Perfil del lactante con insuficiencia respiratoria que se beneficia del uso de cánula nasal de alto flujo, Bogotá - Colombia / Profile of the infant with respiratory failure benefited from the high flow nasal cannula, Bogota ­ Colombia

OBJETIVO: el propósito de este estudio fue determinar los principales desenlaces clínicos en lactantes con insuficiencia respiratoria aguda (IRA), tratados con cánula nasal de alto flujo (CNAF) en una unidad de cuidado intensivo pediátrico (UCIP). MATERIALES Y MÉTODOS: se realizó un estudio observacional descriptivo de cohorte histórica, se reclutaron niños entre 1 y 24 meses que ingresaron a la UCIP de un hospital de referencia con diagnóstico de IRA (Julio 1, 2016 a junio 30, 2017) tratados con CNAF como terapia inicial. Los datos extraídos incluyeron variables demográficas, clínicas y principales desenlaces. RESULTADOS: se identificaron 112 casos que cumplieron los criterios de inclusión durante el periodo del estudio. El diagnóstico más frecuente fue neumonía multilobar (41%), seguido por bronquiolitis (34%). Se encontró que el 22.4% de los niños poseía alguna comorbilidad, siendo la más frecuente la displasia broncopulmonar. El virus más frecuentemente aislado fue el virus sincitial respiratorio (VSR) en el 37.5% de los casos. De los 112 pacientes, 59 niños (53%) requirieron intubación traqueal. Los factores asociados con el riesgo de intubación fueron el diagnóstico de neumonía multilobar, el uso de sedación, el aislamiento de VSR y el sexo femenino. CONCLUSIONES: la CNAF es un sistema de soporte respiratorio no invasivo, seguro, bien tolerado y capaz de disminuir la necesidad de intubación y los días de estancia en cuidado intensivo. En niños con IRA, el diagnóstico de neumonía multilobar, la necesidad de sedación, la presencia de comorbilidades asociadas y el sexo femenino son factores asociados con la necesidad de requerir ventilación mecánica invasiva.

OBJECTIVE: the purpose of this study was to determine the main clinical outcomes in infants with acute respiratory failure (ARF), treated with a high-flow nasal cannula (CNAF) in a pediatric intensive care unit (PICU). MATERIALS AND METHODS: a retrospective observational study was conducted on a cohort of children between 1 and 24 months of age who were admitted to the PICU entered UCIP of a referral hospital with a diagnosis of ARF treated with CNAF as initial therapy. The data extracted included demographic and clinical variables and main outcomes. RESULTS: 112 cases were identified that met the inclusion criteria during the study period. The most frequent diagnosis was pneumonia (41%), followed by bronchiolitis (34%). It was found that 22.4% of the children had some comorbidity, the most frequent being bronchopulmonary dysplasia. The most frequently isolated virus was respiratory syncytial virus (RSV) in 37.5% of the cases. Of the 112 patients, 59 children (53%) required tracheal intubation. The factors associated with the risk of intubation were the diagnosis of pneumonia, the use of sedation, the isolation of RSV and the female gender. CONCLUSIONS: CNAF is a non-invasive respiratory support system, capable of reducing the need for intubation and days of stay in intensive care. In children with ARF, the diagnosis of pneumonia, the need for sedation, the presence of associated comorbidities, and the female gender are factors associated with the need to require invasive mechanical ventilation.

Evidencia disponible sobre el abordaje terapéutico de pacientes con COVID-19: una revisión narrativa / Available evidence regarding therapeutic approach of patients with COVID-19: a narrative review

