Papel de la ecografía en la insuficiencia respiratoria aguda y en el weaning de la ventilación mecánica

Resumen La evaluación integral mediante ecografía se ha convertido en una herramienta indispensable para facilitar el diagnóstico y el manejo terapéutico en los pacientes críticos con insuficiencia respiratoria aguda (IRA). Existe evidencia que apoya el uso de la ecografía para el diagnóstico de neumotórax, síndrome de distrés respiratorio agudo, edema pulmonar cardiogénico, neumonía, tromboembolismo pulmonar agudo y el paciente con COVID-19. Además, en los últimos años se ha desarrollado el uso de la ecografía para evaluar la respuesta a los tratamientos en los pacientes críticos con IRA, brindando una herramienta no invasiva para la titulación de la presión positiva al final de la espiración, monitorizar las maniobras de reclutamiento y la respuesta al prono, así como para facilitar la retirada de la ventilación mecánica. El objetivo de esta revisión es resumir los conceptos básicos sobre la utilidad de la ecografía en el diagnóstico y la monitorización de los pacientes críticos con IRA. Comprehensive ultrasound assessment has become an essential tool to facilitate diagnosis and therapeutic management in critically ill patients with acute respiratory failure (ARF). There is evidence supporting the use of ultrasound for the diagnosis of pneumothorax, acute respiratory distress syndrome, cardiogenic pulmonary edema, pneumonia, acute pulmonary thromboembolism, and the patient with COVID-19. In addition, in recent years, the use of ultrasound to evaluate response to treatments in critically ill patients with ARF has been developed, providing a non-invasive tool for titrating positive end-expiratory pressure, monitoring recruitment maneuvers and response to prone, as well as to facilitate weaning from mechanical ventilation. The objective of this review is to summarize the basic concepts on the utility of ultrasound in the diagnosis and monitoring of critically ill patients with ARF.

Multidisciplinary approach of the sequelae one month after hospital discharge in patients with severe bilateral COVID-19 pneumonia, are there differences depending on the respiratory therapy used during admission to intensive care?

OBJECTIVE: To describe the sequelae one month after hospital discharge in patients who required admission to Intensive Care for severe COVID 19 pneumonia and to analyze the differences between those who received therapy exclusively with high-flow oxygen therapy compared to those who required invasive mechanical ventilation. DESIGN: Cohort, prospective and observational study. SETTING: Post-intensive care multidisciplinary program. PATIENTS OR PARTICIPANTS: Patients who survived admission to the intensive care unit (ICU) for severe COVID 19 pneumonia from April 2020 to October 2021. INTERVENTIONS: Inclusion in the post-ICU multidisciplinary program. MAIN VARIABLES OF INTEREST: Motor, sensory, psychological/psychiatric, respiratory and nutritional sequelae after hospital admission. RESULTS: 104 patients were included. 48 patients received high-flow nasal oxygen therapy (ONAF) and 56 invasive mechanical ventilation (IMV). The main sequelae found were distal neuropathy (33.9% IMV vs 10.4% ONAF); brachial plexopathy (10.7% IMV vs 0% ONAF); decrease in grip strength: right hand 20.67kg (±8.27) in VMI vs 31.8kg (±11.59) in ONAF and left hand 19.39kg (±8.45) in VMI vs 30.26kg (±12.74) in ONAF; and limited muscle balance in the lower limbs (28.6% VMI vs 8.6% ONAF). The differences observed between both groups did not reach statistical significance in the multivariable study. CONCLUSIONS: The results obtained after the multivariate study suggest that there are no differences in the perceived physical sequelae one month after hospital discharge depending on the respiratory therapy used, whether it was high-flow nasal oxygen therapy or prolonged mechanical ventilation, although more studies are needed to be able to draw conclusions.

The role of corticosteroids in patients hospitalized for COVID-19 at Mexico general Hospital.

