Consenso argentino de ventilación no invasiva / Argentine consensus of non-invasive ventilation

Non-invasive ventilation (NIV) is nowadays increasingly used. The significant decrease in tracheal intubation related complications makes it particularly attractive in patients with moderately acute respiratory failure (ARF) who still have some degree of respiratory autonomy. It has also been used to support patients with chronic respiratory failure. However, final outcomes are variable according to the conditions which determined its application. This Consensus was performed in order to review the evidence supporting the use of positive pressure NIV. The patho-physiological background of NIV and the equipment required technology are described. Available evidence clearly suggests benefits of NIV in acute exacerbation of chronic obstructive pulmonary disease (COPD) and in cardiogenic pulmonary edema (Recommendation A). When considering ARF in the setting of acute respiratory distress syndrome results are uncertain, unless dealing with immunosupressed patients (Recommendation B). Positive results are also shown in weaning of mechanical ventilation (MV), particularly regarding acute exacerbation of COPD patients (Recommendation A). An improved quality of life in chronic respiratory failure and a longer survival in restrictive disorders has also been shown (Recommendation B) while its benefit in stable COPD patients is still controversial (Recommendation C). NIV should be performed according to pre-established standards. A revision of NIV related complications is performed and the cost-benefit comparison with invasive MV is also considered.

La ventilación no invasiva (VNI) ha alcanzado notable difusión en los últimos años. El ahorro delas complicaciones causadas por la intubación traqueal la hace especialmente atractiva en pacientesque presentan insuficiencia respiratoria aguda (IRA) no muy grave y que conservan cierta autonomía respiratoria.También se han descripto efectos terapéuticos en pacientes con insuficiencia respiratoria crónica de etiologías diversas. No obstante, los resultados obtenidos son variables según las circunstancias que motivan su aplicación. A fin de revisar la evidencia a favor de su uso se elaboró este Consenso referido particularmente a la VNI a presión positiva. Se describen su fundamento fisiopatológico, esencial para su correcta aplicación, y elequipamiento necesario para implementarla. La evidencia existente en la literatura establece definida utilidad de la VNI en la exacerbación de la EPOC y en el edema agudo de pulmón cardiogénico (Recomendación A).Su beneficio es aún incierto en pacientes con IRA secundaria a síndrome de dificultad respiratoria aguda, salvoen el subgrupo de pacientes inmunosuprimidos (Recomendación B). Los resultados son también favorablesen la desvinculación de la asistencia respiratoria mecánica (ARM), especialmente en pacientes ventilados por exacerbación de EPOC (Recomendación A). En la insuficiencia respiratoria crónica se ha hallado mejoría en la calidad de vida y mayor sobrevida en pacientes con enfermedades restrictivas (Recomendación B), mientrasque existe aún controversia sobre su utilidad en pacientes con EPOC estable (Recomendación C). La VNI debeser aplicada con estándares de cuidados que son establecidos. Se revisan las eventuales complicaciones derivadasde su uso y el beneficio costo-efectividad ahorrando recursos de mayor complejidad y disminuyendolos riesgos que implica la ARM invasiva.

Consenso argentino de ventilación no invasiva / Argentine consensus of non-invasive ventilation

Non-invasive ventilation (NIV) is nowadays increasingly used. The significant decrease in tracheal intubation related complications makes it particularly attractive in patients with moderately acute respiratory failure (ARF) who still have some degree of respiratory autonomy. It has also been used to support patients with chronic respiratory failure. However, final outcomes are variable according to the conditions which determined its application. This Consensus was performed in order to review the evidence supporting the use of positive pressure NIV. The patho-physiological background of NIV and the equipment required technology are described. Available evidence clearly suggests benefits of NIV in acute exacerbation of chronic obstructive pulmonary disease (COPD) and in cardiogenic pulmonary edema (Recommendation A). When considering ARF in the setting of acute respiratory distress syndrome results are uncertain, unless dealing with immunosupressed patients (Recommendation B). Positive results are also shown in weaning of mechanical ventilation (MV), particularly regarding acute exacerbation of COPD patients (Recommendation A). An improved quality of life in chronic respiratory failure and a longer survival in restrictive disorders has also been shown (Recommendation B) while its benefit in stable COPD patients is still controversial (Recommendation C). NIV should be performed according to pre-established standards. A revision of NIV related complications is performed and the cost-benefit comparison with invasive MV is also considered.(AU)