La ausencia de tratamiento específico para COVID-19 demanda una revisión dinámica de la evidencia científica disponible que permita un manejo dirigido a lograr la mejoría clínica, reducción de complicaciones y una menor mortalidad. Los factores independientes de riesgo asociados a mayor mortalidad, falla ventilatoria y necesidad de ventilación mecánica incluyen edad avanzada, enfermedades crónico-degenerativas, obesidad, elevación de ferritina, LDH, ALT y AST, marcadores de incremento en la generación de trombina, datos de daño cardiaco (elevación de troponinas y NT-pro-BNP) y niveles de IL-6 elevados. En ausencia de antivirales de acción directa, el abordaje terapéutico temprano con terapia anti-IL-6, la supresión de la cascada inflamatoria y transducción de señales mediante uso de glucocorticoides, la profilaxis trombótica y anticoagulación, así como la inhibición de la trombogénesis y noxa cardiaca con el uso de colchicina, pueden ser considerados hasta el momento como medidas plausibles en el manejo de los pacientes con COVID-19 en estado moderado y grave. Remdesivir puede considerarse para el tratamiento de pacientes con lesión pulmonar severa sin falla ventilatoria, tras evidencia sólida que ha demostrado mejoría clínica y reducción de mortalidad. En el subgrupo de pacientes graves y bajo ventilación mecánica, el uso de plasma de paciente convaleciente ha producido mejoría clínica, aunque la evidencia es limitada. La pronación en el paciente despierto y bajo ventilación mecánica puede considerarse como medida para mejorar la oxigenación con poca influencia sobre la mortalidad. Esta revisión plantea las medidas terapéuticas disponibles al momento y la estratificación de riesgo para el manejo de pacientes con infección por SARS-CoV-2.

The absence of a specific treatment for COVID-19 demands a dynamic review of the available scientific evidence that allows a management aimed at achieving clinical improvement, reduction of complications, and lower mortality. Independent risk factors associated with increased respiratory failure, mechanical ventilation requirement, and mortality include older age, chronic illness, obesity, ferritin, LDH, ALT, and AST elevation, thrombin release markers, cardiac damage markers (troponins and NT-proBNP elevation) and elevated levels of IL-6. In the absence of specific antiviral agents, the early treatment of mild to severe COVID-19 using IL-6 inhibitors, suppression of inflammatory cascade and signal transduction by using glucocorticoids, use of antithrombotic prophylaxis and anticoagulation, as well as thrombogenesis and cardiac damage inhibition by using colchicine, could be considered as a plausible route. Another drug to be considered in patients with severe lung injury without respiratory failure is remdesivir, which has shown substantial evidence reducing mortality and clinical improvement. In severe COVID-19 and in those that require ventilatory assistance, convalescent plasma use has resulted in clinical improvement despite limited evidence. Prone positioning in awake and intubated patients might be considered to improve oxygenation with scarce effect on mortality. The present review aims to expose the current therapeutic options and risk stratification course for the management of SARS-CoV-2 positive patients.

Protocolo COVID-19: Manejo hospitalario del paciente con enfermedad moderada grave / COVID-19 Protocol: Hospital Management of the Patient with Moderately Severe Illness

Elaborados por MSPAS y asociaciones de médicos especialistas en mayo del 2020 y actualizados en julio del mismo año, estos protocolos pretenden orientar a los profesionales a cargo de la atención de pacientes moderados y críticos con COVID-19. Esta seccionado en una parte general, que incluye los síntomas de las condiciones de alto riesgo, flujogramas y detalles de lo que puede presentarse, así como la sección de adultos, niños y mujeres embarazadas. El estudio afirma que, "el 14% acaba presentando un cuadro grave que requiere hospitalización y oxigenoterapia, y el 5% tiene que ser ingresado en una unidad de cuidados intensivos" Incluye flujogramas de Factores de Riesgo en Paciente Adulto y Mujer Embarazada por categorías, así como notas, comentarios y recomendaciones de los médicos participantes.

Costo efectividad y análisis de impacto presupuestario del óxido nítrico inhalatorio neonatal en un hospital, desde la perspectiva del sistema público de salud / Cost effectiveness and budget impact analysis of inhaled nitric oxide in a neonatal unit from the perspective of the public health system

