Evidence-based practice of non-invasive mechanical ventilation related pressure injury prevention guided by the integrated promoting action on research implementation in health services framework / 中国实用护理杂志

Objective:To use the best evidence of noninvasive mechanical ventilation related pressure injury prevention in the clinic guided by integrated promoting action on research implementation in health services framework (i-PARIHS) and evaluate its effect.Methods:This study is an unsynchronized before and after control study. Convenience sampling method was used to select patients receiving non-invasive mechanical ventilation from 7 wards of Beijing Hospital from October 2019 to September 2021. A total of 575 patients receiving non-invasive mechanical ventilation from October 2019 to September 2020 were included in the control group and 602 patients from October 2020 to September 2021 were included in the trial group. The control group adopted the usual care measures, and the trial group applied the prevention program for noninvasive ventilation related facial pressure injuries. The incidence of pressure injury was compared between the two groups. Nurses in 7 wards were investigated before and after the intervention program to compare the changes of knowledge level.Results:In the control group, there were 354 males, 221 females, aged (77.13 ± 14.49) years old; in the trial group there were 392 males, 210 females, aged (75.60 ± 14.27) years old. The incidence of pressure injury in the trial group was lower than the control group, but showed no significant difference ( P>0.05). In the control group, 11 cases suffered pressure injury, including 5 cases in stage 2, 6 cases in stage 3 and above. There were 9 cases in the trial group, including 8 in stage 2 and 1 in stage 3 and above. The severity of pressure injury in the trial group was lower than that in the control group, and the difference was significant ( χ2 = 3.83, 4.11, both P<0.05). The scores of the nurse′pressure injury knowledge increased from (6.77 ± 1.53) points to (7.15 ± 1.47) points, with a significant difference ( t = -2.31, P<0.05). Conclusions:Management of the prevention of noninvasive mechanical ventilation related facial pressure injury through evidence-based practice can reduce its incidence, reduce its severity, and it is beneficial to improve the clinical nurses' prevention knowledge and clinical practice level of facial pressure injury related to non-invasive mechanical ventilation.

Risk factors for first weaning failure following mandibular distraction osteogenesis in pediatric patients with Pierre Robin sequence: a nested case-control study / 中华麻醉学杂志

Objective:To identify the risk factors for the first weaning failure following mandibular distraction osteogenesis in pediatric patients with Pierre Robin sequence (PRS).Methods:Clinical data of pediatric patients with PRS who underwent mandibular distraction osteogenesis from January 2018 to February 2023 were collected, including sex, age, premature birth, birth weight, surgical weight, cleft palate, syndrome type PRS, laryngeal/tracheobronchial malacia, simple congenital heart disease, complex congenital heart disease, preoperative mechanical ventilation, preoperative pulmonary infection, blood albumin concentration, difficulty in tracheal intubation under a visual laryngoscope, surgical duration, postoperative ventilator-associated pneumonia, duration of mechanical ventilation at first weaning, and traction length at first weaning. Children in whom the first postoperative machine withdrawal failed were included in observation group and matched to control cases(control group) in a 1∶4 ratio. The risk factors of which P values were less than 0.05 would enter the logistic regression analysis to stratify the risk factors for postoperative weaning failure. Results:There were significant differences in birth weight, cleft palate, duration of mechanical ventilation and traction length at first weaning, rate of combined cleft palate, preoperative pulmonary infection rate, rate of preoperative mechanical ventilation, and rate of postoperative ventilator-associated pneumonia between the two groups ( P<0.05). Binary logistic stepwise regression analysis showed that the preoperative mechanical ventilation ( OR=18.154, 95% CI 3.971-82.990, P<0.001) and postoperative ventilator-associated pneumonia ( OR=36.942, 95% CI 1.307-1043.985, P=0.034) were independent risk factors for first weaning failure after mandibular distraction osteogenesis, while birth weight gain ( OR=0.225, 95% CI 0.076-0.668, P=0.007) was a protective factor for first weaning failure ( P<0.05). Conclusions:Preoperative mechanical ventilation and postoperative ventilator-associated pneumonia are independent risk factors and birth weight gain is a protective factor for first weaning failure following mandibular distraction osteogenesis in pediatric patients with PRS.

O Uso de um Ventilador Mecânico Portátil na Ressuscitação Cardiopulmonar é Viável, Melhora os Parâmetros Respiratórios e Previne a Redução da Complacência Pulmonar Dinâmica / Use of a Portable Mechanical Ventilator during Cardiopulmonary Resuscitation is Feasible, Improves Respiratory Parameters, and Prevents the Decrease of Dynamic Lung Compliance

Resumo Fundamentos Para ventilação prática e protetora durante a ressuscitação cardiopulmonar (RCP), desenvolveu-se um ventilador mecânico (VLP2000E) de 150 gramas que limita o pico de pressão inspiratória (PPI) durante ventilação e compressões torácicas simultâneas. Objetivos Avaliar a viabilidade da ventilação com VLP2000E durante RCP e comparar os parâmetros monitorados versus ventilação com bolsa-válvula. Métodos Estudo experimental randomizado com 10 porcos intubados por grupo. Após sete minutos de fibrilação ventricular, iniciaram-se ciclos de RCP de 2 minutos. Todos os animais foram ventilados com VLP2000E após o retorno da circulação espontânea (RCE). Resultados Os grupos bolsa-válvula e VLP2000E apresentaram taxa de RCE (60% vs. 50%, respectivamente) e saturação arterial de oxigênio similares na maioria dos ciclos de RCP, volume corrente basal diferente [0,764 (0,068) vs. 0,591 (0,123) L, p = 0,0309, respectivamente] e, em 14 ciclos, diferentes PPI [52 (9) vs. 39 (5) cm H2O, respectivamente], volume corrente [0,635 (0,172) vs. 0,306 (0,129) L], ETCO2 [14 (8) vs. 27 (9) mm Hg], e pico de fluxo inspiratório [0,878 (0,234) vs. 0,533 (0,105) L/s], todos p < 0,0001. A complacência pulmonar dinâmica (≥ 0,025 L/cm H2O) diminuiu após o RCE no grupo bolsa-válvula, mas se manteve no grupo VLP2000E [ 0,019 (0,006) vs. 0,024 (0,008) L/cm H2O, p = 0,0003]. Conclusões Ventilação com VLP2000E durante RCP é viável e equivalente a ventilação com bolsa-válvula quanto à taxa de RCE e saturação arterial de oxigênio. Esse ventilador produz melhores parâmetros respiratórios, com pressão das vias aéreas e volume corrente menores. Ventilação com VLP2000E também previne a redução significante da complacência pulmonar dinâmica observada após ventilação com bolsa-válvula. Seria interessante realizar mais estudos pré-clínicos para confirmar esses resultados.

