Efectos del Posicionamiento Prono en Individuos con Síndrome de Distrés Respiratorio Agudo. Una Revisión Sistemática / Effects of Prone Positionig in Individuals with Acute Respiratory Distress Syndrome. A systemtic review

Introducción. La presente investigación es una revisión sistemática, donde se identificó, recopiló, tamizó, sistematizó e interpretó la información existente sobre el Síndrome de Distrés Respiratorio Agudo (SDRA) y el posicionamiento prono (PP). Objetivo. Describir los efectos que tiene el posicionamiento en prono para el tratamiento del Síndrome de Distrés Respiratorio Agudo en individuos mayores de 18 años. Métodos. Se realizó una revisión sistemática de articulos científicos relacionados a posicionamiento en prono en individuos con Síndrome de Distrés Respiratorio Agudo. Se revisaron artículos desde el año 2016 a la actualidad en las siguientes bases de datos: Pub Med, Springer, Science Direct, Web of Science y Scopus. El número de artículos científicos incluidos en la síntesis cualitativa fue de 18. Resultados. La PP produce efectos benéficos en el SDRA, mejora la oxigenación y mediciones de gases arteriales, reduce la tasa de mortalidad. También mejora la mecánica pulmonar, reduce el driving pressure y el riesgo de necesitar ventilación mecánica. Conclusión. El posicionamiento en prono produce efectos beneficiosos para el SDRA.

Background. Introduction: The present research is a systematic review, where we identified, collected, 20 sifted, systematized and interpreted the information that exists on Acute Respiratory Distress Syndrome (ARDS) and prone positioning (PP). Objetive. To describe the effects of prone positioning for the treatment of acute respiratory distress syndrome in individuals over 18 years of age. Methods. Systematic review, the number of scientific articles included in the qualitative synthesis is 18, from 2016 to present, on prone positioning in individuals with Acute Respiratory Distress Syndrome. In the following databases: Pub Med, Springer, Science Direct, WEB OF SCIENCE and Scopus. Results: PP produces effects in ARDS, improving oxygenation, producing improvement of arterial gases, reduces mortality rate, normalizes pulmonary mechanics, conduction pressure and reduces the risk of using mechanical ventilation. Conclusion. Prone positioning produces beneficial effects for Acute Respiratory Distress Syndrome.

Ruxolitinib como uso compasivo para la covid-19 frente al tratamiento con cloroquinas: Reporte de 100 casos en el Hospital de Especialidades Portoviejo - Ecuador / Ruxolitinib como uso compasivo para la Covid-19 frente al tratamiento con cloroquinas: Reporte de 100 casos en el Hospital de Especialidades Portoviejo - Ecuador

El uso compasivo de ruxolitinib en la covid-19 demostró una mejoría en las imágenes de tórax y mayor número de altas en el grupo que lo usó vs. el grupo 1 (cloroquinas y azitromicina), con descenso de los marcadores inflamatorios. Existe un artículo que señaló que un caso que fue refractario a la terapia anti-IL6, pero respondió a la inhibición de Jak-Stat con ruxolitinib.1 La comorbilidad más frecuente en ambos grupos fue la hipertensión arterial, seguida por la diabetes tipo 2; el grupo 1 presentó un mayor número de pacientes que no presentaban comorbilidades (18 pacientes). El número de hombres con enfermedad por SARS-CoV2 fue mayor en el grupo 1, con 31 hombres (62,0%) frente un total de 19 mujeres (38,0%), mientras que, en el grupo 2, el 25,0% eran hombres y mujeres, el 25,0%. La gravedad de la covid-19 fue definida como moderada: adolescente o adulto con signos clínicos de neumonía (fiebre, tos, disnea, taquipnea), en particular SpO2 ≥ 90% con aire ambiente; y grave: adolescente o adulto con signos clínicos de neumonía (fiebre, tos, disnea, taquipnea) más alguno de los siguientes: frecuencia respiratoria > 30 inspiraciones/min, dificultad respiratoria grave o SpO2 < 90% con aire ambiente.2 El síndrome de dificultad respiratoria aguda (SDRA) en ambos grupos fue de un pro medio de relación entre la presión arterial de oxígeno y la fracción inspirada de oxígeno (PaFi) en el grupo ruxolitinib 135,3 mmHg vs. Grupo control PaFi 138,9 mmHg. Se definió la eficacia por descenso de los marcadores inflamatorios, mejoría gasométrica de la PaFi, menor requerimiento de oxígeno, disminución del ingreso a unidad de cuidados intensivos de los pacientes con sintomatología grave, demostración de la seguridad del fármaco en los 10 días posteriores a su uso y detallado del número de casos con alta médica.

The group with compassionate use of ruxolitinib for Covid-19 showed improved chest images and a larger number of discharged patients, compared to group 1 (chloro quines and azithromycin), with a decrease in inflammatory markers. There is one arti cle that described a case which refractory to anti-IL6 therapy but responded to Jak-Stat inhibition with ruxolitinib.1 The most common comorbidity in both groups was arterial hypertension, followed by diabetes type 2; group 1 showed a larger number of patients without comorbidities (18 patients). The number of male patients with the disease caused by SARS-CoV2 was larger in group 1, with 31 males (62.0%), compared to a total of 19 females (38.0%), whereas in group 2, 25.0% were males, and 25.0% females. The severity of Covid-19 was defined as moderate: adolescent or adult with clinical signs of pneumonia (fever, cough, dys pnea, tachypnea), particularly SpO2 ≥ 90% on ambient air; and severe: adolescent or adult with clinical signs of pneumonia (fever, cough, dyspnea, tachypnea) plus some of the following: respiratory rate > 30 breaths/min, severe respiratory distress or SpO2 < 90% on ambient air.2 The acute respiratory distress syndrome (ARDS) in both groups had an average ratio of pressure arterial oxygen and fraction of inspired oxygen (PaFi) of 135.3 mmHg in the ruxolitinib group versus 138.9 mmHg in the control group. Efficacy was defined as: decrease in inflammatory markers, gasometric improvement in the PaFi, lower oxygen requirement, lower number of patients with severe symptoms admitted to the Intensive Care Unit, proof of the drug's safety 10 days after use, and detailed number of discharged patients.

