Switches in non-invasive respiratory support strategies during acute hypoxemic respiratory failure: Need to monitoring from a retrospective observational study

Objective To explore combined non-invasive-respiratory-support (NIRS) patterns, reasons for NIRS switching, and their potential impact on clinical outcomes in acute-hypoxemic-respiratory-failure (AHRF) patients. Design Retrospective, single-center observational study. Setting Intensive Care Medicine. Patients AHRF patients (cardiac origin and respiratory acidosis excluded) underwent combined NIRS therapies such as non-invasive-ventilation (NIV) and High-Flow-Nasal-Cannula (HFNC). Interventions Patients were classified based on the first NIRS switch performed (HFNC-to-NIV or NIV-to-HFNC), and further specific NIRS switching strategies (NIV trial-like vs. Non-NIV trial-like and single vs. multiples switches) were independently evaluated. Main variables of interest Reasons for switching, NIRS failure and mortality rates. Results A total of 63 patients with AHRF were included, receiving combined NIRS, 58.7% classified in the HFNC-to-NIV group and 41.3% in the NIV-to-HFNC group. Reason for switching from HFNC to NIV was AHRF worsening (100%), while from NIV to HFNC was respiratory improvement (76.9%). NIRS failure rates were higher in the HFNC-to-NIV than in NIV-to-HFNC group (81% vs. 35%, p < 0.001). Among HFNC-to-NIV patients, there was no difference in the failure rate between the NIV trial-like and non-NIV trial-like groups (86% vs. 78%, p = 0.575) but the mortality rate was significantly lower in NIV trial-like group (14% vs. 52%, p = 0.02). Among NIV to HFNC patients, NIV failure was lower in the single switch group compared to the multiple switches group (15% vs. 53%, p = 0.039), with a shorter length of stay (5 [2–8] vs. 12 [8–30] days, p = 0.001). Conclusions NIRS combination is used in real life and both switches’ strategies, HFNC to NIV and NIV to HFNC, are common in AHRF management. Transitioning from HFNC to NIV is suggested as a therapeutic escalation and in this context performance of a NIV-trial could be beneficial. ... (AU)

Objetivo Explorar los patrones combinados de soporte-respiratorio-no-invasivo (SRNI), las razones para cambiar de SRNI y su potencial impacto en los resultados clínicos en pacientes con insuficiencia-respiratoria-aguda-hipoxémica (IRAH). Diseño Estudio observacional retrospectivo unicéntrico. Ámbito Cuidados Intensivos. Pacientes Pacientes con IRAH (excluyendo causa cardíaca y acidosis respiratoria) que recibieron tanto ventilación-no-invasiva (VNI) como cánula-nasal-de-alto-flujo (CNAF). Intervenciones Se categorizó a los pacientes según el primer cambio de SRNI realizado (CNAF-to-VNI o VNI-to-CNAF) y se evaluaron estrategias específicas de SRNI (VNI trial-like vs. Non-VNI trial-like y cambio único vs. múltiples cambios de NIRS) de manera independiente. Variables de interés principales Razones para el cambio, así como las tasas de fracaso de SRNI y la mortalidad. Resultados Un total de 63 pacientes recibieron SRNI combinado, 58,7% clasificados en el grupo CNAF-to-VNI y 41,3% en el grupo VNI-to-CNAF. Los cambios de CNAF a VNI ocurrieron por empeoramiento de la IRHA (100%) y de VNI a CNAF por mejora respiratoria (76.9%). Las tasas de fracaso de SRNI fueron mayores de CNAF a VNI que de VNI a CNAF (81% vs. 35%, p < 0.001). Dentro de los pacientes de CNAF a VNI, no hubo diferencia en las tasas de fracaso entre los grupos VNI trial-like y no-VNI trial-like (86% vs. 78%, p = 0.575), pero la mortalidad fue menor en el grupo VNI trial-like (14% vs. 52%, p = 0.02). Dentro de los pacientes de VNI a CNAF, el fracaso de VNI fue menor en grupo de cambio único vs. múltiple (15% vs. 53%, p = 0.039). Conclusiones Los cambios de estrategia de SRNI son comunes en el manejo clínico diario de la IRHA. El cambio de CNAF a VNI impresiona de ser una escalada terapéutica y en este contexto la realización de un VNI-trial puede ser beneficioso. Al contrario, cambiar de VNI a CNAF impresiona de ser una desescalada terapéutica y parece segura si no hay fracaso ... (AU)

Effectiveness of Helmet-CPAP in mild to moderate coronavirus type 2 hypoxemia: An observational study.

OBJECTIVE: To determine the relative effectiveness of Helmet-CPAP (H_CPAP) with respect to high-flow nasal cannula oxygen therapy (HFNO) in avoiding greater need for intubation or mortality in a medium complexity hospital in Chile during the year 2021. DESIGN: Cohort analytical study, single center. SETTING: Units other than intensive care units. PATIENTS: Records of adults with mild to moderate hypoxemia due to coronavirus type 2. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Need for intubation or mortality. RESULTS: 159 patients were included in the study, with a ratio by support of 2:10 (H_CPAP:HFNO). The 46.5% were women, with no significant differences by sex according to support (p = 0.99, Fisher test). The APACHE II score, for HFNO, had a median of 10.5, 3.5 units higher than H_CPAP (p < 0.01, Wilcoxon rank sum). The risk of intubation in HFNO was 42.1% and in H_CPAP 3.8%, with a significant risk reduction of 91% (95% CI: 36.9%-98.7%; p < 0.01). APACHE II does not modify or confound the support and intubation relationship (p > 0.2, binomial regression); however, it does confound the support and mortality relationship (p = 0.82, RR homogeneity test). Despite a 79.1% reduction in mortality risk with H_CPAP, this reduction was not statistically significant (p = 0.11, binomial regression). CONCLUSIONS: The use of Helmet CPAP, when compared to HFNO, was an effective therapeutic ventilatory support strategy to reduce the risk of intubation in patients with mild to moderate hypoxemia caused by coronavirus type 2 in inpatient units other than intensive care. The limitations associated with the difference in size, age and severity between the arms could generate bias.

