Trauma resulting in rare avulsion-type renal injury and lobe migration: An uncommon case report.

In this case report, we discuss a rare incident of avulsion-type renal injury in a 24-year-old male with no significant medical history. The injury occurred during a traffic accident, where he was involved in a direct impact collision between a motorcycle and a vehicle, leading to altered corticomedullary differentiation in the right kidney, a retroperitoneal hematoma, and free fluid in the cavity. The patient underwent successful emergency abdominal surgery, which involved the removal of the damaged kidney due to the severity of the injury. During his postoperative recovery in the ICU, he received extensive care, including sedation, mechanical ventilation, and vasopressor support. Ultimately, he made a successful recovery and was discharged after rehabilitation. This case highlights the complexities involved in managing patients with renal injuries resulting from high-energy impact accidents. It emphasizes the importance of a multidisciplinary approach in treatment, the challenges associated with deciding on surgical intervention, and the significance of rehabilitation in patient recovery. The uniqueness of this case, characterized by its distinct mechanism of injury and the severity of the trauma, contributes to our broader understanding of renal trauma management in the field of trauma medicine. It underscores the need for personalized patient care strategies and emphasizes the effectiveness of surgical interventions in severe cases of renal trauma.

Surfactant therapy using vibrating-mesh nebulizers in adults with COVID-19-induced ARDS: A case series.

Coronavirus adult respiratory distress syndrome, characterized by decreased surfactant due to lysis of type II pneumocytes and hyaline membrane formation, contributes to severe hypoxemia. The administration of surfactant via high-flow nasal cannula (HFNC) may positively affect lung structure and function in this context. In this study, we report on five clinical cases, encompassing patients aged 40-60 years of both sexes, who tested positive for coronavirus disease 2019 via real-time polymerase chain reaction and exhibited significant pulmonary compromise with elevated inflammatory biomarkers. These patients were treated with aerosol therapy using surfactant delivered through vibrating-mesh nebulizers alongside HFNC. Of these patients, four demonstrated positive responses to the treatment, suggesting that aerosol therapy with surfactant through vibrating-mesh nebulizers could be a viable rescue therapy in adults receiving HFNC oxygen therapy for hypoxemic respiratory failure caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Unfortunately, one patient had a negative outcome and succumbed. The findings from these cases indicate that the use of aerosol therapy with vibrating-mesh nebulizers as rescue therapy might offer an alternative approach for managing adults with hypoxemic respiratory failure due to SARS-CoV-2, as evidenced by the positive outcomes in four out of the five cases presented.

Use of threshold PEP with an adult non-rebreather oxygen mask plus prone positioning in acute hypoxemic respiratory failure due to SARS-CoV-2 infection during the collapse of the health system in a low-income country.

During the coronavirus disease 2019 pandemic, Ecuador reported a collapse of the healthcare system, in which intensive care unit beds were lacking. Therefore, we sought to determine whether the use of threshold expiratory positive pressure with an adult non-rebreather oxygen mask plus prone positioning is useful for improving oxygenation. Twelve patients were included. Eight patients (66.7%) survived, while four patients (33.3%) died. Baseline arterial oxygen saturation (%) prior placement median (interquartile range) 85.5% (80%-89%) and arterial oxygen saturation (%) post placement of the device was median (interquartile range) (93%-96%) (P = 0.0001). Respiratory rate before placement was median (interquartile range) 38 (36-42) and post placement of the device was median (interquartile range) 24 (22-30) (P = 0.0005). The use of an adapted device might be useful for the management of acute hypoxemic respiratory failure due to severe acute respiratory syndrome coronavirus 2 pneumonia, particularly when mechanical ventilators and high-flow oxygen systems are unavailable.

A 71-Year-Old Man From Ecuador With a History of Type 2 Diabetes Mellitus and Severe COVID-19 Pneumonia and Lung Cavitation Associated With Triple Infection With Trichosporon Asahii, Klebsiella Pneumoniae, and Pseudomonas Aeruginosa.

