ABSTRACT
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.
Subject(s)
Respiratory Distress Syndrome , Electric Impedance , Humans , Lung/diagnostic imaging , Positive-Pressure Respiration , Respiratory Distress Syndrome/therapy , Tomography, X-Ray ComputedABSTRACT
OBJETIVO: Los objetivos principales son describir la práctica de la ventilación mecánica en un periodo de 18 años en México y estimar los cambios en la mortalidad de los pacientes críticos con ventilación mecánica invasiva (VMI). DISEÑO: Subanálisis retrospectivo de un estudio prospectivo y observacional en 1998, 2004, 2010 y 2016. ÁMBITO: Unidades de Cuidados Intensivos (UCI) de México. PARTICIPANTES: Pacientes adultos que ingresaron consecutivamente en la UCI, durante un mes y que recibieron VMI durante más de 12 h o ventilación mecánica no invasiva durante más de una hora. El seguimiento se realizó hasta 28 días después de la inclusión. INTERVENCIONES: Ninguna. VARIABLES DE INTERÉS: Edad, sexo, gravedad al ingreso estimada por el SAPS II, parámetros de la gasometría arterial diaria, variables de tratamiento y complicaciones, fecha y estado al alta de la UCI y del hospital. RESULTADOS: Se incluyó a 959 pacientes en 81 UCI. El volumen corriente (VC) ha disminuido significativamente tanto en pacientes con criterios de SDRA (de 8,5 ml/kg de peso estimado en 1998 a 6 ml/kg en 2016; p < 0,001) como en enfermos sin SDRA (de 9 ml/kg de peso estimado en 1998 a 6ml/kg en 2016; p < 0,001). La estrategia ventilatoria protectora (definida como VC < 6 ml/kg o < 8 ml/kg y una presión meseta < 30 cmH2O) fue: 19% en 1998, 44% en 2004, 58% en 2010 y 75% en 2016 (p < 0,001). La mortalidad ajustada en UCI a lo largo de los 4 periodos fue: en 2004, oportunidad relativa (OR) 1,05 (IC 95%: 0,73-1,72; p = 0,764); en 2010, OR 1,68 (IC 95%: 1,13-2,48; p = 0,009); en 2016, OR 0,85 (IC 95%: 0,60-1,20; p = 0,368). CONCLUSIONES: La práctica clínica de la VMI en las UCI de México se ha modificado a lo largo de un periodo de 18 años. El cambio más significativo es la estrategia ventilatoria basada en VC bajos. Estos cambios no se han asociado a cambios significativos en la mortalidad
OBJECTIVE: The main study objectives were to describe the practice of mechanical ventilation over an 18-year period in Mexico, and estimate changes in mortality among critical patients subjected to invasive mechanical ventilation (IMV). DESIGN: A retrospective subanalysis of a prospective observational study conducted in 1998, 2004, 2010 and 2016 was carried out. SETTING: Intensive Care Units (ICUs) in Mexico. PARTICIPANTS: Adult patients consecutively enrolled in the ICU during one month and who underwent IMV for more than 12hours or noninvasive mechanical ventilation for more than one hour. Follow-up was performed up to a maximum of 28 days after inclusion. INTERVENTIONS: None. PRINCIPAL VARIABLES OF INTEREST: Age, sex, severity upon admission as estimated by SAPS II, parameters of daily arterial blood gases, treatment and complication variables, date and status at discharge from the ICU and from hospital. RESULTS: A total of 959 patients were included in 81 ICUs. Tidal volume (vt) decreased significantly both in patients with acute respiratory distress syndrome (ARDS) criteria (estimated 8.5 ml/kg b.w. in 1998 to 6 ml/kg in 2016; P < 0.001) and in patients without ARDS (estimated 9 ml/kg b.w. in 1998 to 6 ml/kg in 2016; P < 0.001). The ventilatory protective strategy (defined as vt < 6 ml/kg or < 8 ml/kg and a plateau pressure < 30 cmH2O) was: 19% in 1998, 44% in 2004, 58% in 2010 and 75% in 2016 (P < 0.001). The adjusted mortality rate in ICU over the 4 periods was: in 2004, odds ratio (OR) 1.05 (95% confidence interval, 95% CI: 0.73-1.72; P = 0.764); in 2010, OR 1.68 (95% CI: 1.13-2.48; P = 0.009); in 2016, OR 0.85 (95%CI: 0.60-1.20; P = 0.368). CONCLUSIONS: The clinical practice of IMV in Mexican ICUs has been modified over a period of 18 years. The most significant change is the ventilatory strategy based on low vt. These changes have not been associated with significant changes in mortality
Subject(s)
Humans , Male , Middle Aged , Respiration, Artificial/methods , Evidence-Based Medicine , Hospital Mortality , Respiration, Artificial/trends , Mexico , Retrospective Studies , Prospective Studies , Analysis of Variance , Odds Ratio , Risk Factors , Respiratory Distress Syndrome/epidemiology , Positive-Pressure RespirationABSTRACT
OBJECTIVE: The main study objectives were to describe the practice of mechanical ventilation over an 18-year period in Mexico, and estimate changes in mortality among critical patients subjected to invasive mechanical ventilation (IMV). DESIGN: A retrospective subanalysis of a prospective observational study conducted in 1998, 2004, 2010 and 2016 was carried out. SETTING: Intensive Care Units (ICUs) in Mexico. PARTICIPANTS: Adult patients consecutively enrolled in the ICU during one month and who underwent IMV for more than 12hours or noninvasive mechanical ventilation for more than one hour. Follow-up was performed up to a maximum of 28 days after inclusion. INTERVENTIONS: None. PRINCIPAL VARIABLES OF INTEREST: Age, sex, severity upon admission as estimated by SAPS II, parameters of daily arterial blood gases, treatment and complication variables, date and status at discharge from the ICU and from hospital. RESULTS: A total of 959 patients were included in 81 ICUs. Tidal volume (vt) decreased significantly both in patients with acute respiratory distress syndrome (ARDS) criteria (estimated 8.5ml/kg b.w. in 1998 to 6ml/kg in 2016; P<0.001) and in patients without ARDS (estimated 9ml/kg b.w. in 1998 to 6ml/kg in 2016; P<0.001). The ventilatory protective strategy (defined as vt < 6ml/kg or < 8ml/kg and a plateau pressure < 30cmH2O) was: 19% in 1998, 44% in 2004, 58% in 2010 and 75% in 2016 (P<0.001). The adjusted mortality rate in ICU over the 4 periods was: in 2004, odds ratio (OR) 1.05 (95% confidence interval, 95%CI: 0.73-1.72; P=0.764); in 2010, OR 1.68 (95%CI: 1.13-2.48; P=0.009); in 2016, OR 0.85 (95%CI: 0.60-1.20; P=0.368). CONCLUSIONS: The clinical practice of IMV in Mexican ICUs has been modified over a period of 18 years. The most significant change is the ventilatory strategy based on low vt. These changes have not been associated with significant changes in mortality.