Pacientes críticos COVID-19 atendidos por anestesiólogos en el Noroeste de España: estudio multicéntrico, prospectivo, observacional / Critically ill COVID-19 patients attended by anesthesiologists in northwestern Spain: a multicenter prospective observational study

Antecedentes y objetivos: Existe poca información sobre la evolución, complicaciones y los tratamientos recibidos por los pacientes críticos con COVID-19 que requieren ingreso en una unidad de cuidados intensivos (UCI). El objetivo de este estudio es describir la evolución clínica, los tratamientos utilizados, las complicaciones y resultados de pacientes críticos COVID-19 ingresados en siete UCI de Anestesiología en la Región de Galicia durante el pico de la pandemia en marzo-abril 2020. Métodos: Entre el 21 de marzo y el 19 de abril de 2020 evaluamos a todos los pacientes críticos COVID-19 ingresados en las UCI de Anestesiología de siete hospitales en Galicia, en el Noroeste de España. Los resultados, complicaciones y los tratamientos administrados se registraron hasta el 6 de mayo de 2020, fecha final del seguimiento. Resultados: Un total de 97 pacientes críticos COVID-19 fueron incluidos. Durante su estancia en UCI, 80 pacientes (82,5%) necesitaron ventilación mecánica, y 22 pacientes (22,7%) traqueotomía. El decúbito prono se usó frecuentemente en pacientes intubados (67,5%) y despiertos (27,8%). Las medicaciones usadas fueron antivirales (92,7%), corticoides (93,8%), tocilizumab (57,7%), y dosis intermedias y altas de anticoagulantes (83,5%). Las complicaciones más frecuentes fueron infecciones adquiridas en UCI (52,6%), eventos trombóticos (16,5%), y reintubaciones (9,3%). Tras un seguimiento medio de 42 (34-45) días, 15 pacientes fallecieron (15,5%), 73 pacientes (75,2%) habían sido dados de alta de UCI y nueve pacientes (9,3%) permanecían todavía en la unidad. Conclusiones: Un alto porcentaje de nuestros pacientes críticos COVID-19 requirieron ventilación mecánica, posición prona, medicaciones antivirales, corticoides y anticoagulantes. Las complicaciones en UCI fueron frecuentes, principalmente infecciones y eventos trombóticos. Tuvimos una mortalidad relativamente baja del 15,5%.(AU)

Background and objectives: There are limited information on outcome, complications and treatments of critically ill COVID-19 patients requiring admission to an intensive care unit (ICU). The aim of this study is to describe the clinical ICU course, treatments used, complications and outcomes, of critically ill COVID-19 patients admitted in seven ICU in Galicia region during the 2020 March-April pandemic peak. Methods: Between March 21 and April 19, 2020, we evaluated critically ill COVID-19 patients admitted to the ICU of Anesthesia of seven hospitals in Galicia, northwestern Spain. Outcome, complications, and treatments were monitored until May 6, 2020, the final date of follow-up. Results: A total of 97 critically ill COVID-19 patients were included. During ICU stay, mechanical ventilation became necessary in 80 (82.5%) patients, and tracheostomy in 22 (22.7%) patients. Prone position was used frequently in both intubated (67.5%) and awake (27.8%) patients. Medications consisted of antivirals agents (92.7%), corticosteroids (93.8%), tocilizumab (57.7%), and intermediate or high doses of anticoagulants (83.5%). The most frequent complications were ICU-acquired infection (52.6%), thrombosis events (16.5%), and reintubation (9.3%). After a median follow-up of 42 (34-45) days, 15 patients (15.5%) deceased, 73 patients (75.2%) had been discharged from ICU, and nine patients (9.3%) were still in the ICU. Conclusions: A high proportion of our critically ill COVID-19 patients required mechanical ventilation, prone positioning, antiviral medication, corticosteroids, and anticoagulants. ICU complications were frequent, mainly infections and thrombotic events. We had a relatively low mortality of 15,5%.(AU)

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

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

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

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

Predictors of mechanical ventilation and mortality in critically ill patients with COVID-19 pneumonia / Predictores de ventilación mecánica y mortalidad en pacientes críticos con neumonía por COVID-19

Objective To determine if potential predictors for invasive mechanical ventilation (IMV) are also determinants for mortality in COVID-19-associated acute respiratory distress syndrome (C-ARDS). Design Single center highly detailed longitudinal observational study. Setting Tertiary hospital ICU: two first COVID-19 pandemic waves, Madrid, Spain. Patients or participants : 280 patients with C-ARDS, not requiring IMV on admission. Interventions None. Main variables of interest : Target: endotracheal intubation and IMV, mortality. Predictors: demographics, hourly evolution of oxygenation, clinical data, and laboratory results. Results The time between symptom onset and ICU admission, the APACHE II score, the ROX index, and procalcitonin levels in blood were potential predictors related to both IMV and mortality. The ROX index was the most significant predictor associated with IMV, while APACHE II, LDH, and DaysSympICU were the most with mortality. Conclusions According to the results of the analysis, there are significant predictors linked with IMV and mortality in C-ARDS patients, including the time between symptom onset and ICU admission, the severity of the COVID-19 waves, and several clinical and laboratory measures. These findings may help clinicians to better identify patients at risk for IMV and mortality and improve their management. (AU)

Objetivo Determinar si las variables clínicas independientes que condicionan el inicio de ventilación mecánica invasiva (VMI) son los mismos que condicionan la mortalidad en el síndrome de distrés respiratorio agudo asociado con COVID-19 (C-SDRA). Diseño Estudio observacional longitudinal en un solo centro. Ámbito UCI, hospital terciario: primeras dos olas de COVID-19 en Madrid, España. Pacientes o participantes 280 pacientes con C-SDRA que no requieren VMI al ingreso en UCI. Intervenciones Ninguna. Principales variables de interés Objetivo: VMI y Mortalidad. Predictores: demográficos, variables clínicas, resultados de laboratorio y evolución de la oxigenación. Resultados El tiempo entre el inicio de los síntomas y el ingreso en la UCI, la puntuación APACHE II, el índice ROX y los niveles de procalcitonina en sangre eran posibles predictores relacionados tanto con la IMV como con la mortalidad. El índice ROX fue el predictor más significativo asociada con la IMV, mientras que APACHE II, LDH y DaysSympICU fueron los más influyentes en la mortalidad. Conclusiones Según los resultados obtenidos se identifican predictores significativos vinculados con la VMI y mortalidad en pacientes con C-ARDS, incluido el tiempo entre el inicio de los síntomas y el ingreso en la UCI, la gravedad de las olas de COVID-19 y varias medidas clínicas y de laboratorio. Estos hallazgos pueden ayudar a los médicos a identificar mejor a los pacientes en riesgo de IMV y mortalidad y mejorar su manejo. (AU)

Switches in non-invasive respiratory support strategies during acute hypoxemic respiratory failure: Need to monitoring from a retrospective observational study.

