Ventilatory Parameters in Obstetric Patients With COVID-19 and Impact of Delivery: A Multicenter Prospective Cohort Study.

BACKGROUND: Current evidence on obstetric patients requiring advanced ventilatory support and impact of delivery on ventilatory parameters is retrospective, scarce, and controversial. RESEARCH QUESTION: What are the ventilatory parameters for obstetric patients with COVID-19 and how does delivery impact them? What are the risk factors for invasive mechanical ventilation (IMV) and for maternal, fetal, and neonatal mortality? STUDY DESIGN AND METHODS: Prospective, multicenter, cohort study including pregnant and postpartum patients with COVID-19 requiring advanced ventilatory support in the ICU. RESULTS: Ninety-one patients were admitted to 21 ICUs at 29.2 ± 4.9 weeks; 63 patients (69%) delivered in ICU. Maximal ventilatory support was as follows: IMV, 69 patients (76%); high-flow nasal cannula, 20 patients (22%); and noninvasive mechanical ventilation, 2 patients (2%). Sequential Organ Failure Assessment during the first 24 h (SOFA24) score was the only risk factor for IMV (OR, 1.97; 95% CI, 1.29-2.99; P = .001). Respiratory parameters at IMV onset for pregnant patients were: mean ± SD plateau pressure (PP), 24.3 ± 4.5 cm H2O; mean ± SD driving pressure (DP), 12.5 ± 3.3 cm H2O; median static compliance (SC), 31 mL/cm H2O (interquartile range [IQR], 26-40 mL/cm H2O); and median Pao2 to Fio2 ratio, 142 (IQR, 110-176). Respiratory parameters before (< 2 h) and after (≤ 2 h and 24 h) delivery were, respectively: mean ± SD PP, 25.6 ± 6.6 cm H2O, 24 ± 6.7 cm H2O, and 24.6 ± 5.2 cm H2O (P = .59); mean ± SD DP, 13.6 ± 4.2 cm H2O, 12.9 ± 3.9 cm H2O, and 13 ± 4.4 cm H2O (P = .69); median SC, 28 mL/cm H2O (IQR, 22.5-39 mL/cm H2O), 30 mL/cm H2O (IQR, 24.5-44 mL/cm H2O), and 30 mL/cm H2O (IQR, 24.5-44 mL/cm H2O; P = .058); and Pao2 to Fio2 ratio, 134 (IQR, 100-230), 168 (IQR, 136-185), and 192 (IQR, 132-232.5; P = .022). Reasons for induced delivery were as follows: maternal, 43 of 71 patients (60.5%); maternal and fetal, 21 of 71 patients (29.5%); and fetal, 7 of 71 patients (9.9%). Fourteen patients (22.2%) continued pregnancy after ICU discharge. Risk factors for maternal mortality were BMI (OR, 1.10; 95% CI, 1.006-1.204; P = .037) and comorbidities (OR, 4.15; 95% CI, 1.212-14.20; P = .023). Risk factors for fetal or neonatal mortality were gestational age at delivery (OR, 0.67; 95% CI, 0.52-0.86; P = .002) and SOFA24 score (OR, 1.53; 95% CI, 1.13-2.08; P = .006). INTERPRETATION: Contrary to expectations, pregnant patient lung mechanics were similar to those of the general population with COVID-19 in the ICU. Delivery was induced mainly for maternal reasons, but did not change ventilatory parameters other than Pao2 to Fio2 ratio. SOFA24 score was the only risk factor for IMV. Maternal mortality was associated independently with BMI and comorbidities. Risk factors for fetal and neonatal mortality were SOFA24 score and gestational age at delivery.