La ventilación no invasiva (VNI) ha alcanzado notable difusión en los últimos años. El ahorro delas complicaciones causadas por la intubación traqueal la hace especialmente atractiva en pacientesque presentan insuficiencia respiratoria aguda (IRA) no muy grave y que conservan cierta autonomía respiratoria.También se han descripto efectos terapéuticos en pacientes con insuficiencia respiratoria crónica de etiologías diversas. No obstante, los resultados obtenidos son variables según las circunstancias que motivan su aplicación. A fin de revisar la evidencia a favor de su uso se elaboró este Consenso referido particularmente a la VNI a presión positiva. Se describen su fundamento fisiopatológico, esencial para su correcta aplicación, y elequipamiento necesario para implementarla. La evidencia existente en la literatura establece definida utilidad de la VNI en la exacerbación de la EPOC y en el edema agudo de pulmón cardiogénico (Recomendación A).Su beneficio es aún incierto en pacientes con IRA secundaria a síndrome de dificultad respiratoria aguda, salvoen el subgrupo de pacientes inmunosuprimidos (Recomendación B). Los resultados son también favorablesen la desvinculación de la asistencia respiratoria mecánica (ARM), especialmente en pacientes ventilados por exacerbación de EPOC (Recomendación A). En la insuficiencia respiratoria crónica se ha hallado mejoría en la calidad de vida y mayor sobrevida en pacientes con enfermedades restrictivas (Recomendación B), mientrasque existe aún controversia sobre su utilidad en pacientes con EPOC estable (Recomendación C). La VNI debeser aplicada con estándares de cuidados que son establecidos. Se revisan las eventuales complicaciones derivadasde su uso y el beneficio costo-efectividad ahorrando recursos de mayor complejidad y disminuyendolos riesgos que implica la ARM invasiva.(AU)

[Chronic obstructive pulmonary disease]. / Enfermedad pulmonar obstructiva crónica. Consenso argentino.

Several meetings of chest specialists were held in order to update basic knowledge on Chronic Obstructive Pulmonary Disease (COPD) and to establish guidelines regarding its prevention and treatment. This Consensus was prompted by the important morbidity and mortality due to COPD. Pulmonary emphysema, chronic bronchitis and asthma may evolve into COPD when developing chronic, persistent, non reversible airflow obstruction. Its pathologic features, physiopathology, pulmonary function derangements and clinico-radiological picture are summarized. Early detection and prevention accomplished through smoking cessation are essential to stop health damage due to this condition. Strategies directed to smoking cessation are described. Once COPD is established, inhaled bronchodilators (IB)--anticholinergics, beta-2 agonists or both--might be useful. Teophylline is indicated additionally when no improvement is obtained with IB. Inhaled steroids (IE) may stop progression of airways obstruction; they are recommended in patients who remain symttomatic and/or with severe airflow obstruction (FEV1 less than 50% predicted) despite treatment with beta-2 adrenergics and teophylline. Vaccination against influenza and pneumococcal pneumonia is suggested. Other medications (antibiotics, psychoactive drugs, alpha-1 antitrypsine, respiratory stimulants) or surgical interventions, including lung transplantation, might be of help in certain circumstances. In patients with physiotherapy, supplementary nutrition, muscle retraining, prolonged oxygen therapy and, eventually, noninvasive mechanical ventilation might improve survival and quality of life. Acute decompensations leading to respiratory failure should be promptly detected and treated with oxygen, IB, teophylline, corticosteroids, antibiotics and, eventually, mechanical ventilation. The main role of public education in disease prevention is emphasized. Moreover, patient and family education is essential for adequate treatment of COPD.