OBJECTIVE: To explore combined non-invasive-respiratory-support (NIRS) patterns, reasons for NIRS switching, and their potential impact on clinical outcomes in acute-hypoxemic-respiratory-failure (AHRF) patients. DESIGN: Retrospective, single-center observational study. SETTING: Intensive Care Medicine. PATIENTS: AHRF patients (cardiac origin and respiratory acidosis excluded) underwent combined NIRS therapies such as non-invasive-ventilation (NIV) and High-Flow-Nasal-Cannula (HFNC). INTERVENTIONS: Patients were classified based on the first NIRS switch performed (HFNC-to-NIV or NIV-to-HFNC), and further specific NIRS switching strategies (NIV trial-like vs. Non-NIV trial-like and single vs. multiples switches) were independently evaluated. MAIN VARIABLES OF INTEREST: Reasons for switching, NIRS failure and mortality rates. RESULTS: A total of 63 patients with AHRF were included, receiving combined NIRS, 58.7% classified in the HFNC-to-NIV group and 41.3% in the NIV-to-HFNC group. Reason for switching from HFNC to NIV was AHRF worsening (100%), while from NIV to HFNC was respiratory improvement (76.9%). NIRS failure rates were higher in the HFNC-to-NIV than in NIV-to-HFNC group (81% vs. 35%, p < 0.001). Among HFNC-to-NIV patients, there was no difference in the failure rate between the NIV trial-like and non-NIV trial-like groups (86% vs. 78%, p = 0.575) but the mortality rate was significantly lower in NIV trial-like group (14% vs. 52%, p = 0.02). Among NIV to HFNC patients, NIV failure was lower in the single switch group compared to the multiple switches group (15% vs. 53%, p = 0.039), with a shorter length of stay (5 [2-8] vs. 12 [8-30] days, p = 0.001). CONCLUSIONS: NIRS combination is used in real life and both switches' strategies, HFNC to NIV and NIV to HFNC, are common in AHRF management. Transitioning from HFNC to NIV is suggested as a therapeutic escalation and in this context performance of a NIV-trial could be beneficial. Conversely, switching from NIV to HFNC is suggested as a de-escalation strategy that is deemed safe if there is no NIRS failure.

Efecto de la duración del decúbito prono en pacientes con SDRA durante la pandemia por SARS-CoV-2 / Effect of duration of prone position in ARDS patients during SARS-CoV-2 pandemic

Objetivo: Describir las características de los pacientes con síndrome de distrés respiratorio agudo por neumonía bilateral por COVID-19 en ventilación mecánica invasiva (VMI) y analizar el efecto del decúbito prono prolongado>24h (DPP) respecto al decúbito prono<24h (DP). Diseño: Estudio observacional retrospectivo descriptivo. Análisis uni y bivariante. Ámbito: Servicio de Medicina Intensiva del Hospital General Universitario de Elche. Participantes: Pacientes con neumonía por SARS-CoV-2 (2020-2021) en VMI por síndrome de distrés respiratorio agudo moderado-severo. Intervenciones: VMI. Maniobras de DP. Variables de interés principales: Sociodemográficas; analgosedación; bloqueo neuromuscular; DP (duración), estancia y mortalidad en UCI, días de VMI; complicaciones no infecciosas; infecciones asociadas a la asistencia sanitaria. Resultados: Cincuenta y un pacientes precisaron DP y de ellos 31 (69,78%) requirieron DPP. No se encontraron diferencias en las características iniciales de los pacientes (sexo, edad, comorbilidades, gravedad inicial, o en el tratamiento antiviral y antiinflamatorio recibido). Los pacientes con DPP presentaron menor tolerancia a la ventilación en decúbito supino (61,29 vs. 89,47%, p=0,031), mayor estancia hospitalaria (41 vs. 30 días, p=0,023), más días de VMI (32 vs. 20 días, p=0,032), mayor duración del tratamiento con bloqueo neuromuscular (10,5 vs. 3 días, p=0,0002), así como un mayor porcentaje de episodios de obstrucción del tubo orotraqueal (48,39 vs. 15%, p=0,014). Conclusiones: El DPP se asoció con mayor uso de recursos y complicaciones en pacientes con síndrome de distrés respiratorio agudo moderado-severo por COVID-19. (AU)

Objective: To describe the characteristics of patients with acute respiratory distress syndrome due to bilateral COVID-19 pneumonia on invasive mechanical ventilation (IMV) and analyze the effect of prolonged prone decubitus>24h (PPD) compared to prone decubitus<24h (PD). Design: Retrospective observational descriptive study. Uni and bivariate analysis. Setting: Department of Intensive Care Medicine. General University Hospital of Elche. Participants: Patients with SARS-CoV-2 pneumonia (2020–2021) in VMI for moderate-severe acute respiratory distress syndrome, ventilated in PD. Interventions: IMV. PD maneuvers. Main variables of interest: Sociodemographic; analgo-sedation; neuromuscular blockade; PD (duration), ICU stay and mortality, days of IMV; non-infectious complications; health care-associated infections. Results: Fifty-one patients required PD and of these 31 (69.78%) required PPD. No differences were found in patient characteristics (sex, age, comorbidities, initial severity, antiviral and anti-inflammatory treatment received). Patients on PPD had lower tolerance to supine ventilation (61.29 vs. 89.47%, p=0.031), longer hospital stay (41 vs. 30 days, p=0.023), more days of IMV (32 vs. 20 days, p=0.032), longer duration of neuromuscular blockade (10.5 vs. 3 days, p=0.0002), as well as a higher percentage of episodes of orotracheal tube obstruction (48.39 vs. 15%, p=0.014). Conclusions: PPD was associated with higher resource use and complications in patients with moderate-severe acute respiratory distress syndrome by COVID-19. (AU)

Aplicaciones e implicaciones de la pausa al final de la inspiración en ventilación mecánica / Applications and implications of end-inspiratory pause in mechanical ventilation / Aplicações e implicações da pausa ao final da inspiração na ventilação mecânica

Resumen: El uso de la pausa al final de la inspiración (PFI) en ventilación mecánica data de hace más de 50 años y con mayor impulso en la década de los 70, se le atribuye una mejoría en la presión parcial de oxígeno arterial (PaO2) al incrementar la presión media de la vía aérea (Pma), mayor aclaramiento de la presión parcial de dióxido de carbono arterial (PaCO2) y permite la monitorización de la presión meseta (Pmeseta) en la mecánica ventilatoria; sin embargo, los estudios clínicos sobre su uso son escasos y controversiales. En este artículo se abordan los mecanismos fisiológicos, fisiopatológicos y la evidencia sobre el uso de la PFI en ventilación mecánica (VM).

Abstract: The use of the end inspiratory pause (EIP) in mechanical ventilation has been going on for more than 50 years and with greater momentum in the 1970s, an improvement in the partial pressure of arterial oxygen (PaO2) is attributed to the increase mean airway pressure, greater clearance of partial pressure of arterial carbon dioxide and allows monitoring of plateau pressure in ventilatory mechanics; However, the Clinical studies on its use are few and controversial. This article addresses the physiological and pathophysiological mechanisms and the evidence on the use of EIP in mechanical ventilation.

Resumo: A utilização da pausa ao final da inspiração (PFI) na ventilação mecânica remonta a mais de 50 anos e com maior impulso na década de 70, atribui-se uma melhora na pressão parcial de oxigênio arterial (PaO2) pelo aumento da pressão média das vias aéreas (Pma), uma maior depuração da pressão parcial de dióxido de carbono arterial (PaCO2) e permite a monitorização da pressão de platô (Pplateau) na mecânica ventilatória, porém estudos Os dados clínicos sobre seu uso são escassos e controversos. Este artigo aborda os mecanismos fisiológicos e fisiopatológicos e as evidências sobre o uso do PFI na ventilação mecânica (VM).