Early Initiation of Extracorporeal Blood Purification Using the AN69ST (oXiris®) Hemofilter as a Treatment Modality for COVID-19 Patients: a Single-Centre Case Series

Abstract Introduction: Severe coronavirus disease 2019 (COVID-19) is characterised by hyperinflammatory state, systemic coagulopathies, and multiorgan involvement, especially acute respiratory distress syndrome (ARDS). We here describe our preliminary clinical experience with COVID-19 patients treated via an early initiation of extracorporeal blood purification combined with systemic heparinisation and respiratory support. Methods: Fifteen patients were included; several biomarkers associated with COVID-19 severity were monitored. Personalised treatment was tailored according to the levels of interleukin (IL)-6, IL-8, tumour necrosis factor alpha, C-reactive protein (CRP), neutrophil-to-lymphocyte ratio, thrombocyte counts, D-dimers, and fibrinogen. Treatment consisted of respiratory support, extracorporeal blood purification using the AN69ST (oXiris®) hemofilter, and 300 U/kg heparin to maintain activation clotting time ≥ 180 seconds. Results: Ten patients presented with severe to critical disease (dyspnoea, hypoxia, respiratory rate > 30/min, peripheral oxygen saturation < 90%, or > 50% lung involvement on X-ray imaging). The median intensive care unit length of stay was 9.3 days (interquartile range 5.3-10.1); two patients developed ARDS and died after 5 and 26 days. Clinical improvement was associated with normalisation (increase) of thrombocytes and white blood cells, stable levels of IL-6 (< 50 ng/mL), and a decrease of CRP and fibrinogen. Conclusion: Continuous monitoring of COVID-19 severity biomarkers and radiological imaging is crucial to assess disease progression, uncontrolled inflammation, and to avert irreversible multiorgan failure. The combination of systemic heparin anticoagulation regimens and extracorporeal blood purification using cytokine-adsorbing hemofilters may reduce hyperinflammation, prevent coagulopathy, and support clinical recovery.

Early Initiation of Extracorporeal Blood Purification Using the AN69ST (oXiris®) Hemofilter as a Treatment Modality for COVID-19 Patients: a Single-Centre Case Series.

INTRODUCTION: Severe coronavirus disease 2019 (COVID-19) is characterised by hyperinflammatory state, systemic coagulopathies, and multiorgan involvement, especially acute respiratory distress syndrome (ARDS). We here describe our preliminary clinical experience with COVID-19 patients treated via an early initiation of extracorporeal blood purification combined with systemic heparinisation and respiratory support. METHODS: Fifteen patients were included; several biomarkers associated with COVID-19 severity were monitored. Personalised treatment was tailored according to the levels of interleukin (IL)-6, IL-8, tumour necrosis factor alpha, C-reactive protein (CRP), neutrophil-to-lymphocyte ratio, thrombocyte counts, D-dimers, and fibrinogen. Treatment consisted of respiratory support, extracorporeal blood purification using the AN69ST (oXiris®) hemofilter, and 300 U/kg heparin to maintain activation clotting time ≥ 180 seconds. RESULTS: Ten patients presented with severe to critical disease (dyspnoea, hypoxia, respiratory rate > 30/min, peripheral oxygen saturation < 90%, or > 50% lung involvement on X-ray imaging). The median intensive care unit length of stay was 9.3 days (interquartile range 5.3-10.1); two patients developed ARDS and died after 5 and 26 days. Clinical improvement was associated with normalisation (increase) of thrombocytes and white blood cells, stable levels of IL-6 (< 50 ng/mL), and a decrease of CRP and fibrinogen. CONCLUSION: Continuous monitoring of COVID-19 severity biomarkers and radiological imaging is crucial to assess disease progression, uncontrolled inflammation, and to avert irreversible multiorgan failure. The combination of systemic heparin anticoagulation regimens and extracorporeal blood purification using cytokine-adsorbing hemofilters may reduce hyperinflammation, prevent coagulopathy, and support clinical recovery.

Ventilación en posición prona en el manejo de pacientes con síndrome de dificultad respiratoria aguda / Prone ventilation in the management of patients with acute respiratory distress syndrome

INTRODUCCIÓN. El posicionamiento prono es una de las estrategias ventilatorias más estudiadas y difundidas de la medicina intensiva, forma parte del manejo de ventilación protectiva con impacto en disminución de la mortalidad en pacientes con síndrome de dificultad respiratoria aguda. OBJETIVO. Revisar la evidencia disponible acerca de ventilación en posición prona en pacientes con síndrome de dificultad respiratoria aguda, enfocada en el análisis fisiopatológico y clínico. MATERIALES Y MÉTODOS. Se realizó una revisión bibliográfica en la base de datos de buscadores académicos como PubMed, Google Scholar y Elsevier, en los idiomas español e inglés, en el período comprendido entre los años 1970-2020; se seleccionaron 16 publicaciones en texto completo: 3 metaanálisis, 10 estudios randomizado, 3 revisiones sistemáticas. CONCLUSIÓN. En base a la evidencia y percepción recopilada de la experiencia de los autores, la ventilación en posición prona es una estrategia de manejo de primera línea, fiable, que no requiere para su empleo equipamiento costoso ni complejo y ha demostrado mejoría en desenlaces relevantes en el tratamiento del paciente crítico respiratorio como disminución en la mortalidad y optimización de los parámetros ventilatorios y de oxigenación.

INTRODUCTION. Prone positioning is one of the most studied and widespread ventilatory strategies in intensive medicine, it is part of protective ventilation management with an impact on mortality reduction in patients with acute respiratory distress syndrome. OBJECTIVE. To review the available evidence about ventilation in the prone position in patients with acute respiratory distress syndrome, focused on the pathophysiological and clinical analysis. MATERIALS AND METHODS. A bibliographic review was carried out in the databases of academic search engines such as PubMed, Google Scholar and Elsevier, in the Spanish and English languages, in the period between the years 1970-2020, 16 full text publications were selected: 3 meta-analyses, 10 randomized studies, 3 systematic reviews. CONCLUSION. Based on the evidence and perception gathered from the authors' experience, prone ventilation is a reliable first-line management strategy that does not require costly or complex equipment for its use and has demonstrated improvements in relevant outcomes in the treatment of the critically ill respiratory patient, such as decreased mortality and optimization of ventilatory and oxygenation parameters.

Reactive airways dysfunction syndrome following inhalation of hydrogen chloride vapor.