OBJECTIVE: To compare the evolution of hospitalized patients infected with SARS-CoV-2 who received corticosteroid-based treatment versus patients who received standard therapy. METHOD: Retrospective, observational, and analytical study. Clinical records were collected from the different intensive care units, and data were obtained from confirmed COVID-19 patients over 18 years of age who were hospitalized. The population was divided into two groups: patients who received corticosteroid treatment, and those who received standard therapy. RESULTS: A total of 1603 patients were admitted to hospital, and of these 984 (62.9%) were discharged due to death. The main result was the identification by odds ratio (OR: 4.68; 95% confidence interval [95% CI]: 3.75-5.83; p = 0.001) as risk for death to the use of systemic steroids, as well as the use of invasive mechanical ventilation (OR: 2.26; 95% CI: 1.80-2.82; p < 0.001). The male gender was the most affected with 1051 (65.6%) patients. Mean age was 56 years (± 14). CONCLUSIONS: Corticosteroid use was associated with poor prognosis in patients hospitalized for COVID-19 compared to those receiving standard therapy.

OBJETIVO: Comparar la evolución de los pacientes hospitalizados infectados por SARS-CoV-2 que recibieron tratamiento a base de corticoesteroides frente a los pacientes que recibieron la terapia estándar. MÉTODO: Estudio de tipo retrospectivo, observacional y analítico. Se recolectaron los expedientes clínicos de las diferentes unidades de terapia intensiva y se obtuvieron datos de los pacientes confirmados de COVID-19, mayores de 18 años, que estuvieron hospitalizados. Se dividió la población en dos grupos: pacientes que recibieron tratamiento con corticoesteroides y pacientes que recibieron terapia estándar. RESULTADOS: De un total de 1603 pacientes ingresados a hospitalización, 984 (62.9%) fallecieron. El resultado principal fue la identificación mediante razón de momios (odds ratio [OR]: 4.68; intervalo de confianza del 95% [IC95%]: 3.75-5.83; p = 0.001) como riesgo para defunción con uso de esteroides sistémicos, así como con uso de ventilación mecánica invasiva (OR: 2.26; IC95%: 1.80-2.82; p < 0.001). El sexo masculino fue el más afectado, con 1051 (65.6%) pacientes. La media de edad fue de 56 años (± 14). CONCLUSIONES: El uso de corticoesteroides se asoció con mal pronóstico en los pacientes hospitalizados por COVID-19, en comparación con los que recibieron la terapia estándar.

Desafíos en el cuidado de personas con Covid-19 en posición prono: apoyo al estudio internacional PRONEtect.

SINOPSIS: El siguiente editorial presenta los resultados de una encuesta a los líderes de las 13 asociaciones de la Confederación Multidisciplinar Latinoamericana de Heridas, Estomas e Incontinencias (COMLHEI). La encuesta buscó determinar, de manera general, la situación de los pacientes con Covid-19 en posición prono (PP) con desarrollo de lesiones por presión (LPP). Los resultados indican que, en América latina, las LPP en pacientes en PP son frecuentes. Se evidenciaron deficiencias en estudios epidemiológicos y de elementos de protección, prevención y educación, además de brechas entre los diferentes países e instituciones en cuanto a la disponibilidad de personal para poder cumplir con las recomendaciones de posicionamiento de los pacientes. Las autoras sugieren tener en cuenta los resultados del estudio internacional PRONEtect para identificar, revisar y evaluar las pautas internacionales de pronación y cuidado de la piel, y hacer un inventario de los equipos y recursos de capacitación de uso común.