Unvaccinated patients with comorbidities that impair the immune function, such as type 2 diabetes mellitus, are more likely to develop severe COVID-19. The COVID-19-associated acute respiratory distress syndrome has raised new concerns in intensive care units globally owing to the presence of secondary fungal infections. We report the case of a 71-year-old man from Ecuador with a history of type 2 diabetes mellitus, severe COVID-19 pneumonia, and lung cavitation associated with triple infections with Trichosporon asahii, Klebsiella pneumoniae, and Pseudomonas aeruginosa. The patient with a history of high blood pressure and type 2 diabetes was admitted to our hospital from a private care center with a diagnosis of COVID-19-associated acute respiratory distress syndrome. On arrival, the patient presented with signs of hypoxemic respiratory failure. During his stay at another hospital, he had received tocilizumab and corticosteroid therapy. Therefore, intubation was performed and mechanical ventilation was initiated. The patient developed a septic shock and renal failure with a glomerular filtration rate of 27.5 mL/min/1.73 m2; therefore, two hemodiafiltration sessions were started. The bronchoalveolar lavage revealed erythematous lesions in the bronchial tree and abundant purulent secretions and erosions in the bronchial mucosa, with a cavitary lesion in the right bronchial tree. The bronchoalveolar lavage samples were used to isolate Trichosporon asahii, Klebsiella pneumoniae, and Pseudomonas aeruginosa carbapenemase class A. Matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) Biotyper mass spectrometry and polymerase chain reaction (PCR) molecular identification were performed. This case report suggested that patients with severe COVID-19 pneumonia, with or without comorbidities, are more susceptible to opportunistic infections.

Noninvasive Mechanical Ventilation with Average Volume-Assured Pressure Support versus BiPAP S/T in De Novo Hypoxemic Respiratory Failure.

Background: Bilevel positive airway pressure in spontaneous/time and average volume-assured pressure support (BiPAP·S/T-AVAPS) could maintain an adequate tidal volume by reducing the patient's inspiratory effort; however, this ventilatory strategy has not been compared with other ventilatory modes, especially the conventional BiPAP S/T mode, when noninvasive mechanical ventilation (NIMV) is used. The primary objective of this study was to determine the rate of success and failure of the use of BiPAP·S/T-AVAPS versus BiPAP·S/T alone in patients with mild-to-moderate "de novo" hypoxemic respiratory failure. Methods: This was a matched-cohort study. Subjects with mild-to-moderate de novo hypoxemic respiratory failure were divided into two groups according to the ventilatory strategy used. The subjects in the BiPAP·S/T group were paired with those in the BiPAP·S/T-AVAPS group. Results: A total of 58 subjects were studied. Twenty-nine subjects in the BiPAP·S/T group were paired with 29 subjects in the BiPAP·S/T-AVAPS group. Twenty patients (34.5%) presented with "failure of NIMV," while 38 (65.5%) patients did not. In addition, 13 (22.4%) patients died, while 45 (77.6%) recovered. No differences were found in the percentage of intubation (P=0.44) and mortality (P=0.1). Conclusion: The BiPAP S/T-AVAPS ventilator mode was not superior to the BiPAP·S/T mode. A high mortality rate was observed in patients with NIMV failure in both modes. This trial is registered with https://doi.org/10.1186/ISRCTN17904857.

Apnea-Hypopnea Index in Chronic Obstructive Pulmonary Disease Exacerbation Requiring Noninvasive Mechanical Ventilation with Average Volume-Assured Pressure Support.

INTRODUCTION: This study intends to determine the Apnea-Hypopnea Index in patients hospitalized with acute hypercapnic respiratory failure from chronic obstructive pulmonary disease exacerbation, who require noninvasive ventilation with average volume-assured pressure support (AVAPS), as well as describes the clinical characteristics of these patients. MATERIALS AND METHODS: We designed a single-center prospective study. The coexistence of Apnea-Hypopnea Index and clinical, gasometric, spirometric, respiratory polygraphy, and ventilatory characteristics were determined. The clinical characteristics found were categorized and compared according to the Apnea-Hypopnea Index (AHI) < 5, AHI 5-15, and AHI >15. A p value <0.05 was considered statistically significant. RESULTS: During the study period, a total of 100 patients were admitted to the ICU with a diagnosis of acute hypercapnic respiratory failure due to COPD exacerbation. 72 patients presented with acute respiratory failure and fulfilled criteria for ventilatory support. Within them, 24 received invasive mechanical ventilation and 48 NIV. After applying the inclusion criteria for this study, 30 patients were eligible. An AHI >5 was present in 24 of the 30 patients recruited (80%). Neck circumference (cm), Epworth scale, and Mallampati score evidenced significant differences when compared to the patient's AHI <5, AHI 5-15, and AHI >15 (p < 0.05). Furthermore, patients with an AHI >5 had longer hospital admissions, prolonged periods on mechanical ventilation, and a higher percentage of intubation rates. CONCLUSION: Apnea-Hypopnea Index and chronic obstructive pulmonary disease exacerbation are a frequent association found in patients with acute hypercapnic respiratory failure and COPD exacerbations that require NIV. This association could be a determining factor in the response to NIV, especially when AVAPS is used as a ventilatory strategy.

