Ventilación con presión positiva no invasiva, VPPNI, en pacientes con insuficiencia respiratoria aguda hipoxémica / Noninvasive ventilation with positive pressure in patients with acute hypoxemic respiratory failure

Quisimos evaluar la aplicabilidad y eficacia de la ventilación con presión positiva no invasiva (VPPNI) en pacientes con insuficiencia respiratoria aguda (IRA) hipoxémica y aumento del trabajo respiratorio. En un periodo de 10 meses evaluamos a 64 pacientes que ingresaron a nuestro servicio con el diagnóstico de IRA y signos de fatiga muscular, en ausencia de patología crónica. Fueron considerados no aptos para VPPNI quienes tuvieran compromiso de conciencia importante, inestabilidad hemodinámica o más de dos órganos en falla, cirugía reciente de esófago, estómago o duodeno, hemorragia digestiva alta activa, distensión abdominal importante o dificultad en el manejo de secreciones. Luego de aplicar los criterios de exclusión, 14 (23 por ciento) pacientes fueron sometidos a VPPNI por un periodo de 1 a 9 días. La Pa/FiO2, sin cambios significativos en la PaCO2 y frecuencia respiratoria. En 5 pacientes (36 por ciento) fracasó el método, de los cuales 2 fallecieron. Un paciente presentó una escara nasal. Por su mínima invasividad y fácil aplicación, la VPPNI debe ser considerada precozmente en todo paciente con IRA hipoxémica con buen nivel de conciencia y que preserve su ventilación espontánea

Respiratory distress in newborn: treated with ventilation in a level II nursery.

Fifty consecutive neonates with respiratory distress persisting beyond 6 h of age were studied during a 18 month period (total deliveries 2000/y). Twenty two neonates were managed with oxygen hood with increasing oxygen concentration, 28 with continuous positive airway pressure (CPAP) ventilation using a nasal cannula. Of these babies on CPAP, 10 were shifted to intermittent positive pressure ventilation (IPPV) on a pressure limited, time cycled ventilator (Neovent, Vickers). Babies were monitored with continuous hemoglobin oxygen saturation (SaO2), hourly blood pressure and vital charting. Radial arterial blood gas analysis (ABG) was done when feasible and especially on clinical deterioration. Oxygen (FiO2 0.95) from an oxygen concentrator was used as a source of continuous supply of oxygen. Commonest cause of respiratory distress was hyaline membrane disease (18%), followed by wet lung syndromes (14%), meconium aspiration (12%), asphyxia (12%) and septicemia (8%). In 8 babies, a lung biopsy (postmortem) was done to confirm the diagnosis. Nineteen of the 50 babies with respiratory distress died, there was a survival of 50% on CPAP and 30% on IPPV. No case of oxygen toxicity or other major complications was encountered. Even with moderate resources, neonatal ventilation in a Level II nursery is a challenging task. Babies less than 1000g require aggressive measures which is not very economical in a special care baby unit (SCBU).

A home-made IMV-CPAP system for difficult to wean patients.

A continuous, high flow gas was incorporated into the conventional intermittent mandatory ventilation (IMV) circuit attached to the pressure or volume cycled ventilator which had no built-in IMV mode. These created a continuous flow IMV-CPAP system. During the spontaneous breathing period, the gas flow was high enough to raise a 5-6 cm H2O CPAP level and cause minimal airway pressure fluctuation, an indicator of reduced breathing work. Sixteen patients who were unable to tolerate T-piece weaning were weaned successfully by this IMV-CPAP system. They were medical and surgical patients with prolonged ventilatory support (10-62 days). The respiratory mechanics prior to weaning were relatively marginal. Tidal volume, minute volume and respiratory rate were 260.71 +/- 104 cc, 9.71 +/- 3.54 LPM and 30.29 +/- 5.31/minute respectively. During the weaning course arterial pCO2 retained gradually to their steady states in chronic CO2 retaining patients. This resulted in very minimal fluctuations in arterial pH. All patients were weaned successfully with the average weaning duration of 14.19 days.

Inyector jet modificado para ventilación con presión positiva durante laringoscopía / Modified jet injector for ventilation with positive pressure during laringoscopy

Se reporta una serie de 15 pacientes programados para laringoscopía y toma de biopsia, los cuales fueron ventilados en el transoperatorio con un inyector jet de oxígenio modificado y construído en nuestro departamento. Este sistema está basado en el principio de Venturi y consideramos que es una técnica segura y adeucada para el paciente, con una buena aceptación por el cirujano y el anestesiólogo