Abstract Background For practical and protective ventilation during cardiopulmonary resuscitation (CPR), a 150-grams mechanical ventilator (VLP2000E) that limits peak inspiratory pressure (PIP) during simultaneous ventilation with chest compressions was developed. Objectives To evaluate the feasibility of VLP2000E ventilation during CPR and to compare monitored parameters versus bag-valve ventilation. Methods A randomized experimental study with 10 intubated pigs per group. After seven minutes of ventricular fibrillation, 2-minute CPR cycles were delivered. All animals were placed on VLP2000E after achieving return of spontaneous circulation (ROSC). Results Bag-valve and VLP2000E groups had similar ROSC rate (60% vs. 50%, respectively) and arterial oxygen saturation in most CPR cycles, different baseline tidal volume [0.764 (0.068) vs. 0.591 (0.123) L, p = 0.0309, respectively] and, in 14 cycles, different PIP [52 (9) vs. 39 (5) cm H2O, respectively], tidal volume [0.635 (0.172) vs. 0.306 (0.129) L], ETCO2[14 (8) vs. 27 (9) mm Hg], and peak inspiratory flow [0.878 (0.234) vs. 0.533 (0.105) L/s], all p < 0.0001. Dynamic lung compliance (≥ 0.025 L/cm H2O) decreased after ROSC in bag-valve group but was maintained in VLP2000E group [0.019 (0.006) vs. 0.024 (0.008) L/cm H2O, p = 0.0003]. Conclusions VLP2000E ventilation during CPR is feasible and equivalent to bag-valve ventilation in ROSC rate and arterial oxygen saturation. It produces better respiratory parameters, with lower airway pressure and tidal volume. VLP2000E ventilation also prevents the significant decrease of dynamic lung compliance observed after bag-valve ventilation. Further preclinical studies confirming these findings would be interesting.

Desarrollo de ventiladores mecánicos en Chile. Crónica de la iniciativa "Un Respiro para Chile", durante la primera ola de la pandemia COVID-19 / Development of mechanical ventilators in Chile. Chronicle of the initiative "Un Respiro para Chile"

At the beginning of the COVID-19 pandemic in Chile, in March 2020, a projection indicated that a significant group of patients with pneumonia would require admission to an Intensive Care Unit and connection to a mechanical ventilator. Therefore, a paucity of these devices and other supplies was predicted. The initiative "Un respiro para Chile" brought together many people and institutions, public and private. In the course of three months, it allowed the design and building of several ventilatory assistance devices, which could be used in critically ill patients.

Parametrização dos alarmes de frequência respiratória em ventiladores mecânicos de pacientes durante o banho / Parameterization of respiratory rate alarms in mechanical ventilators of patients during the bath / Parametrización de las alarmas de frecuencia respiratoria en ventiladores mecánicos de pacientes durante el baño

RESUMO Objetivo: medir os efeitos da parametrização dos alarmes sonoros de frequência respiratória dos ventiladores mecânicos para redução do número de alarmes disparados durante o banho no leito. Método: ensaio clínico pragmático, para comparar o número de alarmes do ventilador mecânico nos grupos: intervenção - os alarmes de Frequência Respiratória foram parametrizados no início do banho; controle - não realizada parametrização. Estudo registrado em 27/08/2019 no Registro Brasileiro de Ensaios Clínicos, RBR-6y6tyc, Rio de Janeiro, Brasil. Resultados: os modelos de regressão evidenciaram que a parametrização, realizada e mantida durante e após o banho no grupo intervenção, teve o efeito de aumentar 12,5 e 6,4 vezes, respectivamente, o número médio de disparos de alarmes de frequência respiratória alta; e não teve efeito nos alarmes de frequência respiratória baixa. Conclusão: a contribuição deste estudo é auxiliar os profissionais de saúde na formulação de protocolos de parametrização individualizada dos alarmes dos Ventiladores Mecânicos.

ABSTRACT Objective: to measure the effects of parameterizing the audible respiratory rate alarms of mechanical ventilators to reduce the number of alarms triggered during bed bath. Method: pragmatic clinical trial, to compare the number of alarms of the mechanical ventilator, in the groups: intervention - the Respiratory Rate alarms were parameterized at the beginning of the bath; control - no parameterization performed. Study registered on 27/08/2019 in the Brazilian Registry of Clinical Trials, RBR-6y6tyc, Rio de Janeiro, Brazil. Results: Regression models showed that parameterization, performed and maintained during and after bath in the intervention group, had the effect of increasing the average number of high respiratory rate alarm triggers by 12.5 and 6.4 times, respectively; and had no effect on low respiratory rate alarms. Conclusion: The contribution of this study is to assist health professionals in formulating protocols for individualized parameterization of alarms for Mechanical Ventilators.

RESUMEN Objetivo: medir los efectos de la parametrización de las alarmas sonoras de frecuencia respiratoria de los ventiladores mecánicos para reducir el número de alarmas disparadas durante el baño en cama. Método: ensayo clínico pragmático, para comparar el número de alarmas del ventilador mecánico en los grupos: intervención - se parametrizaron las alarmas de Frecuencia Respiratoria al inicio del baño; control - no se realizó parametrización. Estudio registrado el 27/08/2019 en el Registro Brasileño de Ensayos Clínicos, RBR-6y6tyc, Río de Janeiro, Brasil. Resultados: Los modelos de regresión mostraron que la parametrización, realizada y mantenida durante y después del baño en el grupo de intervención, tuvo el efecto de aumentar 12,5 y 6,4 veces, respectivamente, el número medio de disparos de alarmas de frecuencia respiratoria alta; y no tuvo ningún efecto sobre las alarmas de frecuencia respiratoria baja. Conclusión: la contribución de este estudio es ayudar a los profesionales de la salud en la formulación de protocolos para la parametrización individual de las alarmas de los Ventiladores Mecánicos.