El óxido nítrico inhalatorio (ONi) es actualmente la terapia de primera línea en la insuficiencia respiratoria hipoxémica grave del recién nacido; la mayor parte de los centros neonatales de regiones en Chile no cuentan con esta alternativa terapéutica. Objetivo: Determinar el costo-efectividad del ONi en el tratamiento de la insuficiencia respiratoria asociada a hipertensión pulmonar del recién nacido, comparado con el cuidado habitual y el traslado a un centro de mayor complejidad. Pacientes y método: Se modeló un árbol de decisiones clínicas desde la perspectiva del sistema de salud público chileno, se calcularon razones de costo-efectividad incremental (ICER), se realizó análisis de sensibilidad determinístico y probabilístico, se estimó el impacto presupuestario, software: TreeAge Health Care Pro 2014. Resultados: La alternativa ONi produce un aumento promedio en los costos de 11,7 millones de pesos por paciente tratado, con una razón de costo-efectividad incremental comparado con el cuidado habitual de 23 millones de pesos por muerte o caso de oxigenación extracorpórea evitada. Al sensibilizar los resultados por incidencia, encontramos que a partir de 7 casos tratados al año resulta menos costoso el óxido nítrico que el traslado a un centro de mayor complejidad. Conclusiones: Desde la perspectiva de un hospital regional chileno incorporar ONi en el manejo de la insuficiencia respiratoria neonatal resulta la alternativa óptima en la mayoría de los escenarios posibles.

Inhaled nitric oxide (iNO) is currently the first-line therapy in severe hypoxaemic respiratory failure of the newborn. Most of regional neonatal centres in Chile do not have this therapeutic alternative. Objective: To determine the cost effectiveness of inhaled nitric oxide in the treatment of respiratory failure associated with pulmonary hypertension of the newborn compared to the usual care, including the transfer to a more complex unit. Patients and method: A clinical decision tree was designed from the perspective of Chilean Public Health Service. Incremental cost effectiveness rates (ICER) were calculated, deterministic sensitivity analysis was performed, and probabilistic budget impact was estimated using: TreeAge Pro Healthcare 2014 software. Results: The iNO option leads to an increase in mean cost of $ 11.7 million Chilean pesos (€ 15,000) per patient treated, with an ICER compared with the usual care of $ 23 million pesos (€ 30,000) in case of death or ECMO avoided. By sensitising the results by incidence, it was found that from 7 cases and upwards treated annually, inhaled nitric oxide is less costly than the transfer to a more complex unit. Conclusions: From the perspective of a Chilean regional hospital, incorporating inhaled nitric oxide into the management of neonatal respiratory failure is the optimal alternative in most scenarios.

Laparoscopic guided local injection in the X-linked muscular dystrophy mouse (mdx) diaphragm. An advance in experimental therapies for Duchenne Muscular Dystrophy

PURPOSE: To investigate the development of a laparoscopy technique for local injection into the X-linked muscular dystrophy (mdx) diaphragm. METHODS: It was used 10 mice Balb/C57 and 5 mdx mice and three differents decubitus type were tested: the right lateral, supine, and supine decubitus with 20 degrees elevation of the forelimb. Abdominal caudal face and the 10 intercostal space were tested as spot to introduce the needle into the diaphragm. RESULTS: Supine position with elevation of 20 degrees forelimb and the 10th intercostal space are the beneficial position to apply a local injection. CONCLUSION: It was proved to be possible to perform the laparoscopy technique in the X-linked muscular dystrophy diaphragm and this requires a specific position and technique during the surgery. .

effects of surfactant on oxygenation in term infants with respiratory failure

The objective of the study was to evaluate the effects of exogenous surfactant on respiratory indices in term infants with respiratory failure. Consecutive 18 mechanically ventilated term infants, who received a single dose of exogenous surfactant were retrospectively included into the study. The respiratory outcome of surfactant rescue therapy was evaluated by comparing respiratory indices before and six hours after surfactant administration. Median oxygenation index [OI], mean alveolar pressure [MAP] and fraction of inspired oxygen [FiO[2]] values were significantly decreased [P<0.001]; median arterial oxygen partial pressure [PaO[2]], arterial oxygen saturation [SaO[2]] and PaO[2]/FiO[2] values were significantly increased six hours after surfactant treatment [P<0.001]. Rescue therapy with surfactant was found to be effective in the improvement of early respiratory indices in term infants with respiratory failure

Donepezil reverses buprenorphine-induced central respiratory depression in anesthetized rabbits