Enfermedad pulmonar obstructiva cronica / Chronic obstructive pulmonary disease

Dada la importante morbilidad y mortalidad de la Enfermedad Pulmonar Obstructiva Crónica (EPOC) se llevaron a cabo reiterados encuentros de especialistas em medicina respiratoria a fin de actualizar en un Consenso conocimientos básicos acerca de esta afección y efectuar recomendaciones para su prevención y tratameinto. Se incluyen dentro de la EPOC fases evolutivas del enfisema pulmonar, bronquitis crónica y asma bronquial resumiéndose sus alteraciones patológicas, fisiopatogenia, presentación clínico-radiológica y evaluación funcional. Su detección precoz y prevención a través de la cesación del hábito de fumar son esenciales para detener los daños causados por esta afección. Se describen las estrategias que componen un programa de interrupción del hábito. Una vez establecida la EPOC la administración de broncodilatadores inhalatorios (BI) - anticolinérgicos, estimulantes beta-2 adrenérgicos, o ambos - puede ser útil. La teofilina es indicada adicionalmente cuando no existe satisfactoria mejoría con aquellos. La administración de corticoides por vía inhalatoria podría atenuar la evolución de la obstrucción y se recomienda en los pacientes sintomáticos y/o con obstrucción severa al flujo aéreo, a pesar del tratamiento con BI y teofilina. La vacunación antigripal y antineumocóccica es sugerida si bien no hay pruebas concluyentes acerca de su eficacia. Otras medicaciones (antibióticos, drogas psicoactivas, alfa 1 antitripsina, estimulantes respiratorios) o intervenciones quirúrgicas hasta el transplante de pulmón se recomiendan en determinadas circunstancias

Enfermedad pulmonar obstructiva crónica. Consenso argentino. / [Chronic obstructive pulmonary disease]

Several meetings of chest specialists were held in order to update basic knowledge on Chronic Obstructive Pulmonary Disease (COPD) and to establish guidelines regarding its prevention and treatment. This Consensus was prompted by the important morbidity and mortality due to COPD. Pulmonary emphysema, chronic bronchitis and asthma may evolve into COPD when developing chronic, persistent, non reversible airflow obstruction. Its pathologic features, physiopathology, pulmonary function derangements and clinico-radiological picture are summarized. Early detection and prevention accomplished through smoking cessation are essential to stop health damage due to this condition. Strategies directed to smoking cessation are described. Once COPD is established, inhaled bronchodilators (IB)--anticholinergics, beta-2 agonists or both--might be useful. Teophylline is indicated additionally when no improvement is obtained with IB. Inhaled steroids (IE) may stop progression of airways obstruction; they are recommended in patients who remain symttomatic and/or with severe airflow obstruction (FEV1 less than 50

predicted) despite treatment with beta-2 adrenergics and teophylline. Vaccination against influenza and pneumococcal pneumonia is suggested. Other medications (antibiotics, psychoactive drugs, alpha-1 antitrypsine, respiratory stimulants) or surgical interventions, including lung transplantation, might be of help in certain circumstances. In patients with physiotherapy, supplementary nutrition, muscle retraining, prolonged oxygen therapy and, eventually, noninvasive mechanical ventilation might improve survival and quality of life. Acute decompensations leading to respiratory failure should be promptly detected and treated with oxygen, IB, teophylline, corticosteroids, antibiotics and, eventually, mechanical ventilation. The main role of public education in disease prevention is emphasized. Moreover, patient and family education is essential for adequate treatment of COPD.