The clinical observation on mechanical ventilation combined with different doses of sildenafil in the treatment of persistent pulmonary hypertension of newborn / 中国医师进修杂志

Objective:To observe the efficacy and safety of mechanical ventilation combined with different doses of sildenafil in the treatment of persistent pulmonary hypertension of newborn (PPHN).Methods:A total of 160 children with PPHN admitted to Dezhou Maternal and Child Health Hospital from January 2018 to December 2019 were selected and divided into group A, B, C and D by random stratification, with 40 cases in each group. All the children in the group were actively corrected for acidosis, provided with intravenous nutrition support, warmth, anti-infection and other measures, and adopted ventilator to assist mechanical ventilation. Group A, B, and C were given different doses of sildenafil 0.5, 1.0, and 2.0 mg/(kg·time) respectively, while group D was not given sildenafil treatment, but only mechanical ventilation. Blood gas analysis indexes including partial arterial oxygenpressure (PaO 2), partial arterial carbon dioxide pressure (PaCO 2), saturationoxygen (SaO 2), and pulmonary artery pressure (SPAP), systemic blood pressure (SBP) of children were tested before the treatment and 72 h after the treatment. The treatment time, hospitalization time, hospitalization expenses and the incidence of adverse reactions of mechanical ventilation in 4 groups were recorded and compared. Results:The effective rate in the group A, B and C was higher than that in the group D: 80.0%(32/40), 85.0%(34/40), 87.5%(35/40) vs. 57.5%(23/40), the difference was statistically significant ( P<0.05). Before treatment, the levels of blood gas analysis indexes in 4 groups had no significant differences ( P>0.05). After treatment, the level of PaO 2 in the group A, B and C was significantly higher than that in the group D ( P<0.05), the level of PaCO 2 in the group B and C was significantly lower than that in group D ( P<0.05), and the level of SaO 2 in the group B and C was significantly higher than that in the group D ( P<0.05). After treatment, the level of SPAP in group B and C was significantly lower than that in the group D: (28.56 ± 3.93), (27.14 ± 3.32) mmHg(1 mmHg = 0.133 kPa) vs. (33.57 ± 4.68) mmHg, P<0.05, and the level of SBP in 4 groups had no significant difference ( P>0.05). The hospitalization time and mechanical ventilation time in group A, B and C were significantly shorter than those in group D ( P<0.05). No drug-related adverse reactions, pulmonary hemorrhage, hypotension, arrhythmia, pneumothorax and other complications occurred during the treatment in the 4 groups. Conclusions:Mechanical ventilation combined with sildenafil can significantly reduce pulmonary artery pressure and improve pulmonary oxygenation in children with PPHN. In the range of 0.5 - 1.0 mg/kg, the efficacy is more obvious when increasing the dose of sildenafil.

Parametrização dos alarmes de frequência respiratória em ventiladores mecânicos de pacientes durante o banho / Parameterization of respiratory rate alarms in mechanical ventilators of patients during the bath / Parametrización de las alarmas de frecuencia respiratoria en ventiladores mecánicos de pacientes durante el baño

RESUMO Objetivo: medir os efeitos da parametrização dos alarmes sonoros de frequência respiratória dos ventiladores mecânicos para redução do número de alarmes disparados durante o banho no leito. Método: ensaio clínico pragmático, para comparar o número de alarmes do ventilador mecânico nos grupos: intervenção - os alarmes de Frequência Respiratória foram parametrizados no início do banho; controle - não realizada parametrização. Estudo registrado em 27/08/2019 no Registro Brasileiro de Ensaios Clínicos, RBR-6y6tyc, Rio de Janeiro, Brasil. Resultados: os modelos de regressão evidenciaram que a parametrização, realizada e mantida durante e após o banho no grupo intervenção, teve o efeito de aumentar 12,5 e 6,4 vezes, respectivamente, o número médio de disparos de alarmes de frequência respiratória alta; e não teve efeito nos alarmes de frequência respiratória baixa. Conclusão: a contribuição deste estudo é auxiliar os profissionais de saúde na formulação de protocolos de parametrização individualizada dos alarmes dos Ventiladores Mecânicos.

ABSTRACT Objective: to measure the effects of parameterizing the audible respiratory rate alarms of mechanical ventilators to reduce the number of alarms triggered during bed bath. Method: pragmatic clinical trial, to compare the number of alarms of the mechanical ventilator, in the groups: intervention - the Respiratory Rate alarms were parameterized at the beginning of the bath; control - no parameterization performed. Study registered on 27/08/2019 in the Brazilian Registry of Clinical Trials, RBR-6y6tyc, Rio de Janeiro, Brazil. Results: Regression models showed that parameterization, performed and maintained during and after bath in the intervention group, had the effect of increasing the average number of high respiratory rate alarm triggers by 12.5 and 6.4 times, respectively; and had no effect on low respiratory rate alarms. Conclusion: The contribution of this study is to assist health professionals in formulating protocols for individualized parameterization of alarms for Mechanical Ventilators.

RESUMEN Objetivo: medir los efectos de la parametrización de las alarmas sonoras de frecuencia respiratoria de los ventiladores mecánicos para reducir el número de alarmas disparadas durante el baño en cama. Método: ensayo clínico pragmático, para comparar el número de alarmas del ventilador mecánico en los grupos: intervención - se parametrizaron las alarmas de Frecuencia Respiratoria al inicio del baño; control - no se realizó parametrización. Estudio registrado el 27/08/2019 en el Registro Brasileño de Ensayos Clínicos, RBR-6y6tyc, Río de Janeiro, Brasil. Resultados: Los modelos de regresión mostraron que la parametrización, realizada y mantenida durante y después del baño en el grupo de intervención, tuvo el efecto de aumentar 12,5 y 6,4 veces, respectivamente, el número medio de disparos de alarmas de frecuencia respiratoria alta; y no tuvo ningún efecto sobre las alarmas de frecuencia respiratoria baja. Conclusión: la contribución de este estudio es ayudar a los profesionales de la salud en la formulación de protocolos para la parametrización individual de las alarmas de los Ventiladores Mecánicos.