Use of high-flow nasal cannula and intravenous propofol sedation while performing flexible video bronchoscopy in the intensive care unit: Case reports.

Flexible video bronchoscopy is a procedure that plays an important role in diagnosing various types of pulmonary lesions and abnormalities. Case 1 is a 68-year-old male patient with a lesion in the right lung apex of approximately 4 mm × 28 mm with atelectasis bands due to a crash injury. High-flow system with 35 L/min and fraction of inspired oxygen (FiO2) 0.45 and temperature of 34 °C was installed prior to the video bronchoscopy. SpO2 was maintained at 98%-100%. The total dose of sedative was 50 mg of propofol. In Case 2, a 64-year-old male patient with bronchiectasis, cystic lesions and pulmonary fibrosis of the left lung field was placed on a high-flow system with 45 L/min and 0.35 FiO2 at a temperature of 34 °C. SpO2 was maintained at 100%. The total duration of the procedure was 25 min; SpO2 of 100% was sustained with oxygenation during maintenance time with the flexible bronchoscope within the airway. The total dose of propofol to reach the degree of desired sedation was 0.5-1 mg/kg. Both patients presented hypotension. For the patient of case 1, a vasopressor (norepinephrine at doses of 0.04 µg/kg/min) was given, and for the patient of case 2, only saline volume expansion was used. The video bronchoscopy with propofol sedation and high-flow nasal cannula allows adequate oxygenation during procedure in the intensive care unit.

Cavitary Pneumonia Due to Methicillin-Resistant Staphylococcus aureus in a Non-Immunocompromised Patient After an Endoscopy: A Case Report.

BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) pneumonia has well-defined characteristics. We present a case of cavitary pneumonia due to MRSA in a patient who had undergone a recent outpatient gastroscopic procedure. CASE REPORT A 32-year-old man presented at the Emergency Department with tonic-clonic seizures of 2 min durations. He had a history of seizures without current treatment or use of psychostimulant drugs. His personal history referred to hypothyroidism treated with levothyroxine, morbid type 3 obesity, gastritis with a gastric ulcer, penicillin allergies, and an ambulatory endoscopy with a biopsy (7 days ago) for erosive gastropathy. On the 3rd day of admission to the Intensive Care Unit (ICU), a bronchoscopy was performed, which showed a reddened mucosa with hemorrhagic points and a cavitary area in the right main bronchus. Multiple polymerase chain reaction and mass spectrometry analyses of samples of bronchioalveolar lavage from the bronchus revealed MRSA with a mechanism of resistance to the mecA gene (1×105 colony-forming unit/mL). The laboratory results for the cerebrospinal fluid were negative for bacterial growth. CONCLUSIONS This is a rare case of cavitary pneumonia due to MRSA of clinical and epidemiological characteristics, which is unusual after an outpatient endoscopic procedure.

Non-invasive mechanical ventilation with average volume-assured pressure support. Results according to the aetiology of acute respiratory failure.