Factores de riesgo para el fracaso de destete en una población de pacientes con EPOC en ventilación mecánica prolongada

Introducción: Los pacientes con EPOC experimentan episodios de falla respiratoria que requieren de asistencia ventilatoria mecánica (AVM). Debido al compromiso pulmonar, muscular y nutricional, experimentan dificultad en el destete. Hay escasa información de los factores que puedan predecir el fracaso del destete en pacientes con EPOC en VM prolongada (VMP). El objetivo de este trabajo es encontrar factores de riesgo para el fracaso del destete en pacientes con EPOC y evaluar mortalidad según éxito o fracaso en el destete. Materiales y Métodos: El estudio se realizó en un centro de weaning (CW) y se incluyeron pacientes internados en una unidad de terapia intensiva (UTI) por reagudización de su EPOC derivados a nuestro CW traqueostomizados con requerimiento de AVM. Resultados: Se recolectaron los datos de 40 pacientes, de los cuales 21 finalizaron AVM de manera exitosa y 19 fracasaron. El análisis univariado arrojó 4 variables asociadas al fracaso del destete: Pimax (p = 0.035), días de AVM en el CW (p = 0.005), pH (p = 0.039) y la PaCO2 (p = 0.002). Sin embargo, solo la PaCO2 a las 12hs de la prueba de respiración espontánea (PRE) fue predictor de fracaso de destete (p = 0.007). No se encontraron predictores de mortalidad. Conclusión: Encontrar factores de riesgo que permitan identificar el fracaso en la desvinculación de la VM puede contribuir en la decisión de insistir con el destete, o bien, plantear un programa de internación domiciliaria con la finalidad de mejorar la calidad de vida. La única variable asociada al fracaso de destete fue la PaCO2 a las 12hs de comenzada la PRE.(AU)

Introduction: Patients suffering from chronic obstructive pulmonary disease (COPD) have an airflow limitation and require mechanical ventilation (MV). Because of deteriorated lung function, respiratory muscles weakness and malnutrition, patients also present difficulties in the weaning process. Information on the factors that can predict weaning failure in patients with COPD after prolonged MV is scarce. To identify risk factors for weaning failure in patients with COPD and evaluate the mortality depending on weaning success or failure. Materials and Methods: This study was carried out at a weaning center in Buenos Aires, Argentina. We evaluated patients admitted to an intensive care unit (ICU) and referred to the weaning center as a result of COPD exacerbation, after tracheostomy and in need of mechanical ventilation. Results: Data from 40 patients were collected; 21 were successfully weaned from MV and 19 failed the weaning process. Univariate analysis showed 4 variables associated with weaning failure: maximum inspiratory pressure (MIP) (p = 0.035), length of MV at weaning center (p = 0.005), pH (p = 0.039) and PaCO2 (p = 0.002). However, only PaCO2 twelve hours after the spontaneous breathing trial (SBT) was a predictor of weaning failure (p=0.007). Mortality predictors were not found. Conclusion: The only predictive variable associated with weaning failure was PaCO2 twelve hours after SBT. Finding risk factors for failure in discontinuing MV may provide information to decide whether to insist in the weaning process or choose home MV to improve life quality.(AU)

Factores de riesgo para el fracaso de destete en una población de pacientes con EPOC en ventilación mecánica prolongada / Risk Factors for Weaning Failure in Patients with Chronic Obstructive Pulmonary Disease in Prolonged Mechanical Ventilation

Introducción: Los pacientes con EPOC experimentan episodios de falla respiratoria que requieren de asistencia ventilatoria mecánica (AVM). Debido al compromiso pulmonar, muscular y nutricional, experimentan dificultad en el destete. Hay escasa información de los factores que puedan predecir el fracaso del destete en pacientes con EPOC en VM prolongada (VMP). El objetivo de este trabajo es encontrar factores de riesgo para el fracaso del destete en pacientes con EPOC y evaluar mortalidad según éxito o fracaso en el destete. Materiales y Métodos: El estudio se realizó en un centro de weaning (CW) y se incluyeron pacientes internados en una unidad de terapia intensiva (UTI) por reagudización de su EPOC derivados a nuestro CW traqueostomizados con requerimiento de AVM. Resultados: Se recolectaron los datos de 40 pacientes, de los cuales 21 finalizaron AVM de manera exitosa y 19 fracasaron. El análisis univariado arrojó 4 variables asociadas al fracaso del destete: Pimax (p = 0.035), días de AVM en el CW (p = 0.005), pH (p = 0.039) y la PaCO2 (p = 0.002). Sin embargo, solo la PaCO2 a las 12hs de la prueba de respiración espontánea (PRE) fue predictor de fracaso de destete (p = 0.007). No se encontraron predictores de mortalidad. Conclusión: Encontrar factores de riesgo que permitan identificar el fracaso en la desvinculación de la VM puede contribuir en la decisión de insistir con el destete, o bien, plantear un programa de internación domiciliaria con la finalidad de mejorar la calidad de vida. La única variable asociada al fracaso de destete fue la PaCO2 a las 12hs de comenzada la PRE.