Ventilación en posición prona en el manejo de pacientes con síndrome de dificultad respiratoria aguda / Prone ventilation in the management of patients with acute respiratory distress syndrome

INTRODUCCIÓN. El posicionamiento prono es una de las estrategias ventilatorias más estudiadas y difundidas de la medicina intensiva, forma parte del manejo de ventilación protectiva con impacto en disminución de la mortalidad en pacientes con síndrome de dificultad respiratoria aguda. OBJETIVO. Revisar la evidencia disponible acerca de ventilación en posición prona en pacientes con síndrome de dificultad respiratoria aguda, enfocada en el análisis fisiopatológico y clínico. MATERIALES Y MÉTODOS. Se realizó una revisión bibliográfica en la base de datos de buscadores académicos como PubMed, Google Scholar y Elsevier, en los idiomas español e inglés, en el período comprendido entre los años 1970-2020; se seleccionaron 16 publicaciones en texto completo: 3 metaanálisis, 10 estudios randomizado, 3 revisiones sistemáticas. CONCLUSIÓN. En base a la evidencia y percepción recopilada de la experiencia de los autores, la ventilación en posición prona es una estrategia de manejo de primera línea, fiable, que no requiere para su empleo equipamiento costoso ni complejo y ha demostrado mejoría en desenlaces relevantes en el tratamiento del paciente crítico respiratorio como disminución en la mortalidad y optimización de los parámetros ventilatorios y de oxigenación.

INTRODUCTION. Prone positioning is one of the most studied and widespread ventilatory strategies in intensive medicine, it is part of protective ventilation management with an impact on mortality reduction in patients with acute respiratory distress syndrome. OBJECTIVE. To review the available evidence about ventilation in the prone position in patients with acute respiratory distress syndrome, focused on the pathophysiological and clinical analysis. MATERIALS AND METHODS. A bibliographic review was carried out in the databases of academic search engines such as PubMed, Google Scholar and Elsevier, in the Spanish and English languages, in the period between the years 1970-2020, 16 full text publications were selected: 3 meta-analyses, 10 randomized studies, 3 systematic reviews. CONCLUSION. Based on the evidence and perception gathered from the authors' experience, prone ventilation is a reliable first-line management strategy that does not require costly or complex equipment for its use and has demonstrated improvements in relevant outcomes in the treatment of the critically ill respiratory patient, such as decreased mortality and optimization of ventilatory and oxygenation parameters.

A Estratégia Saúde da Família como indicador para o enfrentamento da COVID-19 em Santa Catarina, Brasil / The Family Health Strategy as an indicator for coping with COVID-19 in Santa Catarina, Brazil

Objetivo: analisar relação entre a cobertura pela Estratégia de Saúde da Família e a disponibilidade de respiradores com a taxa de contágio e mortalidade da COVID-19 no Estado de Santa Catarina, Brasil. Materiais e métodos: trata-se de um estudo ecológico, que utiliza modelos computacionais de análise geoespacial sobre o avanço do COVID-19 nos 295 municípios de Santa Catarina. Resultados: o Estado apresentou casos em todos os municípios, e uma taxa de infecção por Covid-19 de 1,63%. No modelo de regressão realizado, a cobertura pela Estratégia de Saúde da Família apresentou correlação com a mortalidade e a taxa de infecção pela Covid-19. A quantidade de respiradores apresentou correlação com a mortalidade. Conclusão: em Santa Catarina a Estratégia de Saúde da Família e a compra de novos respiradores, apresentam-se como aliados no enfrentamento à COVID 19..Au

Objective: to relate the coverage by the FHS and the availability of respirators with the transmission and mortality rate of COVID-19 in the state of Santa Catarina, Brazil. Materials and methods: this is an ecological study, which uses computational models of geospatial analysis on the progress of COVID-19 to the 295 cities in Santa Catarina. The correlation between the FHS coverage and the number of respirators grouped in the mesoregions was calculated with the COVID-19 transmission and mortality rates. Results: the state had low infection rates of 0.07% and mortality of 1.72%, when compared to Brazil. There was an increase in cases in smaller municipalities, indicating the interiorization of the pandemic. There was no correlation between FHS coverage with infection and mortality. However, respirators are associated with lower mortality. Conclusion: regional disparity was found in the presence of respirators in the state's micro-regions, suggesting an imbalance in the quality of care for critically ill patients during the pandemic..Au

Clinical study on Qingfei-Xiaoyan Decoction combined with anti infective mechanical ventilation in the treatment of senile severe pneumonia / 国际中医中药杂志

Objective:To evaluate the clinical efficacy of Qingfei-Xiaoyan Decoction combined with anti infective mechanical ventilation in the treatment of senile severe pneumonia. Methods:A total of 102 patients with severe pneumonia in our hospital from June 2018 to May 2021 who met the inclusion criteria were randomly divided into two groups by random number table method, with 51 in each group. The control group was treated with anti-infection mechanical ventilation, and the study group was treated with Qingfei-Xiaoyan Decoction on the basis of the control group. Both groups were treated for 2 weeks. TCM syndrome scores were performed before and after treatment. The severity of infection was evaluated by clinical pulmonary infection score (CPIS), FVC, FEV1 and peak expiratory flow (PEF) were detected by pulmonary function meter, and the levels of TNF-α, high mobility group box 1 (HMGB1) and CRP were detected by enzyme-linked immunosorbent assay, adverse events were recorded and clinical efficacy was evaluated. Results:The total effective rate was 94.1% (48/51) in the study group and 80.4% (41/51) in the control group, and there was significant difference between the two groups ( χ2=4.320, P=0.038). After treatment, the TCM syndrome score and CPIS score of the study group were significantly lower than those of the control group ( t values were 14.203 and 11.403, respectively, all Ps<0.01), FVC, FEV1 and PEF in the study group were significantly higher than those in the control group ( t values were 4.663, 3.451 and 13.220, respectively, all Ps<0.01), and the levels of serum CRP, TNF-α and HMGB1 in the study group were significantly lower than those in the control group ( t values were 14.672, 10.277 and 24.453, respectively, all Ps<0.01). During the treatment, no serious adverse reactions occurred in both groups. Conclusions:Qingfei-Xiaoyan Decoction combined with anti-infective mechanical ventilation has a significant effect in the treatment of senile severe pneumonia. It can alleviate clinical symptoms, improve lung function, reduce inflammatory reaction with safety.