INTRODUCTION: Until now, the ventilatory strategy with BiPAP S/T plus average volume-assured pressure support (AVAPS) has not been evaluated for its use in the different types of acute respiratory failure (ARF). Consequently we report the results of the use of this ventilatory strategy in these clinical scenarios. MATERIAL AND METHODS: This is a single-centre prospective study. The subjects were categorised according to the type of ARF: (1) hypercapnic ARF: chronic obstructive pulmonary disease and bronchial asthma; and (2) hypoxaemic ARF: pneumonia, acute respiratory distress syndrome, congestive heart failure, and interstitial lung disease. Multiple logistic regression was used to determine predictors of non-invasive mechanical ventilation (NIV) failure (intubation). Further, in a subgroup of patients with de novo hypoxaemic ARF, analysis of variances with repeated measures was used to determine factors associated with NIV outcome. RESULTS: Sixty-eight subjects were included in this study. The NIV success rate was 69.1% and the mortality rate was 20.6%. A multivariate analysis showed that the number of affected lung quadrants on chest X-ray (OR: 4.23, 95% CI: 4.17-4.31; P < 0.001) and ARF precipitating disease (OR: 4.46, 95% CI: 4.43-4.51; P < 0.001) were determinants of NIV failure. In the hypoxaemic ARF subgroup (n = 58), significant differences in several parameters were found between patients with positive and negative outcomes. CONCLUSIONS: The use of BiPAP S/T - AVAPS in subjects with hypercapnic ARF is associated with a better outcome than in those with de novo hypoxaemic ARF.

Invasive Subacute Pulmonary Aspergillosis After Puerperal Sepsis: Case Report.

Subacute invasive aspergillosis is an infection that locally destroys lung parenchyma, and it affects patients with mild immunocompromise. The diagnosis is made by clinical symptoms, imaging, and laboratory results related to the infection. Early diagnosis and treatment is imperative for a favorable patient outcome. In this article, we present the case of a 19-year-old woman who was admitted to the intensive care unit for puerperal sepsis where a hysterectomy was performed. During her hospitalization, she presented atelectasis of the left lung and hemodynamic instability. Chest X-ray and chest computed tomography scan were performed and showed round opacities. It was decided to perform flexible bronchoscopy with bronchoalveolar lavage. An unusual subacute form of implementation of aspergillosis was confirmed by a bronchoalveolar lavage culture that showed the presence of Aspergillus. Images taken during bronchoscopy revealed Aspergillus implantation in the lung and serum galactomannan antigen test was positive. Voriconazole was introduced, 200 mg daily. The patient showed clinical improvement and was discharged from our hospital. We conclude that subacute invasive aspergillosis is a serious infection that can lead to high mortality. Bronchoscopy with bronchoalveolar lavage allows access and effective visualization of the airway as well as sampling for Aspergillus identification.

Mendelson's Syndrome: Chemical Pneumonitis After Pesticide Intake.

BACKGROUND Mendelson's syndrome consists of pulmonary aspiration of acidic gastric contents that results in acute lung injury (chemical pneumonitis). CASE REPORT We present the case of a 15-year-old girl who was admitted to the Emergency Department 1 h after ingestion of an organophosphate pesticide. The patient had abundant emesis of aqueous, transparent content, accompanied by drowsiness and moderate sialorrhea. We observed drooling and foaming at the mouth and tachycardia, and her oxygen saturation dropped to 75%, requiring immediate invasive ventilation. Computed tomography (CT) revealed opacities in both lung bases, while bronchoscopy evidenced burn lesions along the airway. A bronchoalveolar lavage (BAL) was performed and microbiological results were negative. Following the BAL, the patient showed a satisfactory evolution and full recovery. CONCLUSIONS This case report describes chemical pneumonitis due to pulmonary aspiration of sterile gastric contents following ingestion of a pesticide. We discuss the importance of timely diagnosis, the characteristic burn lesions found in bronchoscopy, and the role of bronchoalveolar lavage, which most likely allowed for a rapid recovery with favorable results.

Early Pulmonary Metastasis After a Surgical Resection of Glioblastoma Multiforme. A Case Report.

BACKGROUND Glioblastoma multiforme is one of the most aggressive types of tumors that affect the central nervous system. It has an extremely high morbidity and mortality rate despite immediate treatment and advances in chemotherapy, radiotherapy, and surgery. In the natural history of the disease, extracranial metastases of glioblastoma multiforme are a rare complication that can be localized in the lungs, bone, liver, and lymph nodes. CASE REPORT A 66-year-old male presented with pulmonary metastasis after the surgical resection of a primary glioblastoma multiforme tumor. Seventeen days after surgery while in the intensive care unit, the patient had leukocytosis with a predominance of neutrophils. An exploratory bronchoscopy evidenced a white lesion that prevented the visualization of the bronchus. Consequently, a sample was taken for pathological study that demonstrated pulmonary metastasis due to glioblastoma multiforme. CONCLUSIONS Surgical resection of the tumor can precipitate the appearance of extracranial metastases, especially pulmonary metastases.