Hydrogen chloride is available commercially as an anhydrous gas or an aqueous solution, hydrochloric acid. Exposure to this gas has been associated with the development of reactive airways dysfunction syndrome. However, there are few published reports. A 37-year-old woman developed progressive bronchospasm and acute respiratory failure after cleaning an enclosed space with an unknown concentration of hydrochloric acid gas from a cleaning substance. She had no prior history of asthma or atopy. Severe bronchospasm developed, leading to hypoxemia and diffuse interstitial infiltrates, necessitating orotracheal intubation and admission to the intensive care unit. Asthma-like symptoms such as cough, wheezing, and dyspnea; requiring bronchodilators, and repeated hospitalizations are persistent a year after the accident. Pulmonary function testing showed mild airflow obstruction.

Repercussões da ventilação não invasiva em recém-nascidos prematuros com síndrome do desconforto respiratório agudo: revisão integrativa / Repercussionsof non-invasive ventilation in premature newborns with acute respiratory discomfort syndrome: integrative review / Repercusionesde la ventilación no invasiva en recién nacidos prematuros con síndrome de malestar respiratorio agudo: revisión integrativa

Introdução: Neonatos pré-termos apresentam singularidades anátomo-fisiológicas predispondo-os a complicações respiratórias como a Síndrome do Desconforto Respiratório Aguda. Caracterizada pelo déficit de surfactante pulmonar e consequente insuficiência respiratória, aumentando a necessidade de suporte ventilatório invasivo e não invasivo.Objetivo: Analisar os efeitos da ventilação não invasiva em recém-nascidos prematuros com Síndrome do Desconforto Respiratório Aguda. Metodologia: Trata-se de uma revisão integrativa no qual utilizou-se das bases de dados: SciELO, LILACS, PEDro, MEDLINE e Bireme. Os critérios de inclusão foram estudos relacionadosatemática em portuguêseinglês completos e com publicação entre 2015 a 2020.Resultados:Nos seteestudos sintetizados houve a utilização dos sistemas de suporte ventilatório: pressão positiva em vias aéreas a dois níveis: cânulas nasais aquecidas, umidificadas e de alto fluxo; ventilação de pressão positiva nas vias aéreas nasal, e a ventilação por pressão positiva intermitente nasal. Dois estudos que utilizaram cânulas nasais apontaram efeitos menos benéficos; e um relatou desfechos semelhantes aos demais, além de provocar menor dano nasal. Conclusões: Aventilação não invasiva tevegrande redução do número de falhas de extubação dos pacientes, principalmente naqueles que receberam a ventilação pressão positiva nas vias aéreas nasaise a ventilação por pressão positiva intermitente nasal (AU).

Introduction:Pre-term neonates have anatomophysiologicalsingularities predisposing them to respiratory complications such as Acute Respiratory Discomfort Syndrome. It is characterized by a deficit in pulmonary surfactant and consequent respiratory failure, increasing the need for invasive and non-invasive ventilatory support.Objective:To analyze the effects of non-invasive ventilation in premature newborns with Acute Respiratory Discomfort Syndrome. Methodology:In this integrative review, we used the following databases: SciELO, LILACS, PEDro, MEDLINE, and Bireme. Inclusion criteria were studies wrote in Portuguese and English and published between 2015 and 2020. Results:In the seven synthesized studies, ventilatory support systems were used: positive airway pressure at two levels: heated, humidified, and high-flow nasal cannulas; positive pressure ventilation in the nasal airways; and intermittent positive pressure ventilation. Two studies that used nasal cannulas showed less beneficial effects, and one reported similar outcome to the others, in addition to causing less nasal damage. Conclusions:Non-invasive ventilation had a significant reduction in the number of extubation failures in patients, especially in those who received positive pressure ventilation in the nasal airways and ventilation by positive intermittent nasal pressure (AU).

Introducción:Los neonatos pretérmino presentan singularidades anatomofisiológicasque predisponen a complicaciones respiratorias como el Síndrome de Malestar Respiratorio Agudo. Se caracteriza por un déficit de surfactante pulmonar y la consiguiente insuficiencia respiratoria, aumentando la necesidad de soporte ventilatorio invasivo y no invasivo. Objetivo:Analizar los efectos de la ventilación no invasiva en recién nacidos prematuros con Síndrome de Malestar Respiratorio Agudo. Metodología:En esta revisión integradora se utilizaron las siguientes bases de datos: SciELO, LILACS, PEDro, MEDLINE y Bireme. Los criterios de inclusión fueron estudios escritos en portugués y en inglés y publicados entre 2015 y 2020.Resultados:En los siete estudios sintetizados se utilizaron sistemas de soporte ventilatorio: presión positiva en la vía aéreaen dos niveles: cánulas nasales calentadas, humidificadas y de alto flujo; ventilación con presión positiva en la vía aérea nasal; y ventilación con presión positiva intermitente. Dos estudios que utilizaron cánulas nasales mostraron efectos menos beneficiosos, y uno informó de un resultado similar al de los otros, además de causar menos daño nasal. Conclusiones:La ventilación no invasiva tuvo una reducción significativa en el número de fracasos de extubación en los pacientes, especialmente en aquellos que recibieron ventilación con presión positiva en las vías aéreas nasales y ventilación por presión nasal positiva intermitente (AU).

Driving pressure e mortalidade no trauma sem síndrome do desconforto respiratório agudo: estudo observacional prospectivo / Driving pressure and mortality in trauma without acute respiratory distress syndrome: a prospective observational study

RESUMO Objetivo: Identificar a existência de associação entre os valores de driving pressure e mechanical power e do índice de oxigenação no primeiro dia de ventilação mecânica com a mortalidade de pacientes vítimas de trauma sem diagnóstico de síndrome do desconforto respiratório agudo. Métodos: Foram incluídos pacientes ventilados em modo de pressão ou volume controlado, com coleta de dados 24 horas após sua intubação orotraqueal. O acompanhamento do paciente foi realizado por 30 dias para obter o desfecho clínico. Os pacientes estiveram internados em duas unidades de terapia intensiva do Hospital de Pronto Socorro de Porto Alegre, no período de junho a setembro de 2019. Resultados: Foram avaliados 24 pacientes. Os valores de driving pressure, mechanical power e do índice de oxigenação foram similares entre os pacientes que sobreviveram e os que tiveram desfecho de óbito, sem diferença estatisticamente significativa entre os grupos. Conclusão: Os valores de driving pressure, mechanical power e índice de oxigenação obtidos no primeiro dia de ventilação mecânica não demonstraram ter associação com a mortalidade de pacientes vítimas de trauma sem síndrome do desconforto respiratório agudo.