The effects of positive end-expiratory pressure on central venous pressure in patients with different chest wall elastic resistance / 中华内科杂志

Objective:To investigate the role of chest wall elastic resistance in determining the effects of positive end-expiratory pressure (PEEP) on central venous pressure (CVP) in patients with mechanical ventilation (MV).Methods:In this prospective study, according to the median of ratio of chest wall elastic resistance to respiratory system elastic resistance (Ers), patients were divided into high chest wall elastic resistance group (Ecw/Ers≥0.24) and low chest wall elastic resistance group [elastance of chest wall (Ecw)/Ers<0.24]. PEEP was set at 5, 10, 15 cmH 2O (1 cmH 2O=0.098 kPa) respectively. Clinical data including CVP, heart rate (HR), blood pressure (BP) and respiratory mechanics were recorded. Results:Seventy patients receiving MV were included from November 2017 to December 2018. Clinical characteristics including age, BP, HR, baseline PEEP, the ratio of arterial oxygen partial pressure to fractional inspired oxygen (P/F) and comorbidities were comparable in two groups. However, patients with high Ecw/Ers ratio presented higher body mass index (BMI) than those with low Ecw/Ers ratio[ (25.4±3.2) kg/m 2 vs. (23.4±3.2) kg/m 2, P=0.011]. As PEEP increased from 5 cmH 2O to 10 cmH 2O, CVP in high Ecw/Ers group increased significantly compared with that in low Ecw/Ers group [1.75(1.00, 2.13) mmHg (1 mmHg=0.133kPa) vs. 1.50(0.50, 2.00)mmHg, P=0.038], which was the same as PEEP increased from 10 cmH 2O to 15 cmH 2O [2.00(1.50, 3.00)mmHg vs. 1.50(1.00, 2.00)mmHg, P=0.041] or PEEP increased from 5 cmH 2O to 15 cmH 2O [ 3.75(3.00,4.63)mmHg vs. 3.00(1.63, 4.00)mmHg, P=0.012]. When PEEP increased from 5 cmH 2O to 10 cmH 2O, 10 cmH 2O to 15 cmH 2O and 10 cmH 2O to 15 cmH 2O, there were significant correlations between Ecw/Ers and CVP elevation ( r=0.29, P=0.016; r=0.31, P=0.011; r=0.31, P=0.01 respectively). Conclusions:In patients receiving mechanical ventilation, elevation of PEEP leads to a synchronous change of CVP, which is corelated with patients′ chest wall elastic resistances.

Effects of propofol on inflammatory response and activation of p38 MAPK signaling pathway in rats with ventilator-induced lung injury

ABSTRACT Purpose: To investigate the effects of propofol on inflammatory response and activation of p38 mitogen-activated protein kinase (MAPK) signaling pathway in rats with ventilator-associated lung injury (VALI). Methods: Thirty-six Sprague Dawley (SD) rats were divided into control, VALI and VALI+propofol groups. The VALI group received the mechanical ventilation for 2 h. The VALI+propofol group received the mechanical ventilation for 2 h, which was accompanied by intravenous injection of propofol with dose of 8 mg·kg-1·h-1. At the end, the mean arterial pressure (MAP) and blood gas indexes were measured, and the lung wet/dry mass ratio (W/D) and biochemical indexes of lung tissue and bronchoalveolar lavage fluid (BALF) were determined. Results: Compared with VALI group, in VALI+propofol group the blood pH, partial pressure of oxygen, partial pressure of carbon dioxide and MAP were increased, the lung W/D, lung tissue myeloperoxidase activity and total protein concentration, white blood cell count, and tumor necrosis factor α, interleukin 1β and interleukin 6 levels in BALF were decreased, and the p-p38 MAPK protein expression level and phosphorylated p38 MAPK (p-p38 MAPK)/p38 MAPK ratio were decreased. Conclusions: Propofol treatment may alleviate the VALI in rats by reducing the inflammatory response and inhibiting the activation of p38 MAPK signaling pathway.

Ventilator-associated pneumonia in patients on prolonged mechanical ventilation: description, risk factors for mortality, and performance of the SOFA score / Pneumonia associada à ventilação mecânica em pacientes em ventilação mecânica prolongada: descrição, fatores de risco associados à mortalidade e desempenho do escore SOFA

ABSTRACT Objective: Ventilator-associated pneumonia (VAP) is a serious complication of mechanical ventilation (MV). However, data on VAP in patients on prolonged MV (PMV) are scarce. We aimed to describe the characteristics of VAP patients on PMV and to identify factors associated with mortality. Methods: This was a retrospective cohort study including VAP patients on PMV. We recorded baseline characteristics, as well as 30-day and 90-day mortality rates. Variables associated with mortality were determined by Kaplan-Meier survival analysis and Cox regression model. Results: We identified 80 episodes of VAP in 62 subjects on PMV. The medians for age, Charlson Comorbidity Index, SOFA score, and days on MV were, respectively, 69.5 years, 5, 4, and 56 days. Episodes of VAP occurred between days 21 and 50 of MV in 28 patients (45.2%) and, by day 90 of MV, in 48 patients (77.4%). The 30-day and 90-day mortality rates were 30.0% and 63.7%, respectively. There were associations of 30-day mortality with the SOFA score (hazard ratio [HR] = 1.30; 95% CI: 1.12-1.52; p < 0.001) and use of vasoactive agents (HR = 4.0; 95% CI: 1.2-12.9; p = 0.02), whereas 90-day mortality was associated with age (HR = 1.03; 95% CI: 1.00-1.05; p = 0.003), SOFA score (HR = 1.20; 95% CI: 1.07-1.34; p = 0.001), use of vasoactive agents (HR = 4.07; 95% CI: 1.93-8.55; p < 0.001), and COPD (HR = 3.35; 95% CI: 1.71-6.60; p < 0.001). Conclusions: Mortality rates in VAP patients on PMV are considerably high. The onset of VAP can occur various days after MV initiation. The SOFA score is useful for predicting fatal outcomes. The factors associated with mortality could help guide therapeutic decisions and determine prognosis.