Azygos Vein Aneurysm with Thrombosis and Aspergillus fumigatus Diagnosed Using Bronchoscopy: Case Report.

BACKGROUND The venous system of the posterior thoracic wall merges into a single trunk called the azygos vein, located in the posterior mediastinum, before draining into the superior vena cava. An aneurysm in the azygos vein is extremely rare. Such aneurysms are discovered as incidental radiology findings or while investigating a mediastinal mass. Visualization via bronchoscopy is atypical. CASE REPORT An 86-year-old female patient presented to the Emergency Department with a 5-day complaint of dyspnea and chest pain. She was admitted because of worsening condition leading to respiratory failure and paresthesias. She underwent endotracheal intubation and invasive mechanical ventilatory support. A chest X-ray showed a thickened mediastinum, tortuous thoracic aorta, and bilateral perihilar infiltrate with right predominance. Bronchoscopy revealed bleeding along the right bronchus and a blue protrusion coated with white material at the entrance of the main right bronchus. A pulmonary computed tomography angiography confirmed the presence of an azygos vein dilatation. Culture of bronchoalveolar lavage revealed Aspergillus fumigatus. CONCLUSIONS Bronchoscopy as a diagnostic method allows clinicians to verify the state and permeability of the airways during investigation of azygos vein aneurysms, which are rare entities but should be considered in the differential diagnosis of mediastinal masses and may be complicated by fungal pathogens such as Aspergillus fumigatus mostly in immunocompromised patients.

Ischemic Stroke and Disseminated Tuberculosis in Intensive Care: A Case Report.

BACKGROUND Tuberculosis (TB) continues to be a major public health problem worldwide. Extrapulmonary tuberculosis at the level of the central nervous system is the most devastating and deadly form of tuberculosis. CASE REPORT We present the case of a 73-year-old male Ecuadorian patient with no history of contact with tuberculosis and with a clinical picture of 4 days of evolution characterized by aphasia, deviation of the labial commissure, and deterioration of the level of consciousness with a Glasgow coma score of 7/15. A brain tomography showed evidence of indirect signs of cerebral ischemia; the patient was therefore diagnosed with non-specific cerebrovascular disease. Due to the critical nature of his clinical picture, the patient entered the Intensive Care Unit (ICU), where a chest x-ray was performed and bilateral perihilar alveolar opacities with a reticular and nodular pattern were visualized. These results, combined with the bronchoalveolar brushing, evidenced the presence of Mycobacterium tuberculosis. Adenosine of deaminase (ADA) was also detected in the cerebrospinal fluid with 30.7 µ/L and a molecular biology technique was used with high-multiplex real-time polymerase matrix MALDI-TOF mass spectrometry (Brucker Daltonics) for rapid identification of the causative agent. DNA/polymerase chain reaction (PCR) analyses were used for detection of M. tuberculosis, subsequently confirming the presence of cerebral tuberculosis. CONCLUSIONS This case illustrated an infrequent form of disseminated tuberculosis in a critically ill patient. Timely diagnosis and appropriate management are essential to reducing mortality.

Bronchial Visualization of Tetanic Contractions: A Case Report.

BACKGROUND Tetanus is a potentially fatal infectious disease which, during its evolution, creates multiple complications, usually requiring intensive management and care. CASE REPORT We present a clinical case of a 59-year-old male patient with generalized tetanus admitted to the intensive care unit. Flexible bronchoscopy revealed contraction of the bronchial demonstrating that tetany existed at the respiratory level, which rarely becomes evident. The clinical manifestations included trismus, facial paralysis, neck stiffness, and compromised respiratory function. The patient presented a state of respiratory failure that required invasive mechanical ventilation which was evaluated by bronchoscopy and that showed spasms of the bronchial musculature. The patient presented generalized tetanus in which the bronchial affectation was evaluated by bronchoscopy in the intensive care unit. In developed countries, the anti-tetanus toxoid vaccine has ostensibly decreased its incidence, while it is endemic in developing countries, and although there are measures such as vaccination that try to reduce its incidence, in Ecuador there is an increase in incidences. In this patient case, contraction of the bronchial rings was observed, demonstrating that tetany existed at the respiratory level, which rarely becomes evident. CONCLUSIONS Although muscular contractions are widespread, this clinical case evidences bronchial spams reported and visualized by bronchoscopy.