Factores de riesgo para el desarrollo de síndrome de distrés respiratorio agudo: un estudio de casos y controles

Introducción: El síndrome de distrés respiratorio agudo (SDRA) es una importante causa de falla respiratoria aguda, asociado a un riesgo significativo de mortalidad; a pesar de los avances actuales en ventilación mecánica y en ventilación pulmonar protectora. Objetivo: Determinar factores de riesgo para el desarrollo de SDRA en niños con más de 48 horas de ventilación mecánica. Materiales y Métodos: Se diseñó un estudio de casos y controles, donde se compararon 61 niños con SDRA con 183 controles, con edades entre 1 mes y 15 años. Fue creado un modelo de regresión logística para evaluar el efecto sobre el riesgo. Resultados: En el análisis univariable los factores asociados a SDRA fueron: PELOD, contusión pulmonar, politraumatismo, shock, transfusión de glóbulos rojos, sobrecarga de fluidos, relación PaO2/FiO2, índice de oxigenación, PEEP y pH sérico. Mediante regresión logística binaria se identificó como predictores independientes asociados al desarrollo del SDRA: Más de 3 transfusiones de glóbulos rojos (OR: 1.5; 95% IC 1.2 - 1.9, p = 0.010), sobrecarga de fluidos (OR: 1.3; 95% IC 1.1 - 5.7, p = 0.012) e índice de oxigenación mayor de 8 sin otros criterios de SDRA (OR: 1.9; 95% IC 1.4 - 2.6, p < 0.0001). La mortalidad fue mayor en el grupo con SDRA (37.7% vs. 6.0%, p < 0.0001). Conclusión: Más de 3 transfusiones de glóbulos rojos, la sobrecarga de fluidos y el índice de oxigenación mayor de 8 son factores de riesgo para el desarrollo de SDRA. El reconocimiento temprano de factores de riesgo para SDRA podría contribuir a disminuir su desarrollo.

Introduction: The acute respiratory distress syndrome (ARDS) is an important cause of acute respiratory failure, is associated with a significant risk of mortality; despite current progress in mechanical ventilation and protective lung ventilation. Objective: Determine risk factors for the development of ARDS in children with more than 48 hours of mechanical ventilation. Materials and Methods: Was designed a case-control study, where were compared 61 children with ARDS with 183 controls without ARDS with age between 1 month and 15 years. A logistic regression model was created to evaluate the effect on the risk. Results: In univariate analysis, the factors associated with ARDS were: PELOD score, pulmonary contusion, multiple trauma, shock, red blood cell transfusion, fluid overload, PaO2/FiO2 ratio, oxygenation index, PEEP and pH. Through binary logistic regression was identified as predictors for the development of ARDS: More than 3 red blood cell transfusions (OR: 1.5; 95% CI 1.2 - 1.9, p = 0.010), fluid overload (OR: 1.3; 95% CI 1.1 - 5.7, p = 0.012) and oxygenation index more than 8 without other criteria for ARDS (OR: 1.9; 95% CI 1.4 - 2.6, p < 0.0001). Mortality was higher in the group with ARDS (37.7% vs. 6.0%, p < 0.0001). Conclusion: More than 3 red blood cell transfusions, fluid overload and oxygenation index more than 8 are risk factors for the development of ARDS. Early recognition of risk factors of ARDS could help decrease its development.

OLA strategy for ARDS: Its effect on mortality depends on achieved recruitment (PaO2/FiO2) and mechanical power. Systematic review and meta-analysis with meta-regression / Estrategia OLA para el SDRA: su efecto en la mortalidad depende del reclutamiento alcanzado (PaO2/FiO2) y la potencia mecánica. Revisión sistemática y metaanálisis con metarregresión

Objective: The “Open Lung Approach” (OLA), that includes high levels of positive end-expiratory pressure coupled with limited tidal volumes, is considered optimal for adult patients with ARDS. However, many previous meta-analyses have shown only marginal benefits of OLA on mortality but with statistical heterogeneity. It is crucial to identify the most likely moderators of this effect. To determine the effect of OLA strategy on mortality of ventilated ARDS patients. We hypothesized that the degree of recruitment achieved in the control group (PaO2/FiO2 ratio on day 3 of ventilation), and the difference in Mechanical Power (MP) or Driving Pressure (DP) between experimental and control groups will be the most likely sources of heterogeneity. Design: A Systematic Review and Meta-analysis was performed according to PRISMA statement and registered in PROSPERO database. We searched only for randomized controlled trials (RCTs). GRADE guidelines were used for rating the quality of evidence. Publication bias was assessed. For the Meta-analysis, we used a Random Effects Model. Sources of heterogeneity were explored with Meta-Regression, using a priori proposed set of possible moderators. For model comparison, Akaike's Information Criterion with the finite sample correction (AICc) was used. Patients: Fourteen RCTs were included in the study. Results: Evidence of publication bias was detected, and quality of evidence was downgraded. Pooled analysis did not show a significant difference in the 28-day mortality between OLA strategy and control groups. Overall risk of bias was low. The analysis detected statistical heterogeneity. The two “best” explicative meta-regression models were those that used control PaO2/FiO2 on day 3 and difference in MP between experimental and control groups. The DP and MP models were highly correlated. Conclusions: There is no clear benefit of OLA strategy on mortality of ARDS patients, with significant heterogeneity among RCTs. ... (AU)

Objetivo: La Estrategia Open Lung (EOL), que incluye niveles elevados de presión positiva teleespiratoria junto con volumen corriente bajo, es considerada como el «patrón oro» para los pacientes adultos con SDRA. Sin embargo, varios metaanálisis previos han mostrado únicamente beneficios marginales de la EOL en la disminución de la mortalidad, aunque con gran heterogeneidad estadística. Es crucial identificar los moderadores más probables, así como determinar el efecto de la estrategia EOL en la mortalidad de los pacientes ventilados con SDRA. La hipótesis fue que el grado de reclutamiento alcanzado en el grupo control (cociente PaO2/FiO2 en el día3 de ventilación) y la diferencia en potencia mecánica (MP) o driving pressure (DP) entre el grupo experimental y el grupo control son la fuente más probable de heterogeneidad. Diseño Se realizó una revisión sistemática y metaanálisis de acuerdo con la declaración PRISMA, y se registró en la base de datos PROSPERO (N.° CRD42020179778). Se seleccionaron únicamente ensayos clínicos aleatorizados (ECA). Se estratificó la calidad de la evidencia de acuerdo con la metodología GRADE. Se evaluó el sesgo de publicación. Para el metaanálisis se utilizó el modelo de efectos aleatorios. Se exploraron las fuentes de heterogeneidad mediante metarregresión utilizando a priori un conjunto establecido de posibles moderadores. Para el modelo de comparación se utilizó el criterio de información de Akaike con la corrección para muestras pequeñas (AICc). Pacientes Se incluyeron 14 ECA en el estudio. Resultados Se detectó un sesgo de publicación, y la calidad fue degradada. El análisis combinado no mostró una diferencia estadísticamente significativa en la mortalidad en el día28 entre la estrategia EOL y los grupos control. El riesgo total de sesgo fue bajo. El análisis detectó heterogeneidad estadística. ... (AU)