ABSTRACT Objective: To identify the possible association between driving pressure and mechanical power values and oxygenation index on the first day of mechanical ventilation with the mortality of trauma patients without a diagnosis of acute respiratory distress syndrome. Methods: Patients under pressure-controlled or volume-controlled ventilation were included, with data collection 24 hours after orotracheal intubation. Patient follow-up was performed for 30 days to obtain the clinical outcome. The patients were admitted to two intensive care units of the Hospital de Pronto Socorro de Porto Alegre from June to September 2019. Results: A total of 24 patients were evaluated. Driving pressure, mechanical power and oxygenation index were similar among patients who survived and those who died, with no statistically significant difference between groups. Conclusion: Driving pressure, mechanical power and oxygenation index values obtained on the first day of mechanical ventilation were not associated with mortality of trauma patients without acute respiratory distress syndrome.

Recrutamento alveolar com suspiro: impacto na mecânica respiratória e oxigenação de pacientes ventilados mecanicamente / Alveolar recruitment: impact on respiratory mechanics and oxygenation of mechanically ventilated patients

INTRODUÇÃO: O suspiro caracteriza-se pela realização de uma inspiração lenta e profunda, seguida de uma expiração lenta. Estudos sugerem que a adição de um suspiro por minuto em pacientes com síndrome do desconforto respiratório agudo, ventilados em PSV, melhora a oxigenação e a mecânica pulmonar. OBJETIVO: Avaliar o impacto da manobra de recrutamento alveolar através de suspiro na mecânica pulmonar e oxigenação em pacientes ventilados mecanicamente, além de verificar o impacto hemodinâmico e a incidência de intercorrências associadas à utilização da técnica. MATERIAIS E MÉTODOS: Estudo experimental com 17 pacientes em ventilação mecânica, apresentando relação entre pressão parcial de oxigênio alveolar e fração inspirada de oxigênio (PaO2/FiO2) inferior a 300mmHg. Avaliou-se dados respiratórios, de mecânica pulmonar e hemodinâmicos. Os dados foram coletados durante três períodos: antes do suspiro, imediatamente após e 15 minutos depois da técnica. Dois suspiros por minuto foram administrados utilizando pressão em vias aéreas limitada em 40cmH2O, durante um tempo inspiratório de quatro segundos. RESULTADOS: Após o suspiro, observou-se aumento da PaO2, pressão resistiva, complacência estática e relação PaO2/FiO2, além de diminuição da pressão de platô e pressão parcial de gás carbônico alveolar (PaCO2). Após 15 minutos da retirada do suspiro observou-se que a PaO2, pressão resistiva, complacência estática e relação PaO2/ FiO2 mantiveram-se acima do valor basal, enquanto que a pressão de platô manteve-se abaixo. Não foi observada alteração significante nas variáveis hemodinâmicas. CONCLUSÃO: O suspiro em pacientes ventilados mecanicamente foi capaz de melhorar a oxigenação e a mecânica pulmonar sem comprometer a estabilidade hemodinâmica.

INTRODUCTION: The sigh is characterized by a slow and deep inhalation, followed by a slow exhalation. Studies suggest that the addition of one breath per minute in patients with acute respiratory distress syndrome, ventilated on PSV, improves oxygenation and pulmonary mechanics. OBJECTIVE: Analyze the impact of the alveolar recruitment maneuver through breath in pulmonary mechanics and oxygenation in mechanically ventilated patients, in addition to checking the hemodynamic impact and the incidence of complications associated with the use of the technique. MATERIALS AND METHODS: Experimental study with 17 patients on mechanical ventilation, showing a relationship between partial pressure of alveolar oxygen and fraction of inspired oxygen (PaO2/FiO2) below 300mmHg. Respiratory, pulmonary mechanics, and hemodynamic data were evaluated. Data were collected during three periods: before sigh, immediately after, and 15 minutes after the technique. Two sighs per minute were administered using airways pressure limited to 40 cmH2O, during an inspiratory time of four seconds. RESULTS: After the sigh, there was an increase in PaO2, resistive pressure, static compliance, and PaO2/FiO2 ratio, in addition to a decrease in plateau pressure and partial pressure of alveolar carbon dioxide (PaCO2). After 15 minutes of sigh removal, it was observed that PaO2, resistive pressure, static compliance, and PaO2/ FiO2 ratio remained above the baseline, while the plateau pressure remained below. There was no significant change in hemodynamic variables. CONCLUSION: The sigh in mechanically ventilated patients was able to improve oxygenation and pulmonary mechanics without compromising hemodynamic stability

Esquema de manejo de COVID-19 en adultos / COVID-19 treatment guidelines in adults

RESUMEN Un nuevo coronavirus, denominado COVID-19, fue descubierto por el brote iniciado en China a finales de diciembre del año 2019. Los síntomas característicos son fiebre, tos seca, dificultad respiratoria y malestar general. Muchas investigaciones se están llevando a cabo ya que, si bien no es una enfermedad considerada mortal, tiene un índice de contagio muy alto. Sin embargo, junto a los cuidados hospitalarios y extrahospitalarios, existe un grupo de fármacos que se vienen utilizando para combatir esta enfermedad, tales como hidroxicloroquina, cloroquina, remdesivir, lopinavir/ritonavir, tocilizumab, interferón beta 1B, entre otros.

ABSTRACT A novel coronavirus disease called COVID-19 was discovered as a result of the outbreak that began in China at the end of December 2019. Common symptoms are fever, dry cough, shortness of breath and malaise. Several research are being conducted since the disease has high transmission rate even though it is not considered life-threatening. However, together with hospital and out-of-hospital care, there is a group of medications being used to fight this disease, such as hydroxychloroquine, chloroquine, remdesivir, lopinavir/ritonavir, tocilizumab, interferon beta-1b, among others.