Volume-assured pressure support mode plus pirfenidone as resuscitation therapy in patients with exacerbation of idiopathic pulmonary fibrosis.

INTRODUCTION: Treatment among advanced stage idiopathic pulmonary fibrosis is quite challenging, especially considering that no major evidence has been released about it. This case report demonstrates and discusses the benefit of non-invasive mechanical ventilation in volume-assured pressure support (AVAPS) mode plus pirfenidone based on the relief of apatient'ssymptoms in combination with high-resolution computed tomography (HRCT) evidence. MATERIAL AND METHODS: An 83-year-old female patient with multiple hospital admissions within a six-month period initially presented with cardiac symptoms which were later attributed to apossible exacerbation of her primary diagnosis, idiopathic pulmonary fibrosis. CONCLUSION: The addition of non-invasive mechanical ventilation in AVAPS mode plus pirfenidone can improve the survival rates even in patients with current exacerbations of acute respiratory failure due to idiopathic pulmonary fibrosis.

Spontaneous Pneumothorax After Rupture of the Cavity as the Initial Presentation of Tuberculosis in the Emergency Department.

BACKGROUND Spontaneous pneumothorax can be secondary to a wide variety of lung diseases. Spontaneous pneumothorax secondary to pulmonary tuberculosis occurs in rare cases of residual fibrosis with retractions and bullae. CASE REPORT We present the case of a 65-year-old male patient from a rural area in the province of Los Ríos in Babahoyo, Ecuador, with no history of contact with tuberculosis. The patient arrived at the Emergency Department of the Regional Hospital of the Instituto Ecuatoriano de Seguridad Social (IESS), Babahoyo, due to acute respiratory failure, preceded by 10 days of evolution due to cough accompanied by greenish expectoration, chest pain, asthenia, and weight loss. On chest radiography, a left pneumothorax and interstitial pulmonary infiltrate were reported. A chest tube was placed, and the patient was intubated and was placed on invasive mechanical ventilation due to severe respiratory failure. Use of the GeneXpert MTB/RIF System detected Mycobacterium tuberculosis without resistance to rifampicin. Ziehl-Neelsen (ZN) staining for the identification of bacillus acid-resistant alcohol was positive in alveolar bronchial lavage. MALDI-TOF mass spectrometry and phenotypic analysis showed the presence of Pseudomonas aeruginosa and Klebsiella pneumonia with carbapenemases resistance mechanism, and the KPC type enzyme was identified. The culture for Mycobacterium tuberculosis was positive from the fourth week. CONCLUSIONS Secondary pneumothorax due to rupture of the polymicrobial cavity and especially of tuberculous origin is a very special form of acute respiratory failure in patients with previous structural pulmonary lesions in the Emergency Department.

Use of noninvasive mechanical ventilation with pressure support guaranteed with average volume in de novo hypoxaemic respiratory failure. A pilot study.

