velocidad crítica como el límite inferior del dominio severo. El tiempo mínimo necesario para obtener el VO2max (103 ± 7 s) y la velocidad más alta asociada a la que se puede obtener el VO2max (4,98 ± 0,52 m·s−1) identificaron el límite superior del dominio severo para estos participantes. Conclusión: El concepto de potencia crítica, que no requiere mediciones metabólicas, se puede utilizar para identificar la velocidad más baja a la que se puede obtener el VO2max. Con la adición de mediciones metabólicas, el modelado matemático también puede identificar la velocidad más alta y la duración más corta del ejercicio a la que se puede obtener VO2max. Nivel de Evidencia I; Estudio de cohortes con alto estándar de referencia.

RESUMO Introdução: O domínio de intensidade de exercício severo pode ser definido como a faixa de taxas de trabalho ou velocidades sobre as quais o VO2max pode ser obtido. Objetivos: Nosso propósito foi determinar se a velocidade crítica (execução analógica da potência crítica) identifica o limite inferior do domínio severo e identificar o limite superior do domínio. Métodos: Vinte e cinco indivíduos realizaram cinco testes de corrida até a exaustão, cada um com duração > 2,5 min e < 16 min. A relação velocidade de dois parâmetros contra tempo até a exaustão gerou valores para a velocidade crítica e a relação velocidade de três parâmetros contra tempo para alcançar o VO2max valores gerados para a velocidade limite acima da qual o VO2max pode ser obtido. As relações foram resolvidas para calcular o tempo mínimo necessário para eliciar o VO2max. Resultados: A velocidade crítica (3,00 ± 0,38 m·s−1) e a velocidade limite acima da qual o VO2max pode ser eliciado (2,99 ± 0,37 m·s−1) foram correlacionadas (r = 0,83, p < 0,01) e não diferiram (p = 0,70), confirmando a velocidade crítica como o limite inferior do domínio grave. O tempo mínimo necessário para eliciar o VO2max (103 ± 7 s) e a maior velocidade associada na qual o VO2max pode ser eliciado (4,98 ± 0,52 m·s−1) identificou o limite superior do domínio severo para esses participantes. Conclusão: O conceito de potência crítica, que não requer medidas metabólicas, pode ser usado para identificar a velocidade mais baixa em que o VO2max pode ser eliciado. Com a adição de medidas metabólicas, a modelagem matemática também pode identificar a velocidade mais alta e a duração mais curta do exercício em que o VO2max pode ser obtido. Nível de Evidência I; Estudo de coorte com alto padrão de referência.

Risk factors of mortality among COVID-19 patients receiving non-invasive ventilation at Addis Ababa governmental COVID-19 treatment centers

Introduction: during the global COVID-19 pandemic, non-invasive ventilation has become a widely utilized method for treating patients experiencing acute respiratory failure. Noninvasive pressure ventilation is frequently employed as a standard approach for managing acute respiratory failure resulting from COVID-19 pneumonia, as opposed to invasive ventilation methods. However, there is a lack of research on its effectiveness. Therefore, this study aimed to determine the risk of mortality among COVID-19 patients receiving non-invasive ventilation. Methods: a multi-centric retrospective cross sectional study was conducted on the records of 402 patients at the Eka Kotebe COVID-19 Center, St. Peter COVID-19 Care Center, and Millennium COVID-19 Treatment Center. The systematic random selection technique was employed in order to select the study unit, and data was extracted from patient charts using a pretested method and validated before being entered into Epi-data Manager 4.6 versions. Descriptive, bivariate, and multivariable analyses were performed using binary logistic regression in SPSS 25. In the multivariate logistic regression, a predictor variable was considered to have a significant connection if its p-value was less than 0.05 at a 95% confidence level. Results: four hundred and two patient records were reviewed during the study period and showed the mean patient´s age was 62.6 years, with male predominance. It revealed that 11.7% [CI: 8.7-15.2] of COVID-19 patients who received non-invasive positive pressure ventilation died, as being critical for COVID-19 patients was a main cause of noninvasive initiation. Patients over the age of 60 were more likely to die among those who received noninvasive ventilation for COVID-19 [AOR = 5.4 95% CI 1.32, 23.1]. Conversely, patients without diabetes were less likely to die [AOR = 0.23 95% CI 0.11, 0.48]. Moreover, patients with a tidal volume greater than 500 ml were more likely to pass away [AOR =2.2 95% CI 1.11,4.43], as were those who were on non-invasive ventilation (NIV) for more than 8 days [AOR = 0.24 95% CI.08, 0.81]. Conclusion: the significance of patients who were given non-invasive ventilators ended up dying. Age, diabetes, and high tidal volumes are linked to a higher risk of death. Non-invasive ventilation for over eight days showed a protective effect. Removing factors that caused NIV and ventilated COVID-19 patients' deaths may reduce mortality.