Enfermedad pulmonar obstructiva cronica / Chronic obstructive pulmonary disease

Dada la importante morbilidad y mortalidad de la Enfermedad Pulmonar Obstructiva Crónica (EPOC) se llevaron a cabo reiterados encuentros de especialistas em medicina respiratoria a fin de actualizar en un Consenso conocimientos básicos acerca de esta afección y efectuar recomendaciones para su prevención y tratameinto. Se incluyen dentro de la EPOC fases evolutivas del enfisema pulmonar, bronquitis crónica y asma bronquial resumiéndose sus alteraciones patológicas, fisiopatogenia, presentación clínico-radiológica y evaluación funcional. Su detección precoz y prevención a través de la cesación del hábito de fumar son esenciales para detener los daños causados por esta afección. Se describen las estrategias que componen un programa de interrupción del hábito. Una vez establecida la EPOC la administración de broncodilatadores inhalatorios (BI) - anticolinérgicos, estimulantes beta-2 adrenérgicos, o ambos - puede ser útil. La teofilina es indicada adicionalmente cuando no existe satisfactoria mejoría con aquellos. La administración de corticoides por vía inhalatoria podría atenuar la evolución de la obstrucción y se recomienda en los pacientes sintomáticos y/o con obstrucción severa al flujo aéreo, a pesar del tratamiento con BI y teofilina. La vacunación antigripal y antineumocóccica es sugerida si bien no hay pruebas concluyentes acerca de su eficacia. Otras medicaciones (antibióticos, drogas psicoactivas, alfa 1 antitripsina, estimulantes respiratorios) o intervenciones quirúrgicas hasta el transplante de pulmón se recomiendan en determinadas circunstancias (AU)

Normas establecidas por consenso para el tratamiento del asma bronquial y sus exacerbaciones / Standards established by consensus for the treatment of bronchial asthma and its exacerbations

A group of pulmonologists from different sites of Argentina convened to establish consensus guidelines for treatment of acute and chronic bronchial asthma. General acceptance that in fatal asthma diagnosis and hospital admission are usually too late and treatment insufficient prompted the need for this meeting. The purpose of treatment was devised to keep the patient symptomless, decrease frequency of exacerbations and the risk of severe attacks. Peak expiratory flow rate (PEFR) measurement in all patients was decided. inhalation of anti-inflammatory drugs (corticosteroids, CE, and/or disodium cromoglycate, DSG, in those younger than 20 years) was established as first line of treatment. Inhaled CE (even in high doses such as 2 mg/day) do not provoke significant adverse systemic effects (immune depression, Cushing syndrome, hyperglycemia in diabetics or osteopenia). Secondary local adverse effects are however frequent: oral and pharyngeal candidiasis and dysphonia. It is advisable considering present evidence, that bronchodilators (Bd) be used preferentially on demand. On account of small bronchodilator effect and frequent secondary adverse effects, use of theophylline should be limited to patients not adequately responsive to anti-inflammatory drugs in high dosage. Immunotherapy is not useful in asthma. Four clinical levels were defined in chronic asthma considering severity of dyspnea, frequency of nocturnal bronchial obstruction, levels of PEFR and amount of required Bd. Guidelines of treatment were established for each clinical level considering increasing dosage of CGS, inhaled CE (up to 2 mg/day) and regular administration of Bd. Indications for systemic CE administration were also established. Three levels of acute asthma (sudden worsening of symptoms) were accepted based on clinical evidence and PEFR values. Treatment was quantitatively adjusted to severity. Criteria for hospital admission either in emergency or intensive care areas and treatment procedures were established.

Normas establecidas por consenso para el tratamiento del asma bronquial y sus exacerbaciones / Standards established by consensus for the treatment of bronchial asthma and its exacerbations