Introduction: Patients suffering from chronic obstructive pulmonary disease (COPD) have an airflow limitation and require mechanical ventilation (MV). Because of deteriorated lung function, respiratory muscles weakness and malnutrition, patients also present difficulties in the weaning process. Information on the factors that can predict weaning failure in patients with COPD after prolonged MV is scarce. To identify risk factors for weaning failure in patients with COPD and evaluate the mortality depending on weaning success or failure. Materials and Methods: This study was carried out at a weaning center in Buenos Aires, Argentina. We evaluated patients admitted to an intensive care unit (ICU) and referred to the weaning center as a result of COPD exacerbation, after tracheostomy and in need of mechanical ventilation. Results: Data from 40 patients were collected; 21 were successfully weaned from MV and 19 failed the weaning process. Univariate analysis showed 4 variables associated with weaning failure: maximum inspiratory pressure (MIP) (p = 0.035), length of MV at weaning center (p = 0.005), pH (p = 0.039) and PaCO2 (p = 0.002). However, only PaCO2 twelve hours after the spontaneous breathing trial (SBT) was a predictor of weaning failure (p=0.007). Mortality predictors were not found. Conclusion: The only predictive variable associated with weaning failure was PaCO2 twelve hours after SBT. Finding risk factors for failure in discontinuing MV may provide information to decide whether to insist in the weaning process or choose home MV to improve life quality.

Decanulación después de la estadía en UCI: Análisis de 181 pacientes traqueotomizados / Decannulation after the ICU Stay. Analysis of 181 Tracheostomized Patients

Objetivo: Encontrar predictores de decanulación en pacientes traqueostomizados y desvinculados de la asistencia ventilatoria mecánica. Analizar la mortalidad en el centro de weaning y supervivencia al alta. Materiales y métodos: Estudio retrospectivo. Se revisaron historias clínicas de pacientes que ingresaron al centro de weaning entre enero de 2004 y junio de 2011. Se estudiaron diferentes variables como posibles predictores de decanulación. Se analizó la mortalidad y se realizó seguimiento al alta. Resultados: Se incluyeron 181 pacientes con una media de 62 años. Se logró decanular al 44.2% de los pacientes (mediana 20 días). El análisis univariado encontró 6 variables asociadas al fracaso de decanulación: sexo masculino, antecedentes respiratorios, antecedentes cardiovasculares, albúmina al ingreso al centro de weaning, días de internación en centro de weaning y días de internación en Unidad de Cuidados Intensivos + centro de weaning. La regresión logística encontró como predictores independientes: sexo masculino y antecedentes respiratorios. En el análisis de regresión logística la decanulación fue un factor protectivo con respecto a la mortalidad. El 80% de los pacientes decanulados y el 15,8% de los no decanulados obtuvieron alta médica. La mediana de supervivencia de los decanulados fue de 45.47 meses y los no decanulados de 10.87. Conclusiones: Los pacientes de sexo masculino y aquellos con antecedentes respiratorios se asocian con fracaso de decanulación. Los pacientes decanulados tienen menor riesgo de muerte durante la internación.

Objective: Find predictors of decannulation in tracheostomized patients and without mechanical ventilation. A secondary objective was the analysis of mortality in the weaning center and survival at discharge. Material and methods: We reviewed, retrospectively, the medical records of patients admitted to the weaning center with tracheostomy and without mechanical ventilation between January 2004 and June 2011. Different variables as possible predictors of decannulation were studied. Mortality at weaning center and outcomes during follow up after discharge were analyzed. Results: We included 181 patients with an average age of 62 years old. Decannulation was carried out in 44.2% of the patients. The decannulation process took 20 days. The univariate analysis found six variables associated with decannulation failure: male gender, respiratory or cardiovascular history, albumin at admission to the weaning center, days of hospitalization in the weaning center and admission to intensive care units plus the weaning center. Logistic regression analysis found that male sex and respiratory history were independent predictors. Regarding mortality during hospitalization, logistic regression analysis found that decannulation was a protective factor. Another finding was that 80% of patients decannulated were discharged; only 15.8% of the group was not decannulated. The average survival was 45.47 months among the decannulated patients and 10.87 months for the non decannulated patients. Conclusions: We found that male sex and a history of respiratory failure were factors associated with unsuccessful decannulation. Decannulated patients had lower risk of death during hospitalization.