Non-invasive oxygen therapy in patients with COVID-19: wu ji bi fan: too much of something is not good

In clinical practice, oxygen can save lives, although, wu ji bi fan: too much of something is not good and it can also cause toxicity;14% of patients with coronavirus disease 2019 (COVID-19) will need non-invasive oxygen therapy and approximately 5% will require invasive mechanical ventilation (IMV). Noninvasive oxygen therapy is the first-line treatment for patients with hypoxemic acute respiratory failure secondary to COVID-19. The devices through which this therapy is administered can be classified into low flow and high flow. In the presence of acute hypoxemic respiratory failure, the necessary flow can be 30 to 120 L/min, a number that cannot be achieved with conventional systems (low flow), therefore, high-flow devices can be effective in well-selected patients, the aim is to improve oxygenation, avoid orotracheal intubation of the patient, but without delaying it. Noninvasive oxygen therapy does not increase the risk of aerosol infection. (English) [ FROM AUTHOR]

Unidades de Cuidados Respiratorios Intermedios: preguntas y respuestas

Resumen Las Unidades de Cuidados Respiratorios Intermedios (UCRI) son áreas de monitorización y atención especializada de pacientes con insuficiencia respiratoria aguda o crónica-agudizada, cuya gravedad no precisa de ingreso en una Unidad de Cuidados Intensivos, pero que por su complejidad tampoco pueden ser tratados en planta de hospitalización convencional. Si bien la pandemia por COVID-19 ha demostrado su utilidad en el manejo del paciente respiratorio crítico, la trayectoria histórica de las UCRI viene de muchos años atrás, en la que se ha demostrado su coste-efectividad con creces. El presente documento presenta una serie de preguntas y respuestas sobre la historia de las UCRI, además de los criterios de admisión, infraestructura, recursos humanos y técnicos, y los tipos de Unidades existentes. En el seno del Año UCRI 2021-2022 designado por la Sociedad Española de Neumología y Cirugía Torácica, es oportuna toda divulgación científica vinculada al conocimiento a profundidad de estas Unidades, donde confluyen la multidisciplinariedad y el trabajo de profesionales relacionados con el cuidado del paciente respiratorio crítico. The Intermediate Respiratory Care Units (UCRI) are areas of monitoring and specialized care of patients with acute or chronic-exacerbated respiratory failure, whose severity does not require admission to an Intensive Care Unit, but which due to their complexity cannot be treated in conventional hospitalization. Although the COVID-19 pandemic has proven its usefulness in the management of critical respiratory patients, the historical trajectory of the UCRI comes from many years ago, in which its cost-effectiveness has been demonstrated by far. This document presents a series of questions and answers on the history of the UCRI, in addition to the criteria for admission, infrastructure, human and technical resources, and the types of existing Units. Within the UCRI Year 2021-2022 designated by the Spanish Society of Pneumology and Thoracic Surgery, any scientific dissemination linked to the in-depth knowledge of these Units is timely, where multidisciplinarity and the work of professionals related to the care of critical respiratory patients converge.

Airways management in SARS-COV-2 acute respiratory failure: A prospective observational multi-center study.

OBJECTIVE: Few studies have reported the implications and adverse events of performing endotracheal intubation for critically ill COVID-19 patients admitted to intensive care units. The aim of the present study was to determine the adverse events related to tracheal intubation in COVID-19 patients, defined as the onset of hemodynamic instability, severe hypoxemia, and cardiac arrest. SETTING: Tertiary care medical hospitals, dual-centre study performed in Northern Italy from November 2020 to May 2021. PATIENTS: Adult patients with positive SARS-CoV-2 PCR test, admitted for respiratory failure and need of advanced invasive airways management. INTERVENTIONS: Endotracheal Intubation Adverse Events. MAIN VARIABLES OF INTERESTS: The primary endpoint was to determine the occurrence of at least 1 of the following events within 30 minutes from the start of the intubation procedure and to describe the types of major adverse peri-intubation events: severe hypoxemia defined as an oxygen saturation as measured by pulse-oximetry <80%; hemodynamic instability defined as a SBP 65 mmHg recoded at least once or SBP < 90 mmHg for 30 minutes, a new requirement or increase of vasopressors, fluid bolus >15 mL/kg to maintain the target blood pressure; cardiac arrest. RESULTS: Among 142 patients, 73.94% experienced at least one major adverse peri-intubation event. The predominant event was cardiovascular instability, observed in 65.49% of all patients undergoing emergency intubation, followed by severe hypoxemia (43.54%). 2.82% of the patients had a cardiac arrest. CONCLUSION: In this study of intubation practices in critically ill patients with COVID-19, major adverse peri-intubation events were frequent. CLINICAL TRIAL REGISTRATION: www. CLINICALTRIALS: gov identifier: NCT04909476.