Hemodynamic resuscitation with fluids bolus and norepinephrine increases severity of lung damage in an experimental model of septic shock / La resucitación hemodinámica con bolos de fluidos y noradrenalina incrementa la severidad del daño pulmonar en un modelo experimental de shock séptico

Objective Hemodynamic resuscitation is considered a cornerstone of the initial treatment of septic shock. However, there is growing concern about its side effects. Our objective was to assess the relationship between fluid administration and norepinephrine infusion and the development of lung injury. Design Randomized in vivo study in rabbits. Setting University animal research laboratory. Patients Eighteen New Zealand rabbits. Control group (SHAM, n=6), Sepsis group with or without hemodynamic resuscitation (ETX-R, n=6; ETX-NR, n=6). Interventions Sepsis was induced by intravenous lipopolysaccharide administration and animals were followed-up for 4h. Hemodynamic resuscitation with Ringer lactate (20mL·kg−1) was administered and later norepinephrine was initiated 3h after sepsis induction. At the end, the left lung was excised. Main variables of interestAn indwelling arterial catheter and an esophageal Doppler were placed. Lung mechanics were monitored with side stream spirometry. Lung damage was analyzed by histopathological examination. Results The SHAM group did not show hemodynamic or respiratory changes. Lipopolysaccharide administration aimed an increase in cardiac output and arterial hypotension. In the ETX-NR group, animals remained hypotensive until the end of the experiment. Resuscitation with fluids and norepinephrine reversed arterial hypotension. Compared to the ETX-NR group, the remaining lung of the ETX-R group showed greater accumulation of neutrophils and reactive type-II pneumocytes, thicker alveolar wall, alveolar hemorrhage and non-aerated pulmonary areas. Lung injury score was larger in the ETX-R group. Conclusions In our experimental study, following a strategy with bolus fluids and late norepinephrine used in the early phase of endotoxic septic shock has a negative influence on the development of lung injury. (AU)

Objetivo La resucitación hemodinámica es considerada piedra angular en el tratamiento inicial del shock séptico. Sin embargo, existe creciente preocupación sobre sus efectos indeseables. Nuestro objetivo fue evaluar la relación entre la administración de fluidos e infusión de noradrenalina y el desarrollo de lesión pulmonar. Diseño Estudio aleatorizado en animales vivos. Ámbito Laboratorio universitario de investigación. Participantes Dieciocho conejos de raza New Zealand White. Grupo control (SHAM, n=6), grupo séptico con o sin resucitación hemodinámica (ETX-R, n=6; ETX-NR, n=6). Intervención La sepsis fue inducida tras administración intravenosa de lipopolisacárido, y los animales fueron seguidos durante 4h. La resucitación hemodinámica mediante suero Ringer lactato (20ml·kg-1) y posterior noradrenalina fue iniciada a las 3h de ser inducida la sepsis. Al final del estudio, el pulmón izquierdo fue extraído. Principales variables de interés Fueron empleados catéter arterial y doppler esofágico. La mecánica pulmonar fue monitorizada con sensor de flujo. El daño pulmonar fue analizado mediante examen histopatológico. Resultados El grupo control no mostró cambios hemodinámicos ni respiratorios. La administración del lipopolisacárido produjo un incremento del gasto cardíaco e hipotensión arterial. En el grupo ETX-NR, los animales permanecieron hipotensos hasta el final del estudio. La resucitación con fluidos y noradrenalina revirtió la hipotensión arterial. Comparados con el grupo ETX-NR, en el grupo ETX-R el estudio histopatológico mostró mayor acumulación de neutrófilos, así como mayor presencia de neumocitos activados tipo II, engrosamiento de la pared alveolar, hemorragia alveolar y zonas pulmonares no aireadas. La escala final de daño pulmonar fue mayor en el grupo ETX-R. Conclusiones En nuestro estudio experimental ... (AU)

Ventilación mecánica invasiva en pacientes con COVID-19 en un hospital privado de México. Una serie de casos: descripción y evolución de un protocolo de intubación temprana / Invasive mechanical ventilation in patients with COVID-19 in a private hospital in Mexico. A case series: description and evolution of an early intubation protocol / Ventilação mecânica invasiva em pacientes com COVID-19 em um hospital privado no México. Uma série de casos: descrição e evolução de um protocolo de intubação precoce

Resumen: La mortalidad de los pacientes de COVID-19 en ventilación mecánica y las estrategias empleadas varían en la literatura. El objetivo de esta serie de casos es describir el curso clínico de pacientes en ventilación mecánica invasiva con COVID-19 y su desenlace a 28 días. Se incluyeron 21 pacientes con un promedio de edad de 49 ± 13 años, 81% de sexo masculino y 38% con al menos una comorbilidad. Las variables ventilatorias iniciales fueron PaO2/FiO2 de 135 ± 53, PEEP 12 cmH2O, presión meseta 26 ± 4.8 cmH2O, distensibilidad estática 32 ± 8.5 mL/cmH2O, driving pressure 15 ± 3.9 cmH2O y poder mecánico 19.2 ± 4 J/min. El 67% de los pacientes estuvieron en posición prono y en 76% se empleó bloqueante neuromuscular. Los desenlaces a 28 días fueron 21 días libres de ventilación mecánica y 14% de mortalidad.

Abstract: The mortality and ventilation strategies of COVID-19 ARDS vary in the literature. The objective of this case series is to describe the clinical course of patients on invasive mechanical ventilation with COVID-19 and its outcome at 28 days. Twenty-one patients were included with an average age of 49 ± 13 years, 81% male and 38% with at least one comorbidity. The initial ventilatory variables were PaO2/FiO2 of 135 ± 53, PEEP 12 cmH2O, plateau pressure 26 ± 4.8 cmH2O, static compliance 32 ± 8.5 mL/cmH2O, driving pressure 15 ± 3.9 cmH2O, and mechanical power 19.2 ± 4 J/min. 67% of the patients received prone position and in 76% a neuromuscular blocker was used. The 28-day outcomes were 21 days of mechanical ventilation-free days and 14% mortality.

Resumo: A mortalidade de pacientes com COVID-19 em ventilação mecânica e as estratégias utilizadas variam na literatura. O objetivo desta série de casos é descrever a evolução clínica de pacientes em ventilação mecânica invasiva com COVID-19 e sua evolução em 28 dias. Incluíram-se 21 pacientes com média de idade de 49 ± 13 anos, 81% do sexo masculino e 38% com pelo menos uma comorbidade. As variáveis ventilatórias iniciais foram PaO2/FiO2 135 ± 53, PEEP 12 cmH2O, pressão de platô 26 ± 4.8 cmH2O, complacência estática 32 ± 8.5 mL/cmH2O, pressão motriz 15 ± 3.9 cmH2O e potência mecânica 19.2 ± 4 J/min. 67% dos pacientes estavam em decúbito ventral e em 76% foi utilizado bloqueador neuromuscular. Os resultados aos 28 dias foram 21 dias sem ventilação mecânica e 14% de mortalidade.