Decanulación después de la estadía en UCI: Análisis de 181 pacientes traqueotomizados

Objetivo: Encontrar predictores de decanulación en pacientes traqueostomizados y desvinculados de la asistencia ventilatoria mecánica. Analizar la mortalidad en el centro de weaning y supervivencia al alta. Materiales y métodos: Estudio retrospectivo. Se revisaron historias clínicas de pacientes que ingresaron al centro de weaning entre enero de 2004 y junio de 2011. Se estudiaron diferentes variables como posibles predictores de decanulación. Se analizó la mortalidad y se realizó seguimiento al alta. Resultados: Se incluyeron 181 pacientes con una media de 62 años. Se logró decanular al 44.2% de los pacientes (mediana 20 días). El análisis univariado encontró 6 variables asociadas al fracaso de decanulación: sexo masculino, antecedentes respiratorios, antecedentes cardiovasculares, albúmina al ingreso al centro de weaning, días de internación en centro de weaning y días de internación en Unidad de Cuidados Intensivos + centro de weaning. La regresión logística encontró como predictores independientes: sexo masculino y antecedentes respiratorios. En el análisis de regresión logística la decanulación fue un factor protectivo con respecto a la mortalidad. El 80% de los pacientes decanulados y el 15,8% de los no decanulados obtuvieron alta médica. La mediana de supervivencia de los decanulados fue de 45.47 meses y los no decanulados de 10.87. Conclusiones: Los pacientes de sexo masculino y aquellos con antecedentes respiratorios se asocian con fracaso de decanulación. Los pacientes decanulados tienen menor riesgo de muerte durante la internación.(AU)

Objective: Find predictors of decannulation in tracheostomized patients and without mechanical ventilation. A secondary objective was the analysis of mortality in the weaning center and survival at discharge. Material and methods: We reviewed, retrospectively, the medical records of patients admitted to the weaning center with tracheostomy and without mechanical ventilation between January 2004 and June 2011. Different variables as possible predictors of decannulation were studied. Mortality at weaning center and outcomes during follow up after discharge were analyzed. Results: We included 181 patients with an average age of 62 years old. Decannulation was carried out in 44.2% of the patients. The decannulation process took 20 days. The univariate analysis found six variables associated with decannulation failure: male gender, respiratory or cardiovascular history, albumin at admission to the weaning center, days of hospitalization in the weaning center and admission to intensive care units plus the weaning center. Logistic regression analysis found that male sex and respiratory history were independent predictors. Regarding mortality during hospitalization, logistic regression analysis found that decannulation was a protective factor. Another finding was that 80% of patients decannulated were discharged; only 15.8% of the group was not decannulated. The average survival was 45.47 months among the decannulated patients and 10.87 months for the non decannulated patients. Conclusions: We found that male sex and a history of respiratory failure were factors associated with unsuccessful decannulation. Decannulated patients had lower risk of death during hospitalization.(AU)

Adaptación cultural y validación del Dizziness Handicap Inventory: versión Argentina / Cross-cultural adaptation and validation of the Dizziness Handicap Inventory: Argentine version