Buprenorphine is a mixed opioid receptor agonist-antagonist used in acute and chronic pain management. Although this agent's analgesic effect increases in a dose-dependent manner, buprenorphine-induced respiratory depression shows a marked ceiling effect at higher doses, which is considered to be an indicator of safety. Nevertheless, cases of overdose mortality or severe respiratory depression associated with buprenorphine use have been reported. Naloxone can reverse buprenorphine-induced respiratory depression, but is slow-acting and unstable, meaning that new drug candidates able to specifically antagonize buprenorphine-induced respiratory depression are needed in order to enable maximal analgesic effect without respiratory depression. Acetylcholine is an excitatory neurotransmitter in central respiratory control. We previously showed that a long-acting acetylcholinesterase inhibitor, donepezil, antagonizes morphine-induced respiratory depression. We have now investigated how donepezil affects buprenorphine-induced respiratory depression in anesthetized, paralyzed, and artificially ventilated rabbits. We measured phrenic nerve discharge as an Índex of respiratory rate and amplitude, and compared discharges following the injection of buprenorphine with discharges following the injection of donepezil. Buprenorphine-induced suppression of the respiratory rate and respiratory amplitude was antagonized by donepezil (78.4 ± 4.8 percent, 92.3 percent ± 22.8 percent of control, respectively). These findings indicate that systemically administered donepezil restores buprenorphine-induced respiratory depression in anesthetized rabbits.

Mortalidad en prematuros tratados con surfactante exógeno / Mortality in premature infants treated with exogenous surfactant

Objective: Characterize mortality and associated factors in Chilean prematures born < 32 weeks of gestational age (GA) and treated with exogenous surfactant. Method: Cohort of newborns (n = 2 868) registered between 1998-2005 in the database of the Surfactant National Program. The association of gestational and neonatal variables with mortality was estimated through survival analysis and logistic regression. Results: Global mortality was 35 percent, varying by GA from 86.7 percent (< 25 weeks) to 12.6 percent (32 weeks). There was a clear decrease of mortality during the study period, along with a fall in the gestational age and birth weight (BW) of the patients who died (1 021 g +/- 295 to 854 g +/- 258) and GA (27.7 +/- 2.1 to 26.5 +/- 23) during this period. Pulmonary hemorrhage (PH) was the most important factor associated to mortality, so we decided to stratify the analysis by this condition. In children with PH, the mortality estimated risk lower as the GA increased (OR= 0.73; CI95 0.57-0.93) and every 100 g of additional BW (OR= 0.74; CI95 0.63-0.88). Children not affected by PH also had their OR diminished with major GA (OR= 0.82; CI95 0.76-0.90) and more BW (OR= 0.84; CI95 0.79 - 0.89). In addition, the OR decreased with better Apgar 5 min score (OR= 0.80; CI95 0.75-0.85), use of prenatal corticoids (OR= 0.71; CI95 0.56-0.90) and was higher in boys (OR= 1.36; CI95 1.08-1.71). Conclusions: Mortality in premature newborns decreased 15 percent during this period. Inmaturity and extreme low birth weight factors constitute a challenge to improve survival and avoid further complications like PH.

Objetivo: Caracterizar la mortalidad y factores asociados en prematuros chilenos < 32 semanas de edad gestacional (EG) receptores de surfactante exógeno. Pacientes y Métodos: Cohorte de neonatos 1998-2005 (n = 2 868) de la base de datos del Programa Nacional de Surfactante. Se estimó la mortalidad y su relación con variables maternas, del embarazo y neonatales mediante análisis de sobrevida y regresión logística. Resultados: La mortalidad global fue 35 por ciento, variando por EG entre 86,7 por ciento (< 25 semanas) y 12,6 por ciento (32 semanas). La mortalidad descendió en el período, reduciéndose también el peso de nacimiento (PN) de los fallecidos (1 02 lg +/- 295 a 854 g +/- 258) y su EG (27,7 +/- 2,1 a 26,5 +/- 2,3). La hemorragia pulmonar (HP) fue el factor más importante asociado a mortalidad, por lo que se estratificó el análisis por esa condición. En niños con HP, cada semana adicional de EG disminuye el riesgo de morir (OR: 0,73; IC95 0,57-0,93), así como por cada 100 g de peso adicional (OR: 0,74; IC95 0,63-0,88). Sin HP, el riesgo disminuye con mayor EG (OR: 0,82; IC95 0,76-0,90), mayor PN (OR: 0,84; IC95 0,79-0,89), mejor puntuación Apgar 5 minutos (OR: 0,80; IC95 0,75-0,85) y uso de corticoide prenatal (OR: 0,71; IC95 0,56-0,90), siendo significativamente mayor en varones (OR: 1,36; IC(95)1,08-1,71). Conclusiones: En el período, la mortalidad en prematuros disminuyó en 15 por ciento. La inmadurez y extremo bajo peso de niños actualmente viables, plantean importantes desafíos para mejorar su sobrevida y evitar complicaciones, entre ellas, la HP.