Reclutamiento alveolar agresivo en el SDRA: más sombras que luces / Aggressive alveolar recruitment in ARDS: more shadows than lights

Reclutamiento alveolar en el síndrome de distrés respiratorio agudo (SDRA) se define como la entrada de gas en zonas previamente no ventiladas o en zonas pobremente ventiladas. El reclutamiento alveolar durante una maniobra de reclutamiento (MR) dependerá de la duración de la maniobra, del tejido pulmonar reclutable, del balance entre reclutamiento de áreas colapsadas y sobredistensión de las áreas ventiladas. La estimación del reclutamiento alveolar se realiza con la tomografía computarizada de tórax y,a pie de cama, con la construcción de curvas de volumen y presión, la ecografía pulmonar y la tomografía por impedancia. La evidencia científica nos indica que la utilización de las MR en pacientes con SDRA sigue sujeta a controversia. Estudios aleatorizados del SDRA o bien no han demostrado beneficio o bien han revelado un incremento de la mortalidad y, por ello, no se recomienda su uso rutinario. (AU)

Alveolar recruitment in acute respiratory distress syndrome (ARDS) is defined as the penetration of gas into previously unventilated areas or poorly ventilated areas. Alveolar recruitment during recruitment maneuvering (RM) depends on the duration of the maneuver, the recruitable lung tissue, and the balance between the recruitment of collapsed areas and over-insufflation of the ventilated areas. Alveolar recruitment is estimated using computed tomography of the lung and, at the patient bedside, through assessment of the recruited volume using pressure-volume curves and assessing lung morphology with pulmonary ultrasound and/or impedance tomography. The scientific evidence on RM in patients with ARDS remains subject to controversy. Randomized studies on ARDS have shown no benefit or have even reflected an increase in mortality. The routine use of RM is therefore not recommended. (AU)

Predictors of mechanical ventilation and mortality in critically ill patients with COVID-19 pneumonia.

OBJECTIVE: To determine if potential predictors for invasive mechanical ventilation (IMV) are also determinants for mortality in COVID-19-associated acute respiratory distress syndrome (C-ARDS). DESIGN: Single center highly detailed longitudinal observational study. SETTING: Tertiary hospital ICU: two first COVID-19 pandemic waves, Madrid, Spain. PATIENTS OR PARTICIPANTS: 280 patients with C-ARDS, not requiring IMV on admission. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Target: endotracheal intubation and IMV, mortality. PREDICTORS: demographics, hourly evolution of oxygenation, clinical data, and laboratory results. RESULTS: The time between symptom onset and ICU admission, the APACHE II score, the ROX index, and procalcitonin levels in blood were potential predictors related to both IMV and mortality. The ROX index was the most significant predictor associated with IMV, while APACHE II, LDH, and DaysSympICU were the most with mortality. CONCLUSIONS: According to the results of the analysis, there are significant predictors linked with IMV and mortality in C-ARDS patients, including the time between symptom onset and ICU admission, the severity of the COVID-19 waves, and several clinical and laboratory measures. These findings may help clinicians to better identify patients at risk for IMV and mortality and improve their management.

Prognostic value of the novel P/FPE index to classify ARDS severity: A cohort study / Valor pronóstico del nuevo índice P/FPE para clasificar la severidad del SDRA: Estudio de cohorte

Objective To evaluate the impact of the novel P/FPE index to classify ARDS severity on mortality of patients with ARDS. Design A retrospective cohort study. Setting Twelve-bed medical and surgical intensive care unit from January 2018 to December 2020. Patients A total of 217 ARDS patients managed with invasive mechanical ventilation >48h. Interventions None. Variables ARDS severity on day 1 and day 3 was measured based on PaO2/FiO2 ratio and P/FPE index [PaO2/(FiO2×PEEP)]. Primary outcome was the hospital mortality. Results Hospital mortality rate was 59.9%. Relative to PaO2/FiO2 ratio, 31.8% of patients on day 1 and 77.0% on day 3 were reclassified into a different category of ARDS severity by P/FPE index. The level of PEEP was lower by P/FPE index-based ARDS severity classification than by using PaO2/FiO2 ratio. The performance for predicting mortality of P/FPE index was superior to PaO2/FiO2 ratio in term of AROC (day 1: 0.72 vs. 0.62; day 3: 0.87 vs. 0.68) and CORR (day 1: 0.370 vs. 0.213; day 3: 0.634 vs. 0.301). P/FPE index improved prediction of risk of death compared to PaO2/FiO2 ratio as showed by the qNRI (day 1: 72.0%, p<0.0001; day 3: 132.4%, p<0.0001) and IDI (day 1: 0.09, p<0.0001; day 3: 0.31, p<0.0001). Conclusions Assessment of ARDS severity based on P/FPE index seems better than PaO2/FiO2 ratio for predicting mortality. The value of P/FPE index for clinical decision-making requires confirmation by randomized controlled trials (AU)

Objetivo Evaluar el impacto del índice P/FPE para clasificar la severidad del SDRA y su relación con la mortalidad. Diseño Estudio de cohorte retrospectivo. Contexto Unidad de cuidados intensivos polivalentes de 12 camas desde enero de 2018 hasta diciembre de 2020. Pacientes Se estudió a 217 pacientes con SDRA con ventilación invasiva>48 horas. Intervenciones Ninguna. Variables La severidad del SDRA se evaluó el primer y el tercer día, según el índice PaO2/FiO2 y el índice P/FPE (PaO2/[FiO2×PEEP]). El desenlace primario evaluado fue la mortalidad hospitalaria. Resultados La mortalidad hospitalaria fue 59,9%. Con relación al índice PaO2/FiO2, el 31,8% de los pacientes el día 1 y el 77,0% el día 3 fue reclasificado en categorías diferentes de severidad del SDRA mediante el índice P/FPE. El nivel de PEEP fue más bajo con el uso del índice P/FPE que con el PaO2/FiO2. La predicción de la mortalidad fue superior con el índice P/FPE que con PaO2/FiO2, en términos de AROC (día 1: 0,72 vs. 0,62; día 3: 0,87 vs. 0,68) y CORR (día 1: 0,370 vs. 0,213; día 3: 0,634 vs. 0,301). El índice P/FPE mejoró la predicción del riesgo de muerte comparado con el PaO2/FiO2, como demuestra el qNRI (día 1: 72,0%, p<0,0001; día 3: 132,4%, p<0,0001) y el IDI (día 1: 0,09, p<0,0001; día 3: 0,31, p<0,0001). Conclusiones La evaluación de severidad del SDRA mediante el índice P/FPE parece ser mejor que la del índice PaO2/FiO2 para predecir la mortalidad. El valor del P/FPE para la toma de decisiones clínicas requiere confirmación mediante ensayos clínicos (AU)

PEEP titration by EIT strategies for patients with ARDS: A systematic review and meta-analysis / Evaluación sistemática y metaanálisis de la estrategia eit para la titulación Peep en pacientes con sdra