DESENLACES CLÍNICOS EN PACIENTES CON DIAGNÓSTICO DE NEUMONÍA RELACIONADA CON SARS-COV-2 MANEJADOS CON CÁNULA DE ALTO FLUJO, UNA EXPERIENCIA CLÍNICA. (Estudio CANALF)

Resumen Introducción. La inclusión de los sistemas de soporte ventilatorio no invasivo en el manejo del SDRA en adultos durante la actual pandemia ha sido un salvavidas ante la carencia de recursos en la presente situación sanitaria internacional. Sistemas como la Cánula nasal de alto flujo han demostrado no ser solo un sistema ventilatorio temporal a la espera de una ventilación mecánica invasiva, sino, muy por el contrario se ha evidenciado que es una herramienta de terapia efectiva en el SDRA. Objetivo. Describir una guía fácil para el manejo de cánulas de alto flujo en pacientes hospitalizados con neumonía grave por criterios de ATS secundaria a SARS COV2-COVID 19. Materiales y métodos. El presente es un estudio observacional prospectivo monocéntrico, en el que se incluyeron a 59 pacientes, todos con diagnóstico de neumonía severa relacionada con el SARS-CoV-2 entre enero y abril de 2021. Los pacientes fueron manejados inicialmente en unidad de cuidado intermedio con cánula nasal de alto flujo (CNAF). Resultados. Se pudo demostrar que existe una correlación estadísticamente significativa entre edad >65 años y frecuencia respiratoria ≥28 con la mortalidad;así mismo, entre edad >50 años, NEWS >6 y nuevamente frecuencia respiratoria ≥28 con el fracaso en el tratamiento. Conclusiones. La CNAF en el contexto de insuficiencia respiratoria relacionada a SArs-Cov2, debe convertirse en una alternativa viable de manejo en particular en entornos con acceso limitado a los recursos de la unidad de cuidados intensivos. Introduction. The inclusion of non-invasive ventilatory support systems in the management of ARDS in adults during the current pandemic, has been a lifeline given the lack of resources in the current international health situation. Systems such as the high flow nasal cannula have proven not to be just a temporary ventilatory system while awaiting invasive mechanical ventilation, on the contrary it has been shown that the high flow nasal cannula is an effective therapy tool in ARDS. Objective. To provide an easy guideline for the management of high-flow cannulas in hospitalized patients with severe pneumonia due to ATS criteria secondary to SARS COV2-COVID 19. Materials and methods. This is a prospective, single-centre observational study, including 59 patients, all with a diagnosis of SARS-CoV-2-related pneumonia between January and April 2021. The patients were initially managed in an intermediate care unit with high nasal cannula flow (HFNC). Results. We were able to show that there is a statistically significant correlation between age> 65 years and respiratory rate ≥28 and mortality;likewise, between age> 50 years, NEWS> 6 and again a respiratory rate ≥28 with treatment failure. Conclusions. HFNC in respiratory failure related to coronavirus disease 2019 should become a viable management alternative, particularly in settings with limited access to intensive care unit resources, taking the indications into account and recognizing that a high percentage of patients who receive it can be successfully weaned without the need for invasive mechanical ventilation.

Awake pronation with helmet continuous positive airway pressure for COVID-19 acute respiratory distress syndrome patients outside the ICU: A case series.