BACKGROUND: This study was designed to determine the results associated with the use of noninvasive mechanical ventilation (NIV) using the BiPAP S/T-AVAPS ventilation strategy in subjects with mild to moderate de novohypoxaemicrespiratory failure. METHODS: This is a prospective study that includes subjects with de novohypoxaemic respiratory failure (not produced by acute exacerbations of COPD, chronic lung disease, or congestive heart failure) with mild to moderate PaO2/FiO2, who were admitted to the Intensive Care Unit (ICU) of Santa Maria Clinic in Guayaquil, Ecuador. Subjects were divided into two groups and compared according to their PaO2/FiO2: higher than 100 and up to 200 mm Hg (moderate ARDS) or between 200 and 300 mm Hg (mild ARDS) (both groups were ventilated with the BiPAP S/T-AVAPS strategy). A value of P < 0.05 was considered significant. RESULTS: A total of 38 subjects were analysed in this study. The total rate of intubation was 34.2% while the mortality rate was 28.9%. Significant differences were observed when comparing success versus failure in exhaled tidal volumes (P = 0.04), peak inspired pressure (P < 0.001), PaO2 (P < 0.001), SaO2 (P < 0.002), PaO2/FiO2 (P < 0.002), RR (P < 0.001), HR (P < 0.001), and inspiratory time (P = 0.029) measured at baseline and at 12-hour, 24-hour and 48-hour intervals. CONCLUSION: The BiPAP S/T-AVAPS ventilatory mode can be used in subjects with de novo hypoxaemic respiratory failure with special vigilance concerning exhaled tidal volumes and inspired pressure.

Determinants of immediate failure of noninvasive mechanical ventilation outside the intensive care unit.

BACKGROUND: This study aimed to characterize which are the early determinants of immediate failure of the use of noninvasive mechanical ventilation (NIMV) outside the ICU. METHODS: This prospective study included patients who were admitted to the Military Hospital in Guayaquil, Ecuador. Each variable was analyzed independently by using a multiple logistic regression model toward establishing an association with the event. RESULTS: A total of 249 cases of NIMV over a 10 year period of its application outside the ICU was included in the study. Fifty-five (22.10%) patients were transferred to the ICU, A multivariate analysis showed that the determinants of immediate NIMV failure outside the ICU were the following: age (OR: 1.12; P = 0.03); SBP (OR: 1.04; P = 0.001); HR (OR: 1.66; P < 0.0001); pCO2 (OR: 1.16; P = 0.007); pO2 (OR: 1.35; P = 0.003); levels of IPAP (OR: 1.35; P < 0.0001); and the number of quadrants affected, as shown in a chest X-ray (OR: 1.40; P < 0.0001). CONCLUSIONS: The number of affected quadrants in a chest X-ray, tachyarrhythmia and hypoxemia may be useful in the initial decision in the use of NIMV outside the ICU. High values of IPAP, the persistence of elevated pCO2, arterial hypotension, and age could be useful as a second screening associated with immediate NIMV failure outside the ICU.

Noninvasive mechanical ventilation in patients with chronic obstructive pulmonary disease and severe hypercapnic neurological deterioration in the emergency room.

OBJECTIVES: The objective of this study was to assess the effectiveness of noninvasive motion ventilation (NIMV) in patients with chronic obstructive pulmonary disease (COPD), having infectious exacerbation and severe hypercapnic neurological dysfunction in the emergency room. DESIGN: This is a prospective interventional study. SETTING: The study setting was the emergency room at the Military Hospital in Guayaquil, Ecuador. PATIENTS: A total of 24 patients were studied. Twelve patients had acute exacerbation of their chronic obstructive pulmonary disease: they presented at the emergency room with severe neurological dysfunction, with a Glasgow Coma Scale (GCS) score of less than 8 and a pH of less than 7.25. These patients were compared with 12 controls who were being treated with invasive mechanical ventilation (IMV), who were then matched according to their GCS scores, pH status, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, and age. INTERVENTIONS: We evaluated the effectiveness and safety of applying a ventilatory strategy based on a biphasic positive airway pressure protocol in the emergency room. MEASUREMENTS AND RESULTS: The pH, PCO2, and GCS scores, measured during the first 3 h, were predictors of success for the application of NIMV treatment (P<0.05). Mortality was 33.3 and 16.7% for the IMV and the NIMV groups, respectively (P=0.01). Days of IMV were 5.60+/-1.2 versus 3.6+/-1.1 for NIMV (P=0.006). Days of hospitalization were 11.1+/-4.7 for the IMV group and 6.5+/-1.9 for the NIMV group (P=0.001). The cumulative survival rates at 6 months were 71.4 and 80% for the IMV and NIMV groups, respectively (P=0.80). CONCLUSION: We consider that severe neurological dysfunction and pH of less than 7.25 do not constitute absolute contraindications to the use of NIMV. This kind of management can be implemented in the emergency room with favorable results.