Insuficiência respiratória aguda como manifestação da síndrome de eosinofilia-mialgia associada à ingestão de L-triptofano / Acute respiratory failure as a manifestation of eosinophilia-myalgia syndrome associated with L-tryptophan intake

A síndrome da eosinofilia-mialgia foi descrita em 1989 em pacientes que apresentavam mialgia progressiva e incapacitante e eosinofilia sérica, nos líquidos e secreções. A maioria dos pacientes relatava uso prévio de L-triptofano. Sintomas respiratórios são relatados em até 80 por cento dos casos, eventualmente como manifestação única. O tratamento inclui suspensão da droga e corticoterapia. Relatamos o caso de uma mulher de 61 anos com insuficiência respiratória aguda após uso de L-triptofano, hidroxitriptofano e outras drogas. A paciente apresentava eosinofilia no sangue, lavado broncoalveolar e derrame pleural. Após a suspensão da medicação e corticoterapia, houve melhora clínica e radiológica em poucos dias.

Eosinophilia-myalgia syndrome was described in 1989 in patients who presented progressive and incapacitating myalgia and eosinophilia in blood, fluids and secretions. Most patients report previous L-tryptophan intake. Respiratory manifestations are found in up to 80 percent of the cases, occasionally as the only manifestation. Treatment includes drug discontinuation and administration of corticosteroids. Here, we describe the case of a 61-year-old female admitted with acute respiratory failure after using L-tryptophan, hydroxytryptophan and other drugs. The patient presented eosinophilia, together with elevated eosinophil counts in the bronchoalveolar lavage and pleural effusion. After discontinuation of the drugs previously used, corticosteroids were administered, resulting in clinical and radiological improvement within just a few days.

Inhaled nitric oxide in newborns with severe hypoxic respiratory failure.

BACKGROUND: Respiratory failure in term and near term infants is often associated with persistent pulmonary hypertension of the newborn and contributes to hypoxemia in these infants. Inhaled nitric oxide (iNO) is currently used as a pulmonary vasodilator to improve oxygenation in neonates with severe respiratory failure. OBJECTIVE: To determine outcome of administration of iNO in severe hypoxic respiratory failure. MATERIAL AND METHOD: The present study was conducted from 1999 to 2004 in the neonatal intensive care unit (NICU) at Queen Sirikit National Institute of Child Health. Patients were selected from all infants > or = 34 weeks gestational age who required high frequency oscillatory ventilation (SLE 2000 HFO, SLE, UK) or conventional mechanical ventilation for hypoxemic respiratory failure caused by PPHN. Diagnosis was confirmed by 2-D echocardiogram visualization with right to left shunt through the foramen ovale or patent ductus arteriosus. Inhaled nitric oxide was given as standard therapy in patients who had two oxygenation indices > or = 20 at least 30 minutes apart after being on a mechanical ventilator. RESULTS: Fifty-five cases were enrolled and male to female ratio was 22.2 tol. The survival rate was 76.4 percent. Inhaled nitric oxide significantly improved oxygenation index, arterial alveolar oxygen tension ratio (a/A O2), and alveolar arterial oxygen gradient in survivors at one hour after treatment. The earliest improvement in oxygen saturation was within ten minutes. Meconium aspiration syndrome was the most common underlying cause of PPHN. No acute complication was found during nitric oxide administration. Chronic lung diseases, delayed development and severe hearing loss in long-term follow up were found in 10, 5, and 2 cases, respectively. CONCLUSION: Inhaled nitric oxide should be used early in severe hypoxic respiratory failure with persistent pulmonary hypertension of newborn and can improve survival rates without any major immediate side effects.