Educación en facultades de medicina del mundo durante el periodo de contingencia por SARS-COV-2 / Education in faculties of medicine around the world during the contingency period due to SARS-CoV-2 / Educação em faculdades de medicina em todo o mundo durante o período de contingência SARS-COV-2

Introducción. La pandemia del SARS-CoV-2 se empezó a reportar desde diciembre de 2019 en la localidad de Wuhan, China, luego se presentaron miles de casos en el mundo. Dentro de las medidas adoptadas a nivel mundial en todos los aspectos, se encuentra el distanciamiento social, lo que ha conllevado al cierre de distintos sectores de la economía; entre ellos la educación superior. La educación médica sufre un cambio repentino al suspender las clases presenciales y los campos de práctica; de este modo, se tuvo que afrontar distintos cambios e innovaciones en sus procesos educativos. El objetivo de este trabajo es realizar una revisión sobre las modalidades implementadas y reportadas en la literatura mundial durante la pandemia en las facultades de medicina. Temas a tratar. Educación médica durante pandemia, facultades de medicina, educación virtual, medidas de educación médica durante tiempos de pandemia, experiencias en educación médica previas a la pandemia, educación a distancia y presencialidad asistida por tecnología, plataformas digitales en el proceso de enseñanza, situación futura e interrogantes. Conclusiones. La implementación de la tecnología en la educación médica de una manera única permitirá a los estudiantes desarrollar habilidades de colaboración y mejorar la adaptabilidad. Es todo un reto la educación médica frente a la pandemia de SARS-CoV-2. Cómo citar: Zuluaga-Gómez M.Valencia-Ortiz NL. Educación en facultades de medicina del mundo durante el periodo de contingencia por SARS-COV-2. MedUNAB. 2021;24(1): 92-99. doi: https://doi.org/10.29375/01237047.3942

Introduction. The SARS-CoV-2 pandemic started being reported in December 2019 in the locality of Wuhan, China. Subsequently, thousands of cases arose around the world. Among the measures adopted worldwide in all aspects is social distancing, which has led to closure of various sectors of the economy, among which is higher education. Medical education experienced a sudden change when on-site classes and fields of practice were suspended. In this way, people had to face different changes and innovations in their educational processes. The objective of this study is to review the implemented and reported modalities in the global literature of faculties of medicine during the pandemic. Areas to be Addressed. Medical education during the pandemic, faculties of medicine, virtual education, medical education measures during the pandemic, experiences in medical education prior to the pandemic, e-learning and on-site education assisted by technology, digital platforms in the teaching process, future situations and questions. Conclusions. Uniquely implementing technology in medical education will allow students to develop collaborative skills and improve their adaptability. This is a challenge to medical education during the SARS-CoV-2 pandemic. Cómo citar: Zuluaga-Gómez M.Valencia-Ortiz NL. Educación en facultades de medicina del mundo durante el periodo de contingencia por SARS-COV-2. MedUNAB. 2021;24(1): 92-99. doi: https://doi.org/10.29375/01237047.3942

Introdução. A pandemia SARS-CoV-2 começou a ser relatada em dezembro de 2019 na cidade de Wuhan, China, depois milhares de casos foram notificados em todo o mundo. Entre as medidas adotadas mundialmente em todos os aspectos, está o distanciamento social, que tem levado ao fechamento de diversos setores da economia, entre eles, o ensino superior. Aeducação médica sofreu uma mudança repentina com a suspensão de aulas presenciais e dos campos de prática; dessa forma, diferentes mudanças e inovações tiveram de ser enfrentadas em seus processos educacionais. O objetivo deste trabalho é realizar uma revisão sobre as modalidades implementadas e relatadas na literatura mundial durante a pandemia nas faculdades de medicina. Tópicos a abordar. Educação médica durante a pandemia, faculdades de medicina, educação virtual, medidas de educação médica em tempos de pandemia, experiências na educação médica antes da pandemia, educação a distância e educação presencial assistida por tecnologia, plataformas digitais no processo de ensino, situação futura e questões. Conclusões. A implementação da tecnologia na educação médica de uma maneira única permitirá que os alunos desenvolvam habilidades colaborativas e melhorem a adaptabilidade. A educação médica face à pandemia da SARS-CoV-2 é um grande desafio. Cómo citar: Zuluaga-Gómez M.Valencia-Ortiz NL. Educación en facultades de medicina del mundo durante el periodo de contingencia por SARS-COV-2. MedUNAB. 2021;24(1): 92-99. doi: https://doi.org/10.29375/01237047.3942

Protective mechanical ventilation in patients with risk factors for ARDS: prospective cohort study / Ventilação mecânica protetora em pacientes com fator de risco para SDRA: estudo de coorte prospectiva

ABSTRACT Objective: To evaluate the association that protective mechanical ventilation (MV), based on VT and maximum distending pressure (MDP), has with mortality in patients at risk for ARDS. Methods: This was a prospective cohort study conducted in an ICU and including 116 patients on MV who had at least one risk factor for the development of ARDS. Ventilatory parameters were collected twice a day for seven days, and patients were divided into two groups (protective MV and nonprotective MV) based on the MDP (difference between maximum airway pressure and PEEP) or VT. The outcome measures were 28-day mortality, ICU mortality, and in-hospital mortality. The risk factors associated with the adoption of nonprotective MV were also assessed. Results: Nonprotective MV based on VT and MDP was applied in 49 (42.2%) and 38 (32.8%) of the patients, respectively. Multivariate Cox regression showed that protective MV based on MDP was associated with lower in-hospital mortality (hazard ratio = 0.37; 95% CI: 0.19-0.73) and lower ICU mortality (hazard ratio = 0.40; 95% CI: 0.19-0.85), after adjustment for age, Simplified Acute Physiology Score 3, and vasopressor use, as well as the baseline values for PaO2/FiO2 ratio, PEEP, pH, and PaCO2. These associations were not observed when nonprotective MV was based on the VT. Conclusions: The MDP seems to be a useful tool, better than VT, for adjusting MV in patients at risk for ARDS.