Meta-analysis of efficacy and safety of sedative therapy with midazolam and dexmedetomidine/propofol in critically ill patients undergoing mechanical ventilation / 中国药房

OBJECTIVE To systematically evaluate the efficacy and safety of midazolam and dexmedetomidine/propofol for the sedation of critically ill patients undergoing mechanical ventilation， and to provide evidence-based reference for clinical treatment. METHODS Retrieved from PubMed， Embase， Web of Science， Cochrane Library， Clinical trials. gov， China Journal Full Text Database， Chinese Science and Technology Journal Database， Wanfang database and China Biomedical Literature Database， the data on the efficacy and safety of midazolam and dexmetomidine/propofol for the sedation of critically ill patients undergoing mechanical ventilation were collected from the establishment of the database to March 31， 2023. After extracting data from clinical studies that met the inclusion criteria， the meta-analysis was conducted by using the RevMan 5.3 statistical software. RESULTS A total of 31 literature were included， with a total of 2 765 patients. Results of meta-analysis showed that the mechanical ventilation time [MD＝14.13， 95%CI （13.75， 14.52）， P＜0.000 01] and the length of hospitalization in the intensive care unit [MD＝0.92， 95%CI （0.54， 1.30）， P＜0.000 01] of patients in the midazolam group was longer than dexmedetomidine/ propofol group. The incidence of bradycardia in midazolam group was lower dexmedetomidine/propofol group [OR＝0.60， 95%CI （0.41， 0.90）， P＝0.01]， but there was no statistically significant difference in the incidence of hypotension between the two groups [OR＝0.69， 95%CI （0.47， 1.01）， P＝0.06]. The incidence of delirium [OR＝3.88， 95%CI （2.74， 5.49）， P＜0.000 01]， ventilator- associated pneumonia [OR＝2.32， 95%CI （1.19， 4.51）， P＝0.01]， and respiratory depression [OR＝5.70， 95%CI （3.09， 10.52）， P＜0.000 01] in midazolam group were higher than dexmedetomidine/propofol group. CONCLUSIONS Compared with dexmedetomidine/propofol， midazolam increases patients’ mechanical ventilation time and the length of hospitalization in the intensive care unit in terms of efficacy， and increases the risk of delirium and pulmonary complications in terms of safety， but has a smaller cardiovascular impact.

Influencing factors of survival of patients with airway stenosis requiring clinical interventions after lung transplantation / 器官移植