Objective To determine which method of Positive End-expiratory Pressure (PEEP) titration is more useful, and to establish an evidence base for the clinical impact of Electrical Impedance Tomography (EIT) based individual PEEP setting which appears to be a promising method to optimize PEEP in Acute Respiratory Distress Syndrome (ARDS) patients. Design A systematic review and meta-analysis. Setting 4 databases (PUBMED, EMBASE, Web Of Science, and the Cochrane Library) from 1980 to December 2020 were performed. Participants Randomized clinical trials patients with ARDS. Main variables PaO2/FiO2-ratio and respiratory system compliance. Intervension The quality of the studies was assessed with the Cochrane risk and bias tool. Results 8 trials, including a total of 222 participants, were eligible for analysis. Meta-analysis demonstrates a significantly EIT-based individual PEEP setting for patients receiving higher PaO2/FiO2 ratio as compared to other PEEP titration strategies [5 trials, 202 patients, SMD 0.636, (95% CI 0.364−0.908)]. EIT-drived PEEP titration strategy did not significantly increase respiratory system compliance when compared to other peep titration strategies, [7 trials, 202 patients, SMD −0.085, (95% CI −0.342 to 0.172)]. Conclusions The benefits of PEEP titration with EIT on clinical outcomes of ARDS in placebo-controlled trials probably result from the visible regional ventilation of EIT. These findings offer clinicians and stakeholders a comprehensive assessment and high-quality evidence for the safety and efficacy of the EIT-based individual PEEP setting as a superior option for patients who undergo ARDS (AU)

Objetivo Para determinar qué método de valoración de la presión espirfinal positiva (PEEP) es más útil, y para establecer una base de evidencia para el impacto clínico de la tomode impedeléctrica (EIT) basada en el ajuste individual de PEEP que parece ser un método prometedor para optimizar la PEEP en pacientes con síndrome de dificultad respiraguda (ARDS). Diseño Una revisión sistemática y metanálisis. Ámbito Se realizaron 4 bases de datos (PUBMED, EMBASE, Web Of Science y Cochrane Library) de 1980 a diciembre de 2020. Participantes Ensayos clínicos aleatorizados de pacientes con SDRA. Variables principals PaO2/FiO2 ratio y compatibilidad respiratoria. Intervención La calidad de los estudios se evaluó con la Cochrane risk and bias tool. Resultados Ocho ensayos, incluyendo un total de 222 participantes, fueron elegibles para el análisis. El análisis de ≥ eta demuestra una configuración individual significativamente basada en MEITPpara pacientes que reciben una mayor proporción EE2/P PiO2en comparación con otras estrategias de titulación FOPEEP SMD CI. La estrategia de titulación de PEEP derivada del tie no aumentó significativamente el cumplimiento del sistema respiren comparación con otras estrategias de titulación de PEEP, [7 ensayos, 202 pacientes, DME -0,085, (IC del 95%: −0,342−0,172)]. Conclusiones Los beneficios de la valoración de la PEEP con EIT en los resultados clínicos de SDRA en ensayos controlados con placebo probablemente sean el resultado de la ventilación regional visible del EIT. Estos hallazgos ofrecen a los médicos y a las partes interesadas una evaluación integral y evidencia de alta calidad para la seguridad y eficacia de la configuración individual de PEEP basada en EIT como una opción superior para los pacientes que se someten a SDRA (AU)

Síndrome de Lemierre con distrés respiratorio / Lemierre’s syndrome with acute respiratory distress syndrome

Lemierre’s syndrome is a clinical triad of acute oropharyngeal infection, secondary local invasion and vein thrombosis often involving the internal jugular vein, along with evidence of systemic septic embolism. Usually affecting otherwise healthy adolescents and young adults, anaerobic Fusobacterium spp. are often implicated. Other bacterial species are sometimes found. While being a rare disease with a reported 14.4 cases per million person-years, it carries a mortality rate of 5 to 9%. Clinical presentation can be severe owing to septic shock, multiorgan dysfunction, septic embolization and acute respiratory distress syndrome requiring ICU admission. Treatment involves antibiotic therapy with anaerobic coverage and supportive care. Anticoagulation use is controversial and surgical treatment may be needed to control focus of infection. There is few quality evidence available regarding the clinical management of this syndrome. We report a case of Lemierre syndrome caused by Streptococcus hemolyticus group C, complicated with pulmonary septic embolism, necrotizing pneumonia, empyema and acute respiratory distress syndrome with a degree of severity that required the use of extracorporeal membrane oxygenation to support the patient. (AU)

Papel del ultrasonido pulmonar en la clasificación por fenotipos del SDRA por COVID-19 / Role of lung ultrasound in the classification by phenotypes of ARDS by COVID-19 / Papel da ultrassonografia pulmonar na classificação por fenótipos da SDRA por COVID-19

Resumen: Introducción: La mayoría de los pacientes con COVID-19 mecánicamente ventilados cumplen con los criterios de Berlín para síndrome de distrés respiratorio agudo (SDRA); sin embargo, se ha observado una discrepancia entre el grado de hipoxemia y la distensibilidad pulmonar. Basados en la mecánica respiratoria y hallazgos tomográficos se han propuesto dos fenotipos distintos: L y H, cada fenotipo podría beneficiarse de estrategias de ventilación distintas; sin embargo, realizar tomografías durante la pandemia resulta complicado. Objetivo: Determinar la utilidad del ultrasonido pulmonar para diferenciar los fenotipos del SDRA por COVID-19 mediante la correlación de lung ultrasound score (LUS) y la distensibilidad del sistema respiratorio. Material y métodos: Analizamos de forma prospectiva pacientes con COVID-19 bajo ventilación mecánica invasiva a su ingreso a la unidad de cuidados intensivos (UCI). Resultados: De un total de 90 pacientes, 62% hombres, mediana 60 años, SOFA siete puntos. La incidencia del fenotipo H fue 83.3%. El puntaje de aireación (LUS) tuvo una diferencia significativa entre ambos fenotipos (p = 0.001), con un área bajo la curva de 0.797 (p < 0.001). Con punto de corte para la predicción del fenotipo H: LUS > 18 puntos (sensibilidad 82.6%, especificidad 73.3%). Conclusión: El ultrasonido pulmonar valora de forma confiable el grado de aireación pulmonar y junto con la distensibilidad permite clasificar por fenotipos a los pacientes con SDRA por COVID-19.

Abstract: Introduction: Most mechanically ventilated COVID-19 patients meet the Berlin criteria for acute respiratory distress syndrome (ARDS), however, a discrepancy between the degree of hypoxemia and pulmonary distensibility has been observed. Based on respiratory mechanics and tomographic findings two distinct phenotypes have been proposed: L and H, each phenotype could benefit from distinct ventilation strategies, however, performing tomographic scans during pandemic is complicated. Objective: To determine the usefulness of lung ultrasound to differentiate ARDS phenotypes by COVID-19, by correlating LUS and respiratory system distensibility. Material and methods: We prospectively analyzed patients with COVID-19 under invasive mechanical ventilation on admission to the ICU. Results: Of a total of 90 patients, 62% men, median 60 years, SOFA 7 points. The incidence of phenotype H was 83.3%. LUS had a significant difference between both phenotypes (p = 0.001), with an area under the curve of 0.797 (p < 0.001). With cutoff point for phenotype H prediction: LUS >18 points (sensitivity 82.6%, specificity 73.3%). Conclusion: Lung ultrasound reliably assesses the degree of pulmonary aeration and, together with distensibility, allows the classification of patients with ARDS by COVID-19 phenotypes.