RESUMO Objetivo: Avaliar a associação da ventilação mecânica (VM) protetora, com base no VT e na pressão de distensão máxima (PDM), com a mortalidade em pacientes com fator de risco para SDRA. Métodos: Este estudo de coorte prospectivo foi conduzido em uma UTI e incluiu 116 pacientes em VM que apresentavam pelo menos um fator de risco para o desenvolvimento de SDRA. Os parâmetros ventilatórios foram coletados duas vezes ao dia durante sete dias, e os pacientes foram divididos em dois grupos (VM protetora e VM não protetora) com base na PDM (diferença entre pressão máxima de vias aéreas e PEEP) ou no VT. Os desfechos foram mortalidade em 28 dias, mortalidade na UTI e mortalidade hospitalar. Os fatores de risco associados com a adoção da VM não protetora também foram avaliados. Resultados: A VM não protetora com base no VT e na PDM ocorreu em 49 (42,2%) e em 38 (32,8%) dos pacientes, respectivamente. A regressão multivariada de Cox mostrou que a VM protetora com base na PDM associou-se a menor mortalidade hospitalar (hazard ratio = 0,37; IC95%: 0,19-0,73) e em UTI (hazard ratio = 0,40; IC95%, 0,19-0,85), após ajuste para idade, Simplified Acute Physiology Score 3, uso de vasopressor e valores basais de PaO2/FiO2, PEEP, pH e PaCO2. Essas associações não foram observadas quando a VM não protetora foi baseada no VT. Conclusões: A PDM parece ser uma ferramenta útil, melhor do que o VT, para o ajuste da VM em pacientes sob risco para SDRA.

Reactive airways dysfunction syndrome following inhalation of hydrogen chloride vapor

Hydrogen chloride is available commercially as an anhydrous gas or an aqueous solution, hydrochloric acid. Exposure to this gas has been associated with the development of reactive airways dysfunction syndrome. However, there are few published reports. A 37-year-old woman developed progressive bronchospasm and acute respiratory failure after cleaning an enclosed space with an unknown concentration of hydrochloric acid gas from a cleaning substance. She had no prior history of asthma or atopy. Severe bronchospasm developed, leading to hypoxemia and diffuse interstitial infiltrates, necessitating orotracheal intubation and admission to the intensive care unit. Asthma-like symptoms such as cough, wheezing, and dyspnea; requiring bronchodilators, and repeated hospitalizations are persistent a year after the accident. Pulmonary function testing showed mild airflow obstruction.

Coronavirus 229E with Rhinovirus co-infection causing severe acute respiratory distress syndrome with thrombotic microangiopathy and death during Covid-19 pandemic: lessons to be learnt.

We report on a 3-month old infant male who had a seven-days history of fever and rhinorrhea associated with wheezing prior to his death, during the Covid-19 pandemic. Viral testing for Covid-19 (SARS-CoV-2) was negative but was positive for Coronavirus 229E and RP Human Rhinovirus. The pulmonary histological examination showed diffuse alveolar damage along with thrombotic microangiopathy affecting alveolar capillaries. Also, thrombotic microangiopathy was evident in the heart, lungs, brain, kidneys and liver. Thrombotic microangiopathy is a major pathologic finding in Acute Respiratory Distress Syndrome and in the multiorgan failure. This is the first report that illustrates thrombotic microangiopathy occurring in lung, heart, liver, kidney and brain in Acute Respiratory Distress Syndrome with Coronavirus 229E with Rhinovirus co-infection. The clinical presentation and pathological findings in our case share common features with Covid-19.

Hallazgos de autopsias en la infección por COVID-19 / Autopsy findings in COVID-19 Infection

RESUMEN Fundamento: la neumonía por COVID-19 es una enfermedad recién conocida que se ha extendido de manera rápida por todo el mundo. Los fundamentos patogénicos y los cambios histopatológicos que provoca el COVID-19 no se comprenden en su totalidad, lo cual atenta contra la identificación clínica adecuada de los pacientes y la implementación de estrategias terapéuticos eficaces. Objetivo: describir los hallazgos histopatológicos hallados en autopsia de casos confirmados de COVID-19. Métodos: la evidencia se recopiló mediante una búsqueda en PubMed de publicaciones en idioma inglés, utilizando las palabras claves: coronavirus, COVID-19, autopsy y síndrome de dificultad respiratoria aguda en varias combinaciones en el año 2020. Solo se hallaron cinco artículos con información sobre los resultados de las autopsias de casos confirmados con COVID-19. Resultados: desde el inicio de la pandemia en diciembre de 2019 se han publicado siete informes de autopsias de casos confirmados con COVID-19, recogidos en cuatro artículos. Todas las autopsias han coincidido en el principal hallazgo: daño alveolar difuso con formación de membrana hialina, lo cual se correlaciona con las manifestaciones clínicas del síndrome de dificultad respiratoria aguda. Conclusiones: el COVID-19 produce principalmente daño alveolar, el cual consiste en edema pulmonar con formación de membrana hialina que se expresa clínicamente como un síndrome de dificultad respiratoria aguda.

ABSTRACT Background: COVID-19 pneumonia is a recently recognized disease that has spread rapidly throughout the world. The pathogenic foundations and histopathological changes caused by COVID-19 are not fully understood, which undermines the proper clinical identification of patients and the implementation of effective therapeutic strategies. Objective: to describe the histopathological findings found at autopsy of confirmed cases of COVID-19. Methods: evidence was collected by searching PubMed for English language publications, using the keywords: coronavirus, COVID-19, autopsy and acute respiratory distress syndrome in various combinations in 2020. Only five articles were found with information on the autopsy results of confirmed cases with COVID-19. Results: since the start of the pandemic in December 2019, seven autopsy reports of confirmed cases with COVID-19 have been published, collected in 4 articles. All autopsies have agreed on the main finding: diffuse alveolar damage with hyaline membrane formation, which correlates with the clinical manifestations of acute respiratory distress syndrome. Conclusions: COVID-19 mainly produces alveolar damage, which consists of pulmonary edema with hyaline membrane formation, which is clinically expressed as an acute respiratory distress syndrome.

Coinfección por SARS-CoV-2 y rinovirus-enterovirus en una paciente adulta joven críticamente enferma en Colombia / SARS-CoV-2 and rhinovirus/enterovirus co-infection in a critically ill young adult patient in Colombia

La actual pandemia por SARS-CoV-2 ha ocasionado un enorme problema de salud pública mundial. Se reporta el caso de una paciente adulta joven con SARS-CoV-2 confirmado por laboratorio. Se describe la identificación del virus y el curso clínico, el diagnóstico y el tratamiento de la infección. La paciente tuvo un rápido deterioro clínico a partir de síntomas iniciales leves que progresaron a una neumonía multilobar que requirió su hospitalización en la unidad de cuidados intensivos. Se destaca la importancia de establecer un diagnóstico basado en la clínica y los antecedentes del paciente, y considerando los posibles síntomas gastrointestinales además de los respiratorios. Asimismo, debe indagarse sobre la presencia de factores de riesgo, en este caso, la obesidad. También se señalan las limitaciones en las pruebas diagnósticas y la posibilidad de infección concomitante con otros agentes patógenos respiratorios, así como los hallazgos en las imágenes diagnósticas, los exámenes de laboratorio y el tratamiento en el marco de la limitada información con que se cuenta actualmente.