Objective To analyze the influencing factors of survival of patients with airway stenosis requiring clinical interventions after lung transplantation. Methods Clinical data of 66 patients with airway stenosis requiring clinical interventions after lung transplantation were retrospectively analyzed. Univariate and multivariate Cox’s regression models were adopted to analyze the influencing factors of survival of all patients with airway stenosis and those with early airway stenosis. Kaplan-Meier method was used to calculate the overall survival and delineate the survival curve. Results For 66 patients with airway stenosis, the median airway stenosis-free time was 72 (52,102) d, 27% (18/66) for central airway stenosis and 73% (48/66) for distal airway stenosis. Postoperative mechanical ventilation time [hazard ratio (HR) 1.037, 95% confidence interval (CI) 1.005-1.070, P=0.024] and type of surgery (HR 0.400, 95%CI 0.177-0.903, P=0.027) were correlated with the survival of patients with airway stenosis after lung transplantation. The longer the postoperative mechanical ventilation time, the higher the risk of mortality of the recipients. The overall survival of airway stenosis recipients undergoing bilateral lung transplantation was better than that of their counterparts after single lung transplantation. Subgroup analysis showed that grade 3 primary graft dysfunction (PGD) (HR 4.577, 95%CI 1.439-14.555, P=0.010) and immunosuppressive drugs (HR 0.079, 95%CI 0.022-0.287, P<0.001) were associated with the survival of patients with early airway stenosis after lung transplantation. The overall survival of patients with early airway stenosis after lung transplantation without grade 3 PGD was better compared with that of those with grade 3 PGD. The overall survival of patients with early airway stenosis after lung transplantation treated with tacrolimus was superior to that of their counterparts treated with cyclosporine. Conclusions Long postoperative mechanical ventilation time, single lung transplantation, grade 3 PGD and use of cyclosporine may affect the survival of patients with airway stenosis after lung transplantation.

Effects of esketamine for multimodal analgesia on opioid consumption and gastric motility in mechanically ventilated non-surgical ICU patients / 中国药房

OBJECTIVE To investigate the effects of esketamine for multimodal analgesia on opioid consumption and gastric motility in mechanically ventilated non-surgical intensive care unit （ICU） patients. METHODS Forty cases of mechanically ventilated non-surgical patients in the ICU of our hospital from February 1st， 2023 to July 31st， 2023 were selected and randomly divided into control group and esketamine （S-K） group using grouping method with opaque envelopes， with 20 cases in each group. Control group was given sufentanil， and S-K group was infused with Esketamine hydrochloride injection at a constant rate of 0.2 mg/（kg·h）+ sufentanil. The treatment period length， analgesic compliance rate， sedation level， analgesic and sedative consumption， and gastric motility indexes were compared between the two groups. RESULTS There was no statistically significant difference in the treatment period length， analgesic compliance rate， sedation level， or the consumption of propofol and midazolam between the two groups （P＞0.05）. The consumption of sufentanil in the S-K group was significantly less than control group （P＜ 0.05）. Compared with 1 h after randomization， the antral contraction frequency， antral contraction amplitude and antral motility index of patients in the S-K group were significantly higher at 72 h after randomization and were significantly higher than control group （P＜0.05）. CONCLUSIONS Esketamine may reduce opioid consumption and improve gastric motility in mechanically ventilated non-surgical ICU patients while ensuring a level of analgesic sedation.

Interpretation of 2023 American Heart Association and American Academy of Pediatrics focused update on neonatal resuscitation guidelines / 中国当代儿科杂志

In November 2023, the American Heart Association and the American Academy of Pediatrics jointly released key updates to the neonatal resuscitation guidelines based on new clinical evidence. This update serves as an important supplement to the "Neonatal resuscitation: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care". The aim of this paper is to outline the key updates and provide guidance on umbilical cord management and the selection of positive pressure ventilation equipment and its additional interfaces in neonatal resuscitation.