A group of pulmonologists from different sites of Argentina convened to establish consensus guidelines for treatment of acute and chronic bronchial asthma. General acceptance that in fatal asthma diagnosis and hospital admission are usually too late and treatment insufficient prompted the need for this meeting. The purpose of treatment was devised to keep the patient symptomless, decrease frequency of exacerbations and the risk of severe attacks. Peak expiratory flow rate (PEFR) measurement in all patients was decided. inhalation of anti-inflammatory drugs (corticosteroids, CE, and/or disodium cromoglycate, DSG, in those younger than 20 years) was established as first line of treatment. Inhaled CE (even in high doses such as 2 mg/day) do not provoke significant adverse systemic effects (immune depression, Cushing syndrome, hyperglycemia in diabetics or osteopenia). Secondary local adverse effects are however frequent: oral and pharyngeal candidiasis and dysphonia. It is advisable considering present evidence, that bronchodilators (Bd) be used preferentially on demand. On account of small bronchodilator effect and frequent secondary adverse effects, use of theophylline should be limited to patients not adequately responsive to anti-inflammatory drugs in high dosage. Immunotherapy is not useful in asthma. Four clinical levels were defined in chronic asthma considering severity of dyspnea, frequency of nocturnal bronchial obstruction, levels of PEFR and amount of required Bd. Guidelines of treatment were established for each clinical level considering increasing dosage of CGS, inhaled CE (up to 2 mg/day) and regular administration of Bd. Indications for systemic CE administration were also established. Three levels of acute asthma (sudden worsening of symptoms) were accepted based on clinical evidence and PEFR values. Treatment was quantitatively adjusted to severity. Criteria for hospital admission either in emergency or intensive care areas and treatment procedures were established.(Au)

[Standards established by consensus for the treatment of bronchial asthma and its exacerbations]. / Normas establecidas por consenso para el tratamiento del asma bronquial y sus exacerbaciones.

A group of pulmonologists from different sites of Argentina convened to establish consensus guidelines for treatment of acute and chronic bronchial asthma. General acceptance that in fatal asthma diagnosis and hospital admission are usually too late and treatment insufficient prompted the need for this meeting. The purpose of treatment was devised to keep the patient symptomless, decrease frequency of exacerbations and the risk of severe attacks. Peak expiratory flow rate (PEFR) measurement in all patients was decided. inhalation of anti-inflammatory drugs (corticosteroids, CE, and/or disodium cromoglycate, DSG, in those younger than 20 years) was established as first line of treatment. Inhaled CE (even in high doses such as 2 mg/day) do not provoke significant adverse systemic effects (immune depression, Cushing syndrome, hyperglycemia in diabetics or osteopenia). Secondary local adverse effects are however frequent: oral and pharyngeal candidiasis and dysphonia. It is advisable considering present evidence, that bronchodilators (Bd) be used preferentially on demand. On account of small bronchodilator effect and frequent secondary adverse effects, use of theophylline should be limited to patients not adequately responsive to anti-inflammatory drugs in high dosage. Immunotherapy is not useful in asthma. Four clinical levels were defined in chronic asthma considering severity of dyspnea, frequency of nocturnal bronchial obstruction, levels of PEFR and amount of required Bd. Guidelines of treatment were established for each clinical level considering increasing dosage of CGS, inhaled CE (up to 2 mg/day) and regular administration of Bd. Indications for systemic CE administration were also established. Three levels of acute asthma (sudden worsening of symptoms) were accepted based on clinical evidence and PEFR values. Treatment was quantitatively adjusted to severity. Criteria for hospital admission either in emergency or intensive care areas and treatment procedures were established.

Normas establecidas por consenso para el tratamiento del asma bronquial y sus exacerbaciones. / [Standards established by consensus for the treatment of bronchial asthma and its exacerbations]

A group of pulmonologists from different sites of Argentina convened to establish consensus guidelines for treatment of acute and chronic bronchial asthma. General acceptance that in fatal asthma diagnosis and hospital admission are usually too late and treatment insufficient prompted the need for this meeting. The purpose of treatment was devised to keep the patient symptomless, decrease frequency of exacerbations and the risk of severe attacks. Peak expiratory flow rate (PEFR) measurement in all patients was decided. inhalation of anti-inflammatory drugs (corticosteroids, CE, and/or disodium cromoglycate, DSG, in those younger than 20 years) was established as first line of treatment. Inhaled CE (even in high doses such as 2 mg/day) do not provoke significant adverse systemic effects (immune depression, Cushing syndrome, hyperglycemia in diabetics or osteopenia). Secondary local adverse effects are however frequent: oral and pharyngeal candidiasis and dysphonia. It is advisable considering present evidence, that bronchodilators (Bd) be used preferentially on demand. On account of small bronchodilator effect and frequent secondary adverse effects, use of theophylline should be limited to patients not adequately responsive to anti-inflammatory drugs in high dosage. Immunotherapy is not useful in asthma. Four clinical levels were defined in chronic asthma considering severity of dyspnea, frequency of nocturnal bronchial obstruction, levels of PEFR and amount of required Bd. Guidelines of treatment were established for each clinical level considering increasing dosage of CGS, inhaled CE (up to 2 mg/day) and regular administration of Bd. Indications for systemic CE administration were also established. Three levels of acute asthma (sudden worsening of symptoms) were accepted based on clinical evidence and PEFR values. Treatment was quantitatively adjusted to severity. Criteria for hospital admission either in emergency or intensive care areas and treatment procedures were established.