RESUMO Objetivo: A pneumonia associada à ventilação mecânica (PAVM) é uma séria complicação da ventilação mecânica (VM). Entretanto, dados sobre PAVM em pacientes em VM prolongada (VMP) são escassos. Nosso objetivo foi descrever as características de pacientes com PAVM em VMP e identificar fatores associados à mortalidade. Métodos: Estudo de coorte retrospectivo incluindo pacientes com PAVM em VMP. Foram registradas características basais, bem como as taxas de mortalidade em 30 e 90 dias. As variáveis associadas à mortalidade foram determinadas por meio da análise de sobrevida de Kaplan-Meier e do modelo de regressão de Cox. Resultados: Foram identificados 80 episódios de PAVM em 62 indivíduos em VMP. As medianas de idade, índice de comorbidade de Charlson, pontuação no SOFA, e dias em VM foram, respectivamente, de 69,5 anos, 5, 4 e 56 dias. Os episódios de PAVM ocorreram entre o 21º e o 50º dia de VM em 28 pacientes (45,2%) e até o 90º dia de VM em 48 pacientes (77,4%). As taxas de mortalidade em 30 e 90 dias foram de 30,0% e 63,7%, respectivamente. A mortalidade em 30 dias associou-se a pontuação no SOFA (razão de risco [RR] = 1,30; IC95%: 1,12-1,52; p < 0,001) e uso de drogas vasoativas (RR = 4,0; IC95%: 1,2-12,9; p = 0,02), enquanto a mortalidade em 90 dias associou-se a idade (RR = 1,03; IC95%: 1,00-1,05; p = 0,003), pontuação no SOFA (RR = 1,20; IC95%: 1,07-1,34; p = 0,001), uso de drogas vasoativas (RR = 4,07; IC95%: 1,93-8,55; p < 0,001) e DPOC (RR = 3,35; IC95%: 1,71-6,60; p < 0,001). Conclusões: As taxas de mortalidade em pacientes com PAVM em VMP são consideravelmente altas. O início da PAVM pode ocorrer vários dias após a instituição da VM. O escore SOFA é útil para predição de desfechos fatais. Os fatores associados à mortalidade podem ajudar a orientar as decisões terapêuticas e a determinar o prognóstico.

Uso de máquina de anestesia como ventilador mecánico en pacientes COVID-19 en Áreas Críticas del Hospital de Especialidades Carlos Andrade Marín / Use of anesthesia machine as a mechanical ventilator in COVID-19 patient in Critical Areas of Carlos Andrade Marín Specialty Hospital

1. INTRODUCCIÓNLa pandemia ocasionada por el Corona-virus tipo 2 del Síndrome Respiratorio Agudo Grave (SARSCoV-2) en la actua-lidad, anticipa una demanda de ventila-dores mecánicos, la Organización Mun-dial de la Salud (OMS), reporta que el 5% de los contagiados cae de forma rápida en insuficiencia respiratoria y requiere de cuidados intensivos1-3. La Food and Drug Administration (FDA), quien aprobó de manera temporal el uso de la Máquina de Anestesia (MA) como Ventilador Mecánico (VM) y la American Society of Anesthesiologists (ASA) junto con la Anesthesia Patient Safety Founda-tion (APSF), publicaron una declaración donde se reconoció que las máquinas de anestesia no están diseñadas para entregar apoyo ventilatorio a largo plazo, sin em-bargo, se han transformado en la primera línea natural de apoyo durante la pan-demia cuando no hay suficientes ventila-dores en áreas críticas hospitalarias1,2,4.Países como Chile por medio de la So-ciedad de Anestesiología de Chile (SACHA), ha puesto en práctica estas recomendaciones previo a un informe técnico. De igual manera en la Unidad Técnica de Anestesiología y a través de este protocolo se procura estandarizar el manejo de la MA con varias recomenda-ciones, para que puedan ser utilizadas en forma segura y efectiva, dado que el uso de las máquinas de anestesia como VM "es una maniobra de salvataje"2. De esta manera se pretende entregar li-neamientos para dar asistencia ventila-toria a pacientes que requieren ventilación mecánica por un cuadro positivo para In-fección por Coronavirus-19 (COVID-19) utilizando una MA, ante la imposibilidad de disponer de un Ventilador de Cuidados Intensivos (VCI).

1. INTRODUCTIONThe pandemic caused by the Severe Acute Respiratory Syndrome (SARSCoV-2) Coronavirus type 2, currently anticipates a demand for mechanical ventilators, the World Health Organization (WHO), re-ports that 5% of infected people rapidly fall into respiratory failure and require in-tensive care1-3 .The Food and Drug Administration (FDA), which temporarily approved the use of the Anesthesia Machine (AM) as a Mechanical Ventilator (MV). The Ame-rican Society of Anesthesiologists (ASA) together with the Anesthesia Patient Safety Foundation (APSF), issued a state-ment acknowledging that anesthesia ma-chines are not designed to deliver long-term ventilation support, however, they have become the first natural line of su-pport during the pandemic, when there are not enough ventilators in critical hos-pital areas1,2,4.Countries such as Chile, through the Society of Anesthesiology of Chile (SACHA), have implemented these re-commendations prior to a technical report. Similarly, in the Technical Unit of Anesthesiology and through this protocol, it is trying to standardize the management of AM with several recommendations, so they can be used in the safest and most effective way, since the use of anesthesia machines as a MV "is a dangerous ma-neuver"2.In this way, guidelines are provided to in order to give mechanical ventilation as-sistance the patients who required me-chanical ventilation due to one posi-tive picture of Coroanvirus-19 Infection (COVID-19) using an AM, given the im-possibility of having an Intensive Care Ventilator (IVC).