High-flow nasal cannula and non-invasive mechanical ventilation in pediatric asthma exacerbation: two-year prospective observational study in intensive care / Cánula nasal de alto flujo y ventilación no invasiva en asma pediátrico grave: estudio observacional prospectivo de dos años de duración en cuidados intensivos

Abstract Background: Asthma is a common cause of admission to the pediatric intensive care unit (PICU). We described and analyzed the therapies applied to children admitted to a tertiary PICU because of asthma. Later, we evaluated high-flow nasal cannula (HFNC) use in these patients and compared their evolution and complications with those who received non-invasive ventilation. Methods: We conducted a prospective observational study (October 2017-October 2019). Collected data: epidemiological, clinical, respiratory support therapy needed, complementary tests, and PICU and hospital stay. Patients were divided into three groups: (1) only HFNC; (2) HFNC and non-invasive mechanical ventilation (NIMV); and (3) only NIMV. Results: Seventy-six patients were included (39 female). The median age was 2 years and 1 month. The median pulmonary score was 5. The median PICU stay was 3 days, and the hospital stay was 6 days. Children with HNFC only (56/76) had fewer PICU days (p = 0.025) and did not require NIMV (6/76). Children with HFNC had a higher oxygen saturation/fraction of inspired oxygen ratio ratio (p = 0.025) and lower PCO2 (p = 0.032). In the group receiving both therapies (14/76), NIMV was used first in all cases. No epidemiologic or clinical differences were found among groups. Conclusion: HFNC was a safe approach that did not increase the number of PICU or hospital days. On admission, normal initial blood gases and the absence of high oxygen requirements were useful in selecting responders to HFNC. Further randomized and multicenter clinical trials are needed to verify these data.

Resumen Introducción: El asma es una causa frecuente de ingreso en la unidad de cuidados intensivos pediátricos (UCIP). En este, cuadro el uso de cánula nasal de alto flujo (CNAF) se ha visto extendido. En este trabajo se describe el tratamiento global en la UCIP ante el ingreso por asma en un hospital monográfico pediátrico y se evalúa la respuesta al uso de la CNAF, comparando la evolución de los pacientes con aquellos que recibieron ventilación no invasiva (VNI). Métodos: Se llevó a cabo un estudio observacional prospectivo (de octubre del 2017 a octubre del 2019). Se describieron epidemiología, clínica, tratamiento y soporte respiratorio. Para la comparación se crearon tres grupos de pacientes: 1) solo CNAF; 2) CNAF y VNI; y 3) solo VNI. Resultados: Se incluyeron 76 pacientes. La mediana de edad fue de dos años y un mes; la mediana de índice pulmonar fue 5. La mediana de ingreso en UCIP fue de tres días y de ingreso hospitalario, seis días. Los niños con solo CNAF (56/76) mostraron menos días de UCIP (p = 0.025) y no requirieron VNI (6/76). También mostraron mayor SatO2/FiO2 (saturación de oxígeno/fracción de oxígeno inspirado) (p = 0.025) y menor nivel de PCO2 (presión parcial de CO2) (p = 0.032). La VNI se utilizó primero siempre en el grupo que recibió ambas modalidades (14/76). No se encontraron diferencias epidemiológicas o clínicas entre grupos. Conclusiones: En nuestra serie, el uso de CNAF no aumentó los días de ingreso en la UCIP ni de hospital. Tampoco requirió cambio a VNI. Al ingreso, una gasometría normal y bajo requerimiento de oxígeno permitieron seleccionar a los pacientes respondedores. Se necesitan más ensayos multicéntricos clínicos aleatorizados para verificar estos datos.

Intensivist-led ultrasound-guided percutaneous tracheostomy: a phase IV cohort study / Traqueostomia percutânea guiada por ultrassom conduzida por intensivistas: um estudo de coorte de fase IV

ABSTRACT Objective: To describe, with a larger number of patients in a real-world scenario following routine implementation, intensivist-led ultrasound-guided percutaneous dilational tracheostomy and the possible risks and complications of the procedure not identified in clinical trials. Methods: This was a phase IV cohort study of patients admitted to three intensive care units of a quaternary academic hospital who underwent intensivist-led ultrasound-guided percutaneous tracheostomy in Brazil from September 2017 to December 2021. Results: There were 4,810 intensive care unit admissions during the study period; 2,084 patients received mechanical ventilation, and 287 underwent tracheostomy, 227 of which were performed at bedside by the intensive care team. The main reason for intensive care unit admission was trauma, and for perform a tracheostomy it was a neurological impairment or an inability to protect the airways. The median time from intubation to tracheostomy was 14 days. Intensive care residents performed 76% of the procedures. At least one complication occurred in 29.5% of the procedures, the most common being hemodynamic instability and extubation during the procedure, with only 3 serious complications. The intensive care unit mortality was 29.1%, and the hospital mortality was 43.6%. Conclusion: Intensivist-led ultrasound-guided percutaneous tracheostomy is feasible out of a clinical trial context with outcomes and complications comparable to those in the literature. Intensivists can acquire this competence during their training but should be aware of potential complications to enhance procedural safety.