Resumo: Introdução: A maioria dos pacientes com COVID-19 ventilados mecanicamente atende aos critérios de Berlim para SDRA, no entanto, foi observada uma discrepância entre o grau de hipoxemia e a complacência pulmonar. Com base na mecânica respiratória e nos achados tomográficos, dois fenótipos diferentes foram propostos: L e H, cada fenótipo poderia se beneficiar de diferentes estratégias de ventilação, porém, realizar a tomografia durante a pandemia é complicado. Objetivo: Determinar a utilidade da ultrassonografia pulmonar para diferenciar os fenótipos de SDRA por COVID-19, correlacionando LUS e complacência do sistema respiratório. Material e métodos: Analisamos prospectivamente pacientes com COVID-19 sob ventilação mecânica invasiva na admissão à UTI. Resultados: De um total de 90 pacientes, 62% homens, idade média de 60 anos, SOFA 7 pontos. A incidência do fenótipo H foi de 83.3%. O LUS apresentou diferença significativa entre os dois fenótipos (p = 0.001), com área sob a curva de 0.797 (p < 0.001). Com ponto de corte para a predição do fenótipo H: LUS > 18 pontos (sensibilidade 82.6%, especificidade 73.3%). Conclusão: A ultrassonografia pulmonar avalia de forma confiável o grau de aeração pulmonar e, juntamente com a distensibilidade, permite que os pacientes com SDRA por COVID-19 sejam classificados por fenótipos.

Lesión pulmonar autoinflingida por el paciente en la Unidad de Cuidados Intensivos / Patient Self-Inflicted Lung Injury (P-SILI) in the Intensive Care Unit / Lesão pulmonar auto-infligida pelo paciente na Unidade de Cuidados Intensivos

Resumen: Hasta la fecha, no se ha demostrado superioridad de algún modo de ventilación mecánica invasiva en particular, la mayoría de los autores destacan la individualización de la programación y modalidad de la ventilación mecánica, teniendo en cuenta la presencia de asincronías y buscando el mejor confort del paciente, incluso la ventilación espontánea, aunque al parecer se asemeja a la manera fisiológica de la mecánica respiratoria, no está exenta de complicaciones. Tres mecanismos potenciales se proponen para el desarrollo de lesión pulmonar por esfuerzo respiratorio espontáneo: sobredistensión global y local, aumento de la perfusión pulmonar y la presencia de asincronías paciente-ventilador, derivadas en una lesión autoinfligida por el paciente o «P-SILI¼, por sus siglas en inglés Patient Self Inflicted Lung Injury. En los últimos 20 años se han desarrollado estrategias que permiten minimizar los riesgos asociados a la ventilación mecánica, la más importante de todas es mantener soporte ventilatorio guiado por metas, identificación del posible desarrollo del paciente y extubar al paciente lo más rápido posible, siempre y cuando sus condiciones lo permitan.

Abstract: To date, the superiority of any particular mode of invasive mechanical ventilation has not been demonstrated; most authors emphasize the individualization of the programming and modality of mechanical ventilation, taking into account the presence of asynchronies and seeking the best patient comfort; even spontaneous ventilation, although it seems to resemble the physiological manner of respiratory mechanics, is not free of complications. Three potential mechanisms are proposed for the development of lung injury by spontaneous respiratory effort: global and local overdistension, increased pulmonary perfusion and the presence of patient-ventilator asynchronies, resulting in a Patient Self-Inflicted Injury or «P-SILI¼. In the last twenty years, strategies have been developed to minimize the risks associated with mechanical ventilation, the most important of which is to maintain goal-directed ventilatory support, identify the possible development of the patient and extubate the patient as quickly as possible, as long as the patient's conditions allow it.

Resumo: Até o momento, nenhum modo específico de ventilação mecânica invasiva se mostrou superior, a maioria dos autores enfatiza a individualização da programação e modalidade de ventilação mecânica, levando em consideração a presença de assincronia e buscando o melhor conforto do paciente. Mesmo a ventilação espontânea, embora pareça assemelhar-se à maneira fisiológica da mecânica respiratória, não é isenta de complicações. Três mecanismos potenciais são propostos para o desenvolvimento de lesão pulmonar por esforço respiratório espontâneo: hiperdistensão global e local, aumento da perfusão pulmonar e presença de assincronia paciente-ventilador, derivada de uma lesão autoinfligida pelo paciente ou «P-SILI¼ por suas siglas em inglês patient self inflicted lung injury. Nos últimos vinte anos, foram desenvolvidas estratégias para minimizar os riscos associados à ventilação mecânica. O mais importante de tudo é manter o suporte ventilatório guiado por metas, identificar o possível desenvolvimento do paciente e extubar o paciente o mais rápido possível, enquanto suas condições permitirem.

Effect of the duration of prone position in ARDS patients during the SARS-CoV-2 pandemic.

OBJECTIVE: To describe the characteristics of patients with acute respiratory distress syndrome (ARDS) due to bilateral COVID-19 pneumonia on invasive mechanical ventilation (IMV), and to analyze the effect of prone position >24 h (prolonged) (PPP) compared to prone decubitus <24 h (PP). DESIGN: A retrospective observational descriptive study was carried out, with uni- and bivariate analyses. SETTING: Department of Intensive Care Medicine. Hospital General Universitario de Elche (Elche, Alicante, Spain). PARTICIPANTS: Patients with SARS-CoV-2 pneumonia (2020-2021) on IMV due to moderate-severe ARDS, ventilated in prone position (PP). INTERVENTIONS: IMV. PP maneuvers. MAIN VARIABLES OF INTEREST: Sociodemographic characteristics, analgo-sedation, neuromuscular blockade (NMB), PD duration, ICU stay and mortality, days of IMV, non-infectious complications, healthcare associated infections. RESULTS: Fifty-one patients required PP, and of these, 31 (69.78%) required PPP. No differences were observed in terms of patient characteristics (gender, age, comorbidities, initial severity, antiviral and antiinflammatory treatment received). Patients on PPP had poorer tolerance to supine ventilation (61.29% vs 89.47%, p = 0.031), longer hospital stay (41 vs 30 days, p = 0.023), more days of IMV (32 vs 20 days, p = 0.032), longer duration of NMB (10.5 vs 3 days, p = 0.0002), as well as a higher percentage of episodes of orotracheal tube obstruction (48.39% vs 15%, p = 0.014). CONCLUSIONS: PPP was associated with greater resource use and complications in patients with moderate-severe ARDS due to COVID-19.