Desafios para o desenvolvimento de ventiladores alternativos de baixo custo durante a pandemia de COVID-19 no Brasil / Challenges for the development of alternative low-cost ventilators during COVID-19 pandemic in Brazil

RESUMO A pandemia por COVID-19 tem deixado os gestores, os profissionais de saúde e a população preocupados com a potencial escassez de ventiladores pulmonares para suporte de pacientes graves. No Brasil, há diversas iniciativas com o intuito de produzir ventiladores alternativos para ajudar a suprir essa demanda. Para auxiliar as equipes que atuam nessas iniciativas, são expostos alguns conceitos básicos sobre fisiologia e mecânica respiratória, os termos comumente utilizados no contexto da ventilação mecânica, as fases do ciclo ventilatório, as diferenças entre disparo e ciclagem, os modos ventilatórios básicos e outros aspectos relevantes, como mecanismos de lesão pulmonar induzida pela ventilação mecânica, pacientes com drive respiratório, necessidade de umidificação de vias aéreas, risco de contaminação cruzada e disseminação de aerossóis. Após a fase de desenvolvimento de protótipo, são necessários testes pré-clínicos de bancada e em modelos animais, a fim de determinar a segurança e o desempenho dos equipamentos, seguindo requisitos técnicos mínimos exigidos. Então, é imprescindível passar pelo processo regulatório exigido pela Agência Nacional de Vigilância Sanitária (ANVISA). A empresa responsável pela fabricação do equipamento deve estar regularizada junto à ANVISA, que também deve ser notificada da condução dos testes clínicos em humanos, seguindo protocolo de pesquisa aprovado pelo Comitê de Ética em Pesquisa. O registro do ventilador junto à ANVISA deve ser acompanhado de um dossiê, composto por documentos e informações detalhadas neste artigo, que não tem o propósito de esgotar o assunto, mas de nortear os procedimentos necessários.

ABSTRACT The COVID-19 pandemic has brought concerns to managers, healthcare professionals, and the general population related to the potential mechanical ventilators' shortage for severely ill patients. In Brazil, there are several initiatives aimed at producing alternative ventilators to cover this gap. To assist the teams that work in these initiatives, we provide a discussion of some basic concepts on physiology and respiratory mechanics, commonly used mechanical ventilation terms, the differences between triggering and cycling, the basic ventilation modes and other relevant aspects, such as mechanisms of ventilator-induced lung injury, respiratory drive, airway heating and humidification, cross-contamination risks, and aerosol dissemination. After the prototype development phase, preclinical bench-tests and animal model trials are needed to determine the safety and performance of the ventilator, following the minimum technical requirements. Next, it is mandatory going through the regulatory procedures as required by the Brazilian Health Regulatory Agency (Agência Nacional de Vigilância Sanitária - ANVISA). The manufacturing company should be appropriately registered by ANVISA, which also must be notified about the conduction of clinical trials, following the research protocol approval by the Research Ethics Committee. The registration requisition of the ventilator with ANVISA should include a dossier containing the information described in this paper, which is not intended to cover all related matters but to provide guidance on the required procedures.

Toma de decisiones y consideraciones éticas en el soporte ventilatorio en áreas críticas hospitalarias en el contexto de pandemia COVID-19 / Decision-making and ethical considerations in ventilatory support in critical hospital areas in the context of the COVID-19 pandemic

Objetivo. Los recursos hospitalarios resultan insuficientes ante la demanda de pacientes graves con COVID-19. La adecuada gestión de recursos es esencial para brindar la mejor atención posible. Se revisaron criterios que ayuden a tomar decisiones adecuadas y oportunas, siguiendo principios éticos. La priorización del soporte ventilatorio invasivo debe hacerse de manera transparente y objetiva, evaluando integralmente al paciente y basado en criterios objetivos como escalas de pronóstico, ciclo de vida o compromiso clínico. El tratamiento sintomático (incluyendo cuidados paliativos) es indispensable en esta pandemia y la comunicación con el aciente o la familia permiten humanizar la atención del personal de salud.

Objetive. Hospital resources are insufficient given the demand for seriously ill patients with COVID-19. Proper resource management is essential to provide the best possible care. Criteria to help make appropriate and timely decisions were reviewed, following ethical principles. The prioritization of invasive ventilatory support must be done in a transparent and objective manner, comprehensively evaluating the patient and based on objective criteria such as prognostic scales, life cycle or clinical commitment. Symptomatic treatment (including palliative care) is essential in this pandemic and communication with the patient or family makes it possible to humanize the care of health personnel.

Comparação entre técnicas de higiene brônquica em pacientes mecanicamente ventilados: ensaio clínico randomizado / Comparison of bronchial hygiene techniques in mechanically ventilated patients: a randomized clinical trial

RESUMO Objetivo: Comparar a eficiência das técnicas de vibrocompressão e hiperinsuflação com ventilador mecânico de forma isolada e a associação das duas técnicas (hiperinsuflação com ventilador mecânico + vibrocompressão), na quantidade de secreção aspirada e na alteração de parâmetros hemodinâmicos e pulmonares. Métodos: Ensaio clínico randomizado com pacientes críticos em ventilação mecânica, realizado na unidade de terapia intensiva de um hospital universitário. Os pacientes foram randomizados para receber uma das técnicas de higiene brônquica por 10 minutos (vibrocompressão, ou hiperinsuflação com ventilador mecânico, ou hiperinsuflação com ventilador mecânico + vibrocompressão). Após, foram novamente randomizados para receber inicialmente a técnica (previamente randomizada) ou apenas a aspiração isolada. Foram analisados o peso de secreção aspirada (em gramas), dados de mecânica ventilatória e cardiopulmonares, antes e após a aplicação das técnicas. A frequência de reintubação traqueal, o tempo de ventilação mecânica e a mortalidade, também foram avaliados. Resultados: Foram incluídos 93 pacientes (29 vibrocompressão, 32 hiperinsuflação com ventilador mecânico e 32 hiperinsuflação com ventilador mecânico + vibrocompressão) em ventilação mecânica por mais de 24 horas. O grupo hiperinsuflação com ventilador mecânico + vibrocompressão foi o único que apresentou aumento significativo da secreção aspirada, quando comparado a aspiração isolada 0,7g (0,1 - 2,5g) versus 0,2g (0,0 - 0,6g), com valor de p = 0,006. Conclusão: Quando comparada à aspiração isolada, a associação das técnicas hiperinsuflação com ventilador mecânico + vibrocompressão foi mais eficiente na quantidade de secreção aspirada.