RESUMO Objetivo: Descrever, com um número maior de pacientes em um cenário do mundo real após a implementação rotineira, a traqueostomia percutânea guiada por ultrassom conduzida por intensivistas e os possíveis riscos e complicações do procedimento não identificados em estudos clínicos. Métodos: Trata-se de estudo de coorte de fase IV de pacientes internados em três unidades de terapia intensiva de um hospital acadêmico quaternário que foram submetidos a traqueostomia percutânea guiada por ultrassom conduzida por intensivistas no Brasil de setembro de 2017 a dezembro de 2021. Resultados: Entre as 4.810 admissões na unidade de terapia intensiva durante o período do estudo, 2.084 pacientes receberam ventilação mecânica, e 287 foram submetidos a traqueostomia, 227 das quais foram realizadas à beira do leito pela equipe de terapia intensiva. O principal motivo para a admissão na unidade de terapia intensiva foi trauma, e para a realização de uma traqueostomia foi comprometimento neurológico ou incapacidade de proteger as vias aéreas. O tempo médio entre a intubação e a traqueostomia foi de 14 dias. Residentes de terapia intensiva realizaram 76% dos procedimentos. Ao menos uma complicação ocorreu em 29,5% dos procedimentos, sendo instabilidade hemodinâmica e extubação durante o procedimento as complicações mais comuns, com apenas três complicações graves. A mortalidade na unidade de terapia intensiva foi de 29,1%, e a mortalidade hospitalar foi de 43,6%. Conclusão: A traqueostomia percutânea guiada por ultrassom conduzida por intensivistas é viável fora do contexto de um estudo clínico com resultados e complicações comparáveis aos da literatura. Os intensivistas podem adquirir essa competência durante seu treinamento, mas devem estar cientes das possíveis complicações para aumentar a segurança do procedimento.

Características de pacientes con SARS-CoV-2 en estado crítico en un centro COVID-19 de referencia en Uruguay

Introducción: la pandemia de COVID-19 produjo una alta mortalidad en el mundo. Sin embargo, las presentaciones más críticas de la enfermedad han sido poco caracterizadas en nuestra región. Objetivo: estudiar la presentación clínica, evolución y mortalidad en pacientes ingresados en la unidad de medicina intensiva de un centro COVID-19 de referencia. Pacientes y método: estudio clínico, prospectivo, observacional de SARS-CoV-2 durante las primeras etapas de la pandemia en Uruguay. Se definió mortalidad en unidad de cuidados intensivos (UCI) como desenlace primario. Resultados: en 274 pacientes, la edad mediana fue de 65 años (IQR 54-73), el sexo masculino representó el 57% y el índice de Charlson tuvo una mediana de 3 (IQR 2-5). La mortalidad en UCI fue 59,9%. Las principales causas de muerte fueron: hipoxemia refractaria, disfunción orgánica múltiple y shock refractario. La edad (Odds Ratio (OR) = 1,06; IC de 95% 1,03 - 1,09), ocupación de camas (OR = 1,04, IC 95%: 1,02 - 1,07), sexo masculino (OR = 2,14, IC 95%: 0,93 - 5,06), ventilación mecánica invasiva (OR = 51,7, IC 95%: 16,5 - 208,6), coinfección al ingreso (OR = 2,34, IC 95%: 0,88 - 6,77) y enfermedad renal crónica previa (OR = 13,1, IC 95%: 2,29 - 129,2) fueron predictores independientes de mortalidad. La primera ola de la pandemia se produjo por la circulación de las variantes P.6 y P.1 del coronavirus, en una población con muy bajo porcentaje de vacunación (8%). Conclusiones: estos resultados en pacientes críticos aportan una descripción detallada del impacto de la pandemia por SARS-CoV-2 en un centro de referencia y constituyen una base para enfrentar futuros eventos epidémicos.