Insuficiência respiratória persistente secundária a insuficiência cardíaca diastólica / Persistent respiratory insufficiency secondary to diastolic heart failure

Foram estudados 2 pacientes de 85 anos de idade com diagnóstico de insuficiência cardíaca diastólica e insuficiência respiratória persistente, caracterizada por distúrbio ventilatório obstrutivo grave e alterações das trocas gasosas. A possibilidade de que esse comprometimento respiratório decorresse de doença pulmonar primária foi excluída. Sinais radiológicos de edema pulmonar leve foram observados em um dos doentes nos 4 anos anteriores à primeira internação. O quadro respiratório foi atribuído a lesões pulmonares condicionadas à presença de edema pulmonar crônico. A incidência da doença em pacientes muito idosos pode dar origem a uma enfermidade que poderia ser denominada doença pulmonar congestiva.

Terapia com surfactante pulmonar exógeno em pediatria / Exogenous surfactant therapy in pediatrics

OBJETIVO: Revisar o estágio atual do conhecimento sobre a utilização do surfactante exógeno nas diferentes doenças pulmonares que levam à insuficiência respiratória aguda em crianças. FONTES DOS DADOS: Este manuscrito baseia-se na experiência clínica dos autores sobre o assunto e na revisão da literatura recente através de consulta aos bancos de dados ONIA, Mdconsult, Medline e Cochrane Database Library. SíNTESE DOS DADOS: Apesar do sucesso obtido com a utilização do surfactante exógeno na síndrome de desconforto respiratório do recém-nascido, questões permanecem indefinidas, como o momento do seu emprego, muito precoce (profilático), baseado na idade gestacional ou em testes rápidos de maturidade pulmonar, ou então mais tardiamente, após o quadro clínico instalado. Em outras patologias graves que levam à insuficiência respiratória grave com necessidade de suporte ventilatório, o seu uso ainda é controverso, e os dados da literatura são limitados e conflitantes. Porém, relatos de uso clínico em várias destas situações, com sucesso, têm sido freqüentes. A pesquisa em surfactante tem-se centrado ultimamente na sua inativação por várias substâncias que podem estar presentes na via aérea. Nas patologias em que a inativação parece ser um fator importante, novos surfactantes com adição de adjuvantes para reverter a tendência à inativação (por exemplo: polietilenoglicol) estão atualmente em fase de testes. CONCLUSÕES: A terapia com surfactante exógeno ainda não é um tema esgotado, nem mesmo na SDR. Os surfactantes podem ser ainda aperfeiçoados, sobretudo para resistir à inibição, e as formas de utilização em outras doenças que não a SDR deverão ser aperfeiçoadas.

Crisis bronquial obstructiva severa, refractaria al tratamiento, tratada con ketamina en infusión continua / Acute bronchial obstructive crisis, refractary to treatment, treated with ketamine in continuos infusion

Comunicamos el caso de una preescolar que ingresa a nuestra unidad de cuidados intensivos, con crisis bronquial obstructiva grave e insuficiente respiratoria global que no responde al tratamiento convencional, y en el que se utiliza con éxito ketamina en infusión ev continua. Se han descrito mortalidades tan altas como 35 por ciento, en pacientes clínicamente similares manejados con ventilación mecánica, por lo que nos ha parecido importante describir la evolución y el tratamiento de esta paciente. No encontramos en la revisión de la literatura nacional otras comunicaciones relacionadas

Complicação do sarampo em paciente gestante / Measles complication in a young pregnancy

Paciente gestante, 33 anos, admitida na Unidade de Terapia Intensiva Adulto do Hospital Municipal Professor Doutor Alípio Corrêa Neto com diagnóstico de sarampo e pneumonia interstical, evoluindo com insuficiência respiratória aguda e SARA. Durante a investigação, foi isolado na secreção traqueal o Criptococus neoformans, porém não se demonstrou ser paciente portadora do vírus HIV. Após a instituição do suporte ventilatório adequado e da medicação antimicótica (Fluconazol), o paciente apresentou uma evolução satisfatória do quadro de insuficiência respiratória e da pneumonia intersticial, recebendo alta da unidade de terapia intensiva adulto, prosseguindo o tratamento ambulatorial para Criptococose

Terapia transfusional com plasma e derivados / Transfusion therapy with plasma and derivatives

Nesta revisäo säo analisadas as principais indicaçöes para o uso do plasma e seus derivados. Particularmente, säo focalizadas a utilizaçäo dos fatores de coagulaçäo no tratamento das hemofilias e da doença de von Willebrand, e o uso terapêutico da albumina e das imunoglobulinas