Introducción y objetivos: El Dizziness Handicap Inventory es una herramienta útil para cuantificarla autopercepción de la discapacidad en pacientes con vértigo, mareo o inestabilidad y su impacto en actividades de la vida diaria. El Dizziness Handicap Inventory identifica problemas de orden funcional, físico y emocional relacionados con trastornos del equilibrio. Nuestro objetivo es realizar la adaptación cultural y validación del Dizziness Handicap Inventory al castellano argentino a partir de la versión española. Métodos: Se incluyeron personas sanas y pacientes con vértigo, mareo o inestabilidad, de 18 a 85 años, argentinos nativos capaces de comprender castellano. Sobre la versión española se realizaron modificaciones lingüísticas y culturales para obtenerla versión argentina. Esta versión se administró a un grupo de 108 pacientes, 2 veces, en un lapso de 24 a 72 h. Se evaluó consistencia interna, confiabilidad test-retest y validez de constructo a través de: Escala Visual Análoga, Romberg, Romberg en tándem y marcha en tándem. Resultados: Se encontró una alta consistencia interna (Alfa=0,87), y muy alta confiabilidad testretest del Dizziness Handicap Inventory total (coeficiente de correlación intraclase: 0,98) y sus subescalas. Se encontraron correlaciones significativas entre Romberg y el Romberg en tándemcon el Dizziness Handicap Inventory total y la subescala funcional. La subescala emocional mostró una correlación significativa cuando se comparó con Romberg y Romberg en tándem ojos abiertos (p < 0,05).Conclusiones: La versión argentina del Dizziness Handicap Inventory mostró ser una herramienta confiable y válida para cuantificar la autopercepción de la discapacidad debida a vértigo, mareo o inestabilidad(AU)

Introduction and objectives: The Dizziness Handicap Inventory is a useful tool for quantifying self-perceived handicap in patients with vertigo, dizziness or unsteadiness and its impact on daily living activities. The Dizziness Handicap Inventory identifies functional, physical and emotional disorders related to balance disturbance. Our objective was to cross-culturally adapt the Peninsular Spanish version of the Dizziness Handicap Inventory for use in Argentina and validate the adapted Argentinian version. Methods: We included both healthy subjects and patients with vertigo, dizziness or unsteadiness, aged 18 to 85 years, native Spanish-speaking Argentinians. We introduced linguistic and cultural modifications to the Peninsular Spanish version to obtain the Argentinian one. This version was given twice to 108 patients, 24 to 72 h apart. Internal consistency, test-retest reliability and construct validity were assessed using a visual analogue scale, the Romberg test, the tandem Romberg test and the tandem gait test. Results: We found high internal consistency (Alfa=0.87) and very high test-retest reliability for the total Dizziness Handicap Inventory score (intraclass correlation coefficient: 0.98) and its subscales. The total Dizziness Handicap Inventory and the functional subscale were found to correlate significantly with the Romberg and tandem Romberg tests. The emotional subscales howed a significant correlation with the Romberg test and the eyes-open tandem Romberg test(P<.05)Conclusions: The Argentinian version of the Dizziness Handicap Inventory proved to be a reliable and valid tool to quantify self-perceived handicap resulting from vertigo, dizziness or unsteadiness(AU)

[Cross-cultural adaptation and validation of the Dizziness Handicap Inventory: Argentine version]. / Adaptación cultural y validación del Dizziness Handicap Inventory: versión Argentina.

INTRODUCTION AND OBJECTIVES: The Dizziness Handicap Inventory is a useful tool for quantifying self-perceived handicap in patients with vertigo, dizziness or unsteadiness and its impact on daily living activities. The Dizziness Handicap Inventory identifies functional, physical and emotional disorders related to balance disturbance. Our objective was to cross-culturally adapt the Peninsular Spanish version of the Dizziness Handicap Inventory for use in Argentina and validate the adapted Argentinian version. METHODS: We included both healthy subjects and patients with vertigo, dizziness or unsteadiness, aged 18 to 85 years, native Spanish-speaking Argentinians. We introduced linguistic and cultural modifications to the Peninsular Spanish version to obtain the Argentinian one. This version was given twice to 108 patients, 24 to 72 h apart. Internal consistency, test-retest reliability and construct validity were assessed using a visual analogue scale, the Romberg test, the tandem Romberg test and the tandem gait test. RESULTS: We found high internal consistency (α=0.87) and very high test-retest reliability for the total Dizziness Handicap Inventory score (intraclass correlation coefficient: 0.98) and its subscales. The total Dizziness Handicap Inventory and the functional subscale were found to correlate significantly with the Romberg and tandem Romberg tests. The emotional subscale showed a significant correlation with the Romberg test and the eyes-open tandem Romberg test (P<.05) CONCLUSIONS: The Argentinian version of the Dizziness Handicap Inventory proved to be a reliable and valid tool to quantify self-perceived handicap resulting from vertigo, dizziness or unsteadiness.