OBJECTIVE: Continuous positive airway pressure (CPAP) is an important therapeutic tool in COVID-19 acute respiratory distress syndrome (ARDS) since it improves oxygenation, reduces respiratory rate and can prevent intubation and intensive care unit (ICU) admission. CPAP during pronation has seldom been described and never during sedation. DESIGN: Case series. SETTING: High dependency unit of San Carlo University Hospital (Potenza, Italy). PATIENTS: Eleven consecutive patients with COVID-19 ARDS. INTERVENTION: Helmet CPAP in prone position after failing a CPAP trial in the supine position. MAIN VARIABLE OF INTEREST: Data collection at baseline and then after 24, 48 and 72h of pronation. We measured PaO2/FIO2, pH, lactate, PaCO2, SpO2, respiratory rate and the status of the patients at 28-day follow up. RESULTS: Patients were treated with helmet CPAP for a mean±SD of 7±2.7 days. Prone positioning was feasible in all patients, but in 7 of them dexmedetomidine improved comfort. PaO2/FIO2 improved from 107.5±20.8 before starting pronation to 244.4±106.2 after 72h (p<.001). We also observed a significantly increase in Sp02 from 90.6±2.3 to 96±3.1 (p<.001) and a decrease in respiratory rate from 27.6±4.3 to 20.1±4.7 (p=.004). No difference was observed in PaCO2 or pH. At 28 days two patients died after ICU admission, one was discharged in the main ward after ICU admission and eight were discharged home after being successfully managed outside the ICU. CONCLUSIONS: Helmet CPAP during pronation was feasible and safe in COVID-19 ARDS managed outside the ICU and sedation with dexmedetomidine safely improved comfort. We recorded an increase in PaO2/FIO2, SpO2 and a reduction in respiratory rate.

Oxigenación con membrana extracorpórea en el paciente COVID-19: resultados del Registro Español ECMO-COVID de la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE)