ABSTRACT Objective: To compare the effects of vibrocompression and hyperinflation with mechanical ventilator techniques alone and in combination (hyperinflation with mechanical ventilator + vibrocompression) on the amount of aspirated secretion and the change in hemodynamic and pulmonary parameters. Methods: A randomized clinical trial with critically ill patients on mechanical ventilation conducted in the intensive care unit of a university hospital. The patients were randomly allocated to receive one of the bronchial hygiene techniques for 10 minutes (vibrocompression or hyperinflation with mechanical ventilator or hyperinflation with mechanical ventilator + vibrocompression). Afterwards, the patients were again randomly allocated to receive either the previous randomly allocated technique or only tracheal aspiration. The weight of aspirated secretions (in grams), ventilatory mechanics and cardiopulmonary data before and after the application of the techniques were analyzed. The tracheal reintubation frequency and time and mortality on mechanical ventilation were also evaluated. Results: A total of 93 patients (29 vibrocompression, 32 hyperinflation with mechanical ventilator and 32 hyperinflation with mechanical ventilator + vibrocompression) on mechanical ventilation for more than 24 hours were included. The hyperinflation with mechanical ventilator + vibrocompression group was the only one that presented a significant increase in aspirated secretions compared to tracheal aspiration alone [0.7g (0.1 - 2.5g) versus 0.2g (0.0 - 0.6g), p value = 0.006]. Conclusion: Compared to tracheal aspiration alone, the combination of hyperinflation with mechanical ventilator + vibrocompression techniques was most efficient for increasing the amount of aspirated secretions.

Application effect of noninvasive mechanical ventilation in chronic obstructive pulmonary disease patients with respiratory failure / 中国基层医药

Objective@#To explore the application effect of noninvasive mechanical ventilation in chronic obstructive pulmonary disease(COPD) patients with respiratory failure.@*Methods@#From April 2016 to October 2017, 150 COPD patients with respiratory failure in Ningbo Geriatric Rehabilitation Hospital were selected, and they were divided into observation group and control group by using the random number table method, with 75 cases in each group.The control group was treated with conventional comprehensive therapy, the observation group was treated with noninvasive mechanical ventilation method on the basis of the control group.The clinical effect of the two groups was compared.@*Results@#In the observation group, the RR, HR and arterial blood PaCO2 were significantly better than those in the control group(t=13.29, 12.48, 13.42, all P<0.05). The PaO2, pH value in the observation group were significantly higher than those in the control group(t=5.91, 2.88, all P<0.05). The total effective rate of the observation group was 97.33%(73/75), which was higher than 73.33%(55/75) of the control group, the difference was statistically significant(χ2=1.81, P<0.05).@*Conclusion@#Application of noninvasive mechanical ventilation in COPD patients with respiratory failure can significantly improve respiratory function, and not only effectively shorten the treatment time, but also improve the treatment effect, and it is worthy of clinical promotion.

Effect of NIPPV in the treatment of AECOPD complicated with type Ⅱ respiratory failure and its influence on blood gas index / 中国基层医药

Objective To investigate the effect of noninvasive positive pressure ventilation(NIPPV) in the treatment of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) complicated with type Ⅱ respiratory failure and its influence on blood gas index.Methods From August 2014 to December 2016,the clinical data of 79 patients with AECOPD complicated with type Ⅱ respiratory failure in the Central Hospital of Shanxi Coal were retrospectively analyzed.The patients were divided into two groups according to different treatment methods.Thirty-five patients in the control group were treated with conventional therapy,44 patients in the observation group were treated with conventional NIPPV.The blood gas index,nutritional index,plasma N-terminal brain natriuretic peptide precursor(NT-proBNP),lactate (Lac) and the changes of procalcitonin (PCT),soluble myeloid cell trigger receptor-1 (sTREM-1) level were compared between the two groups.Results There were no statistically significant differences in respiratory frequency,blood gas index and APACHE Ⅱ score between the two groups before treatment(P =0.282,0.177,0.485,0.472,0.485).The levels of pH (7.41 ± 0.07) and PaO2 [(82.30 ± 6.99)mmHg] in the observation group were higher than those in the control group(t =9.357,5.328,P =0.000,0.000).The respiratory frequency [(20.02 ± 2.15) times/min],PaCO2 [(52.36 ± 5.15) mmHg] and APACHE Ⅱ score[(18.20 ± 1.01) points] in the observation group were lower than those in the control group(t =7.782,10.608,9.360,P =0.000,0.000,0.000).There were no statistically significant differences between the two groups in the levels of nutritional indicators before treatment (t =0.027,0.039,0.068,P =0.488,0.485,0.473).After treatment,the serum total protein level in the observation group was higher than that in the control group,but the levels of serum albumin and hemoglobin had no statistically significant differences compared with those in the control group (t =3.606,1.659,0.034,P =0.000,0.051,0.486).There were no statistically significant differences in the levels of Lac,NT-proBNP,inflammatory factors between the two groups before treatment(P =0.465,0.477,0.451,0.493).The levels of Lac [(1.57 ± 0.55) mmol/L],NT-proBNP [(130.25 ± 42.36) ng/L],PCT [(0.16 ± 0.09) g/L],sTREM-1 [(66.36 ± 12.87) ng/L] in the observation group were lower than those in the control group (t =7.662,2.248,4.030,2.709,P =0.000,0.014,0.000,0.004).After treatment,the respiratory rate,blood gas index and APACHE Ⅱ score of the two groups were improved compared with those of the control group (all P ＜ 0.05).The respiratory rate per minute,pH,PaO2,PaCO2 and APACHE Ⅱ scores in the observation group were better than those in the control group(all P ＜ 0.05).The levels of serum total protein,hemoglobin and Lac,NT-proBNP,inflammatory factors in the two groups were lower than those before treatment,and the levels of serum total protein and Lac,NT-proBNP,PCT,sTREM-1 in the observation group were higher than those in the control group (all P ＜ 0.05).The serum albumin level in the control group after treatment was lower than that before treatment,and there was no statistically significant difference between the two groups after treatment (P ＞ 0.05).Conclusion NIPPV in the treatment of AECOPD complicated with type Ⅱ respiratory failure can effectively improve the blood gas status and nutritional status of patients,and reduce the body Lac and NT-proBNP levels.