The current SARS-CoV-2 pandemic has caused a huge global public health problem. We report the case of a young adult patient with laboratory-confirmed SARS-CoV-2. We describe the identification of the virus and the clinical course, diagnosis, and treatment of the infection including her rapid clinical deterioration from the mild initial symptoms, which progressed to multilobar pneumonia requiring admission to the intensive care unit. This case highlights the importance of establishing a diagnosis based on the clinical findings and the patient's history bearing in mind the possibility of gastrointestinal symptoms in addition to respiratory ones. Besides, the presence of risk factors should be investigated; in this case, we proposed obesity as a possible risk factor. Furthermore, limitations in diagnostic tests and the possibility of co-infection with other respiratory pathogens are highlighted. We describe the imaging, laboratory findings, and treatment taking into account the limited current evidence.

SARS-CoV-2 y RT-PCR en pacientes asintomáticos: resultados de una cohorte de trabajadores del Aeropuerto Internacional El Dorado de Bogotá, 2020 / SARS-CoV-2 and RT-PCR in asymptomatic patients: Results of a cohort of workers at El Dorado International Airport in Bogotá, 2020

Introducción. La pandemia de COVID-19 ha ocasionado cerca de 25 millones de casos en el mundo. Se ha descrito que los pacientes asintomáticos pueden ser fuentes de transmisión. Sin embargo, es difícil detectarlos y no es claro su papel en la dinámica de transmisión del virus, lo que obstaculiza la implementación de estrategias para la prevención. Objetivo. Describir el comportamiento de la infección asintomática por SARS-CoV-2 en una cohorte de trabajadores del Aeropuerto Internacional El Dorado "Luis Carlos Galán Sarmiento" de Bogotá, Colombia. Materiales y métodos. Se diseñó una cohorte prospectiva de trabajadores del Aeropuerto El Dorado. El seguimiento se inició en junio de 2020 con una encuesta a cada trabajador para caracterizar sus condiciones de salud y trabajo. Cada 21 días se tomó una muestra de hisopado nasofaríngeo para detectar la presencia del SARS-CoV-2 mediante reacción en cadena de la polimerasa con transcriptasa inversa (RT-PCR). Se analizó el comportamiento del umbral del ciclo (cycle threshold) de los genes ORFlab y N según el día de seguimiento. Resultados. En los primeros tres seguimientos de la cohorte se encontró una incidencia de la infección por SARS-CoV-2 del 16,51 %. La proporción de contactos positivos fue del 14,08 %. La mediana del umbral del ciclo fue de 33,53. Conclusión. Se determinaron las características de la infección asintomática por el SARS-CoV-2 en una cohorte de trabajadores. La detección de infectados asintomáticos sigue siendo un reto para los sistemas de vigilancia epidemiológica.

Introduction: The 2019 coronavirus pandemic (COVID-19) has caused around 25 million cases worldwide. Asymptomatic patients have been described as potential sources of transmission. However, there are difficulties to detect them and to establish their role in the dynamics of virus transmission, which hinders the implementation of prevention strategies. Objective: To describe the behavior of asymptomatic SARS-CoV-2 virus infection in a cohort of workers at the El Dorado "Luis Carlos Galán Sarmiento" International Airport in Bogotá, Colombia. Materials and methods: A prospective cohort of 212 workers from the El Dorado airport was designed. The follow-up began in June, 2020. A survey was used to characterize health and work conditions. Every 21 day, a nasopharyngeal swab was taken to identify the presence of SARS-CoV-2 using RT-PCR. We analyzed the behavior of the cycle threshold (ORFlab and N genes) according to the day of follow-up. Results: In the first three follow-ups of the cohort, we found an incidence of SARS-CoV-2 infection of 16.51%. The proportion of positive contacts was 14.08%. The median threshold for cycle threshold was 33.53. Conclusion: We characterized the asymptomatic SARS-CoV-2 infection in a cohort of workers. The identification of asymptomatic infected persons continues to be a challenge for epidemiological surveillance systems.

Síndrome do desconforto respiratório agudo associada à COVID-19 tratada com DEXametasona (CoDEX): delineamento e justificativa de um estudo randomizado / COVID-19-associated ARDS treated with DEXamethasone (CoDEX): study design and rationale for a randomized trial

RESUMO Objetivo: A infecção causada pelo coronavírus da síndrome respiratória aguda grave 2 (SARS-CoV-2) disseminou-se por todo o mundo e foi categorizada como pandemia. As manifestações mais comuns da infecção pelo SARS-CoV-2 (doença pelo coronavírus 2019 - COVID-19) se referem a uma pneumonia viral com graus variáveis de comprometimento respiratório e até 40% dos pacientes hospitalizados, que podem desenvolver uma síndrome do desconforto respiratório agudo. Diferentes ensaios clínicos avaliaram o papel dos corticosteroides na síndrome do desconforto respiratório agudo não relacionada com COVID-19, obtendo resultados conflitantes. Delineamos o presente estudo para avaliar a eficácia da administração endovenosa precoce de dexametasona no número de dias vivo e sem ventilação mecânica nos 28 dias após a randomização, em pacientes adultos com quadro moderado ou grave de síndrome do desconforto respiratório agudo causada por COVID-19 provável ou confirmada. Métodos: Este é um ensaio pragmático, prospectivo, randomizado, estratificado, multicêntrico, aberto e controlado que incluirá 350 pacientes com quadro inicial (menos de 48 horas antes da randomização) de síndrome do desconforto respiratório agudo moderada ou grave, definida segundo os critérios de Berlim, causada por COVID-19. Os pacientes elegíveis serão alocados de forma aleatória para tratamento padrão mais dexametasona (Grupo Intervenção) ou tratamento padrão sem dexametasona (Grupo Controle). Os pacientes no Grupo Intervenção receberão dexametasona 20mg por via endovenosa uma vez ao dia, por 5 dias, e, a seguir, dexametasona por via endovenosa 10mg ao dia por mais 5 dias, ou até receber alta da unidade de terapia intensiva, o que ocorrer antes. O desfecho primário será o número de dias livres de ventilação mecânica nos 28 dias após a randomização, definido como o número de dias vivo e livres de ventilação mecânica invasiva. Os desfechos secundários serão a taxa de mortalidade por todas as causas no dia 28, a condição clínica no dia 15 avaliada com utilização de uma escala ordinal de seis níveis, a duração da ventilação mecânica desde a randomização até o dia 28, a avaliação com o Sequential Organ Failure Assessment Score após 48 horas, 72 horas e 7 dias, e o número de dias fora da unidade de terapia intensiva nos 28 dias após a randomização.