RESUMEN Introducción y objetivos: la oxigenación con membrana extracorpórea (ECMO) ha resultado ser una opción terapéutica en los pacientes con insuficiencia respiratoria y/o cardiaca severa por COVID-19. Las indicaciones y manejo de estos pacientes están aún por determinar. Nuestro objetivo es evaluar los resultados de la terapia ECMO en pacientes COVID-19 incluidos en un registro prospectivo e intentar optimizar los resultados. Métodos: en marzo de 2020 se inició un registro multicéntrico anónimo prospectivo de pacientes COVID-19 tratados mediante ECMO veno-arterial (V- A) o veno-venosa (V-V). Se registraron las variables clínicas, analíticas y respiratorias pre-implante, datos de implante y evolución de la terapia. El evento primario fue la mortalidad hospitalaria de cualquier causa y los eventos secundarios fueron la recuperación funcional y el evento combinado de recuperación funcional y mortalidad de cualquier causa a partir de los 3 meses de seguimiento post-alta. Resultados: se analizaron un total de 365 pacientes procedentes de 25 hospitales, 347 V-V y 18 V-A (edad media 52.7 y 49.4 años respectivamente). Los pacientes con ECMO V-V fueron más obesos, presentaban menos fracaso orgánico diferente al pulmonar y precisaron menos terapia inotrópica previa al implante. El 33.3% y 34.9% de los pacientes con ECMO V-A y V-V respectivamente fueron dados de alta del hospital (p=NS) y la mortalidad fue similar, del 56.2% y 50.9% de los casos respectivamente, la inmensa mayoría durante la ECMO y predominantemente por fracaso multiorgánico. El 14.0% (51 pacientes) permanecían ingresados. El seguimiento medio fue de 196+/-101.7 días. En el análisis multivariante, resultaron protectores de evento primario en pacientes con ECMO V-V el peso corporal (OR 0.967, IC 95% 0.95-0.99, p=0.004) y la procedencia del propio hospital (OR 0.48, IC 95% 0.27-0.88, p=0.018), mientras que la edad (OR 1.063, IC 95% 1.005-1.12, p=0.032), la hipertensión arterial (3.593, IC 95% 1.06-12.19, p=0.04) y las complicaciones en ECMO globales (2.44, IC 95% 0.27-0.88, p=0.019), digestivas (OR 4,23, IC 95% 1.27-14.07, p=0.019) y neurológicas (OR 4.66, IC 95% 1.39-15.62, p=0.013) fueron predictores independientes de mortalidad. El único predictor independiente de aparición de los eventos secundarios resultó el momento de seguimiento del paciente. Conclusiones: la terapia con ECMO permite supervivencias hospitalarias hasta del 50% en pacientes con COVID-19 grave. La edad, la HTA y las complicaciones en ECMO son los predictores de mortalidad hospitalaria en pacientes con ECMO V-V. Un mayor peso corporal y la procedencia del propio hospital son factores protectores. La recuperación funcional sólo se ve influenciada por el tiempo de seguimiento transcurrido tras el alta. La estandarización de los criterios de implante y manejo del paciente con COVID grave, mejoraría los resultados y la futura investigación clínica Background and aim: COVID-19 patients with severe heart or respiratory failure are potential candidates for extracorporeal membrane oxygenation (ECMO). Indications and management of these patients are unclear. Our aim is to describe the results of a prospective registry of COVID-19 patients treated with ECMO. Methods: an anonymous prospective registry of COVID-19 patients treated with veno-arterial (V-A) or veno-venous (V-V) ECMO was created on march 2020. Clinical, analytical and respiratory pre-implantation variables, implantation data and post-implantation course data were recorded. The primary endpoint was all cause in-hospital mortality. Secondary events were functional recovery and the combined endpoint of mortality and functional recovery in patients followed at least 3 months after discharge. Results: Three hundred and sixty-six patients from 25 hospitals were analyzed, 347 V-V ECMO and 18 V-A ECMO patients (mean age 52.7 and 49.5 years respectively). Patients with V-V ECMO were more obese, had less frequently organ damage other than respiratory failure and needed less inotropic support. Thirty three percent of V-A ECMO and 34.9% of V-A ECMO were discharged (p=NS). Hospital mortality was non-significantly different, 56.2% versus 50.9% respectively, mainly during ECMO therapy and mostly due to multiorgan failure. Other 51 patients (14%) remained admitted. Mean follow-up was 196+/-101.7 days (95% IC 95170.8-221.6). After logistic regression, body weight (OR 0.967, IC 95% 0.95-0.99, p=0.004) and ECMO implantation in the own centre (OR 0.48, IC 95% 0.27-0.88, p=0.018) were protective for hospital mortality. Age (OR 1.063, IC 95% 1.005-1.12, p=0.032), arterial hypertension (3.593, IC 95% 1.06-12.19, p=0.04) and global (2.44, IC 95% 0.27-0.88, p=0.019), digestive (OR 4,23, IC 95% 1.27-14.07, p=0.019) and neurological (OR 4.66, IC 95% 1.39-15.62, p=0.013) complications during ECMO therapy were independent predictors of primary endpoint occurrence. Only the post-discharge day at follow-up was independent predictor of both secondary endpoints occurrence. Conclusions: hospital survival of severely ill COVID-19 patients treated with ECMO is near 50%. Age, arterial hypertension and ECMO complications are predictors of hospital mortality, and body weight and implantation in the own centre are protective. Functional recovery is only predicted by the follow-up time after discharge. A more homogeneous management of these patients is warranted for clinical results and future research optimization.

Summary of recommendations and key points of the consensus of Spanish scientific societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the use of non-invasive ventilation and high-flow oxygen therapy with nasal cannulas in adult, pediatric, and neonatal patients with severe acute respiratory failure.

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analogue classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

[Alternative CPAP methods for the treatment of secondary serious respiratory failure due to pneumonia by COVID-19]. / Métodos alternativos de CPAP para el tratamiento de insuficiencia respiratoria grave secundaria a neumonía por COVID-19.