Introduction: COVID-19 has caused high mortality worldwide. However, the most critical presentations of the disease have been poorly characterized in our region. Objective: to study the clinical presentation, progression, and mortality in patients admitted to the Intensive Care Unit (ICU) of a COVID-19 Reference Center. Patients and methods: clinical, prospective, observational study of SARS-CoV-2 during the early stages of the pandemic in Uruguay. ICU mortality was defined as the primary outcome. Results: in 274 patients, the median age was 65 years (IQR 54-73), male gender accounted for 57%, and the Charlson Index was 3 (IQR 2-5). ICU mortality was 59.9%. The main causes of death were refractory hypoxemia, multiple organ dysfunction, and refractory shock. Age (Odds Ratio (OR) = 1.06; 95% CI 1.03 - 1.09), bed occupancy (OR= 1.04, 95% CI: 1.02 -1.07), male gender (OR= 2.14, 95% CI 0.93 - 5.06), invasive mechanical ventilation (OR= 51.7, 95% CI 16.5 - 208.6), coinfection at admission (OR= 2.34, 95% CI 0.88 - 6.77), and pre-existing chronic kidney disease (OR= 13.1, 95% CI 2.29 - 129.2) were independent predictors of mortality. The first wave of the pandemic was driven by the circulation of the P.6 and P.1 variants of the coronavirus in a population with a very low vaccination percentage (8%). Conclusions: these results in critical patients provide a detailed description of the impact of the SARS-CoV-2 pandemic in a reference center and serve as a foundation for addressing future epidemic events.

Introdução: a COVID-19 causou alta morbimortalidade em todo o mundo, embora as formas graves da doença tenham sido pouco caracterizadas nos países da América Latina. Objetivos: analisar o quadro clínico, a evolução e a mortalidade em pacientes com COVID-19 atendidos em uma unidade de terapia intensiva (UTI) em um Centro de Referência. Métodos: Estudo clínico, prospectivo e observacional de pacientes com SARS-CoV-2 durante a primeira onda da pandemia no Uruguai. A mortalidade na UTI foi o resultado primário. Resultados: oram estudados 274 pacientes, com uma mediada de idade de 65 anos (IQR 54-73), sendo a maioria do sexo masculino (57%). O índice de Charlson foi de 3 (IQR 2-5). A mortalidade geral na UTI foi de 59,9%. As principais causas de morte foram hipoxemia refratária, disfunção orgânica múltipla e choque refratário. A idade (Odds Ratio (OR) = 1,06; IC 95% 1,03-1,09), ocupação de leitos (OR = 1,04; IC 95%: 1,02-1,07), sexo masculino (OR = 2,14; IC 95%: 0,93-5,06), ventilação mecânica invasiva (OR = 51,7; IC 95%: 16,5-208,6), coinfecção na admissão (OR = 2,34; IC 95%: 0,88-6,77) e doença renal crônica pré-existente (OR = 13,1; IC 95%: 2,29-129,2) foram preditores independentes de mortalidade. A primeira onda da pandemia foi impulsionada pela circulação das variantes P.6 e P.1 do SARS-CoV-2 em uma população com uma taxa de vacinação muito baixa (8%). Conclusões: esses resultados em pacientes críticos fornecem uma descrição detalhada do impacto da pandemia SARS-CoV-2 em um Centro de Referência e constituem uma base para o enfrentamento de futuros eventos epidêmicos.