Clasificación mapuche y fracasos orgánicos precoces: resultados del estudio multicéntrico / MAPUCHE classification and precocious organic failure results of multicentral study

Se presentan los resultados referentes a la mortalidad en terapia intensiva en función de la determinación de niveles de gravedad MAPUCHE y fracasos orgánicos precoces en el marco del estudio multicéntrico de la SATI. En el mismo se recogieron los datos de dos mil doscientos pacientes provenientes de 22 centros de terapia intensiva de diversos puntos del país. La distribución de los enfermos mostró que la mayoría se hallaba en el nivel II. La mortalidad general fue del 30,9 por ciento y ella se incrementaba significativamente a medida que lo hacían los niveles MAPUCHE, siendo mayor en pacientes clínicos en el nivel I y II. Los subniveles demostraron idéntica correlación con la mortalidad. La presencia de fallas precoces determinó una mortalidad significativamente mayor y el número de las mismas se correlacionó significativamente con la mortalidad. Los resultados muestran la utilidad de los sistemas empleados en la determinación de los niveles de gravedad en pacientes críticos asistidos en centros diferentes. Se recalca la importancia de la realización de estudios multicéntricos para valorar la utilidad de uno o más indicadores

Clasificación mapuche y fracasos orgánicos precoces: resultados del estudio multicéntrico / MAPUCHE classification and precocious organic failure results of multicentral study

Se presentan los resultados referentes a la mortalidad en terapia intensiva en función de la determinación de niveles de gravedad MAPUCHE y fracasos orgánicos precoces en el marco del estudio multicéntrico de la SATI. En el mismo se recogieron los datos de dos mil doscientos pacientes provenientes de 22 centros de terapia intensiva de diversos puntos del país. La distribución de los enfermos mostró que la mayoría se hallaba en el nivel II. La mortalidad general fue del 30,9 por ciento y ella se incrementaba significativamente a medida que lo hacían los niveles MAPUCHE, siendo mayor en pacientes clínicos en el nivel I y II. Los subniveles demostraron idéntica correlación con la mortalidad. La presencia de fallas precoces determinó una mortalidad significativamente mayor y el número de las mismas se correlacionó significativamente con la mortalidad. Los resultados muestran la utilidad de los sistemas empleados en la determinación de los niveles de gravedad en pacientes críticos asistidos en centros diferentes. Se recalca la importancia de la realización de estudios multicéntricos para valorar la utilidad de uno o más indicadores (AU)

Comparison between high and moderate doses of hydrocortisone in the treatment of status asthmaticus.

In a group of 40 adult patients in status asthmaticus, the responses to two different dosages of hydrocortisone were studied. All patients received a uniform treatment and were sequentially assigned to one of the following two groups: high dosage of hydrocortisone (80 mg/kg/day); or moderate dosage (6 mg/kg/day). The hydrocortisone was given intravenously in divided doses every six hours. The study lasted five days, and forced spirometry was performed daily at noon. The condition of all of the patients improved gradually, and when comparing both groups, no statistically significant differences were found in their spirometric measurements. We did not find any difference in the reversal of airway obstruction in the treatment of status asthmaticus by using a high dosage of hydrocortisone when compared with a lower moderate one.