INTRODUCTION: The use of devices that provide continuous positive pressure in the airway has shown improvement in various pathologies that cause respiratory failure. In the COVID-19 pandemic episode the use of these devices has become widespread, but, due to the shortage of conventional continuous positive airway pressure (CPAP) devices, alternative devices have been manufactured. The objective of this study is to describe the use of these devices, as well as their efficacy. MATERIAL AND METHODS: Data are collected from patients admitted for pneumonia due to COVID-19 at the IFEMA Field Hospital. Data are collected from 23 patients with respiratory failure and need for ventilatory support. RESULTS: Study carried out on a total of 23 patients, dated admission to IFEMA. Alternative CPAP was used in five patients (21.7%), while ventilatory support with a reservoir mask or Ventimask Venturi effect was used in the remaining 18 patients (78.3%). A progressive increase in saturation is observed in those patients in whom alternative CPAP was used (from 94% on average to 98 and 99% on average after 30 and 60 minutes with the mask, respectively), although this change was not significant (p = 0.058 and p = 0.122, respectively). No significant change in RF was observed at the beginning and end of the measurement in patients who used alternative CPAP (p = 0.423), but among those who did not use alternative CPAP (p = 0.001). A statistically significant improvement in the variable oxygen saturation / fraction inspired by oxygen is observed in patients who used alternative CPAP (p = 0.040) CONCLUSION: The use of these devices has helped the ventilatory work of several patients by improving their oxygenation parameters. To better observe the evolution of patients undergoing this therapy and compare them with patients with other types of ventilatory support, further studies are necessary.

Role of SARS-CoV-2 neurotropism and neuroinvasion in COVID-19 patients disease severity.

The disease caused by the new SARS-CoV-2 coronavirus (COVID-19) spread rapidly from China to the entire world. Approximately one third of SARS-CoV-2-infected patients have neurological disorders, especially those classified as severe cases and that require mechanical ventilation. On the other hand, almost nine out of 10 patients admitted to an Intensive Care Unit could not breathe spontaneously, thus requiring invasive and non-invasive ventilatory support. So far, whether early neurological disorders such as hyposmia or anosmia, dysgeusia or ageusia, headache and vertigo are significant in the progression to the severe form of the disease or whether they are related to entry to the central nervous system via peripheral nerves has not been determined. Considering the great similarity between SARS-CoV and SARS-CoV-2, and that the severity of the condition that leads to death cannot be explained solely by lung involvement, it is important to determine whether SARS-CoV-2 potential invasion to the central nervous system is partially responsible for the severe respiratory component observed in patients with COVID-19.

La enfermedad (COVID-19) producida por el nuevo coronavirus SARS-CoV-2 se extendió rápidamente desde China a todo el mundo. Aproximadamente una tercera parte de los pacientes infectados de SARS-CoV-2 presenta alteraciones neurológicas, con mayor frecuencia los clasificados como graves que requirieron ventilación mecánica. Por otro lado, casi nueve de cada 10 pacientes admitidos en una unidad de cuidados intensivos no podían respirar espontáneamente, por lo que ameritaron apoyo ventilatorio invasivo y no invasivo. Hasta el momento no se ha determinado si las alteraciones neurológicas tempranas como la hiposmia o anosmia, disgeusia o ageusia, cefalea y vértigo son significativas en la progresión a la forma grave de la enfermedad y se relacionan con la entrada al sistema nervioso central a través de los nervios periféricos. Considerando la gran similitud entre SARS-CoV y SARS-CoV-2 y que la severidad del cuadro que conduce a la muerte no puede ser explicado únicamente por la afección pulmonar, es importante determinar si la invasión potencial del SARS-CoV-2 al sistema nervioso central es parcialmente responsable del componente respiratorio severo que presentan los pacientes con COVID-19.