Abstract Objective: The infection caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreads worldwide and is considered a pandemic. The most common manifestation of SARS-CoV-2 infection (coronavirus disease 2019 - COVID-19) is viral pneumonia with varying degrees of respiratory compromise and up to 40% of hospitalized patients might develop acute respiratory distress syndrome. Several clinical trials evaluated the role of corticosteroids in non-COVID-19 acute respiratory distress syndrome with conflicting results. We designed a trial to evaluate the effectiveness of early intravenous dexamethasone administration on the number of days alive and free of mechanical ventilation within 28 days after randomization in adult patients with moderate or severe acute respiratory distress syndrome due to confirmed or probable COVID-19. Methods: This is a pragmatic, prospective, randomized, stratified, multicenter, open-label, controlled trial including 350 patients with early-onset (less than 48 hours before randomization) moderate or severe acute respiratory distress syndrome, defined by the Berlin criteria, due to COVID-19. Eligible patients will be randomly allocated to either standard treatment plus dexamethasone (Intervention Group) or standard treatment without dexamethasone (Control Group). Patients in the intervention group will receive dexamethasone 20mg intravenous once daily for 5 days, followed by dexamethasone 10mg IV once daily for additional 5 days or until intensive care unit discharge, whichever occurs first. The primary outcome is ventilator-free days within 28 days after randomization, defined as days alive and free from invasive mechanical ventilation. Secondary outcomes are all-cause mortality rates at day 28, evaluation of the clinical status at day 15 assessed with a 6-level ordinal scale, mechanical ventilation duration from randomization to day 28, Sequential Organ Failure Assessment Score evaluation at 48 hours, 72 hours and 7 days and intensive care unit -free days within 28.

Analysis of epidemiological profile and ventilator parameters of postpartum women submitted to mechanical ventilation guided by electrical impedance tomography / Análise de perfil epidemiológico e parâmetros ventilatórios de puérperas submetidas à ventilação mecânica por meio da tomografia por impedância elétrica

INTRODUCTION: Pregnancy-related diseases have aggravated the situation of postpartum women, who end up using Mechanical Ventilation (MV) when admitted to Intensive Care Units (ICU). Although MV has benefits, it is associated with deleterious effects that can be minimized with the use of Electrical Impedance Tomography (EIT). OBJECTIVE: The aim was to analyze the epidemiological profile and ventilatory parameters of mothers, which developed HELLP Syndrome, sepsis and/or Acute Respiratory Distress Syndrome (ARDS), under MV and monitored with EIT. METHODS: The study was observational, cross-sectional, retrospective and prospective conducted between March and September 2018, using data collection forms filled from the database and sociodemographic, obstetric and ventilatory records of postpartum women admitted to adult ICU. RESULTS: The sample consisted of 13 postpartum women, 8 with sepsis (61.5%), 7 with HELLP syndrome (53.8%) and 4 with ARDS (30.8%). Five patients (38.5%) evolved with more than one of these conditions. Regarding the ventilatory parameters evaluated, VT 378.9 (±103.9) mL were observed and mean values found for PEEP 9.8 (±1.9) cmH2O and driving pressure 11.1 (±1.4) cmH2O are below recommendations in the literature, predicting lower mortality and morbidity index. CONCLUSION: The relevance of the driving pressure assessment in the MV setting was demonstrated, a parameter assessed by the EIT and directly related to static lung compliance (Cstat), PEEP, VT and optimization of regional pulmonary ventilation. It is highlighted the need for future research with greater clinical significance regarding the profile of postpartum women about the increasingly frequent diseases in this population.

INTRODUÇÃO: As doenças relacionadas à gravidez tem agravado o quadro de puérperas, que acabam fazendo uso de Ventilação Mecânica (VM) quando internadas em Unidades de Terapia Intensiva (UTI). A VM, apesar de trazer benefícios, está associada a efeitos deletérios que podem ser minimizados com o uso da Tomografia por Impedância Elétrica (TIE). OBJETIVO: Analisar o perfil epidemiológico e parâmetros ventilatórios de puérperas que evoluíram com Síndrome HELLP, Sepse e/ou Síndrome do Desconforto Respiratório Agudo (SDRA), sob VM e monitoradas com a TIE. MÉTODOS: Estudo observacional, transversal retrospectivo e prospectivo, realizado entre março e setembro de 2018, por meio de fichas de coletas preenchidas a partir de banco de dados/prontuários sociodemográficos, obstétricos e ventilatórios de puérperas internadas em UTI. RESULTADOS: Amostra composta por 13 puérperas, oito com Sepse (61,5%), sete com Síndrome HELLP (53,8%) e quatro com SDRA (30,8%), demonstrando que cinco (38,5%) pacientes evoluíram com mais de uma dessas patologias. Acerca dos parâmetros ventilatórios avaliados, observou-se VT 378.9 (± 103.9) e que valores médios encontrados para PEEP 9.8 (±1.9) e driving pressure 11.1 (±1.4) estão abaixo dos preconizados pela literatura, predizendo menores índices de mortalidade e morbidade. CONCLUSÃO: Demonstrou-se relevância da avaliação de driving pressure no cenário da VM, parâmetro avaliado por meio da TIE e diretamente relacionado à Cst, PEEP, VT e otimização da ventilação pulmonar regional. Destaca-se a necessidade de pesquisas futuras que apresentem maiores significâncias clínicas voltadas ao perfil de puérperas em relação às doenças cada vez mais frequentes nesta população.