Severe infection due to the SARS-CoV-2 coronavirus: Experience of a tertiary hospital with COVID-19 patients during the 2020 pandemic. / Infección grave por coronavirus SARS-CoV-2: experiencia en un hospital de tercer nivel con pacientes afectados por COVID-19 durante la pandemia 2020.

OBJECTIVE: To describe the clinical and respiratory characteristics of a cohort of 43 patients with COVID-19 after an evolutive period of 28 days. DESIGN: A prospective, single-center observational study was carried out. SETTING: Intensive care. PATIENTS: Patients admitted due to COVID-19 and respiratory failure. INTERVENTIONS: None. VARIABLES: Automatic recording was made of demographic variables, severity parameters, laboratory data, assisted ventilation (HFO: high-flow oxygen therapy and IMV: invasive mechanical ventilation), oxygenation (PaO2, PaO2/FiO2) and complications. The patients were divided into three groups: survivors (G1), deceased (G2) and patients remaining under admission (G3). The chi-squared test or Fisher exact test (categorical variables) was used, along with the Mann-Whitney U-test or Wilcoxon test for analyzing the differences between medians. Statistical significance was considered for p<0.05. RESULTS: A total of 43 patients were included (G1=28 [65.1%]; G2=10 [23.3%] and G3=5 [11.6%]), with a mean age of 65 years (range: 52-72), 62% males, APACHE II 18 (15-24), SOFA 6 (4-7). Arterial hypertension (30.2%) and obesity (25.6%) were the most frequent comorbidities. High-flow oxygen therapy was used in 62.7% of the patients, with failure in 85%. In turn, 95% of the patients required IMV and 85% received ventilation in prone decubitus. In the general population, initial PaO2/FiO2 improved after 7 days (165 [125-210] vs.194 [153-285]; p=0.02), in the same way as in G1 (164 [125-197] vs. 207 [160-294]; p=0.07), but not in G2 (163 [95-197] vs. 135 [85-177]). No bacterial coinfection was observed. The incidence of IMV-associated pneumonia was high (13 episodes/1000 days of IMV). CONCLUSIONS: Patients with COVID-19 require early IMV, a high frequency of ventilation in prone decubitus, and have a high incidence of failed HFO. The lack of improvement of PaO2/FiO2 at 7 days could be a prognostic marker. .

Simultaneous mechanical ventilation of several patients with a single ventilator.

INTRODUCTION: Simultaneous mechanical ventilation of several patients with a single ventilator might reduce the deficit of these devices for the care of patients with acute respiratory failure due to Covid-19. OBJECTIVE: To communicate the results of a mechanical ventilation exercise with a ventilator in a lung simulator, and simultaneously in two and four. RESULTS: No statistically significant differences were observed between programmed, recorded and measured positive end-expiratory pressure, mean airway pressure and peak pressure, except when simultaneously ventilating four lung simulators. CONCLUSIONS: Simultaneous mechanical ventilation should be implemented by medical personnel with experience in the procedure, be restricted to two patients and carried out in the intensive care unit.

INTRODUCCIÓN: La ventilación mecánica simultánea a varios pacientes con un solo ventilador podría disminuir el déficit de esos dispositivos para atender a los enfermos con insuficiencia respiratoria aguda por Covid-19. OBJETIVO: Comunicar los resultados de un ejercicio de ventilación mecánica con un ventilador en un simulador de pulmón, y simultáneamente en dos y cuatro. RESULTADOS: No se observaron diferencias estadísticamente significativas entre la presión positiva al final de la espiración, presión media de la vía aérea y presión pico programadas, registradas y medidas, excepto al ventilar simultáneamente cuatro simuladores de pulmón. CONCLUSIONES: La ventilación mecánica simultánea debe ser instaurada por personal médico con experiencia en el procedimiento, restringirse a dos pacientes y ser realizada en la unidad de cuidados intensivos.