Intraoperative effects of an alveolar recruitment manoeuvre in patients undergoing laparoscopic colon surgery.

INTRODUCTION: Pulmonary atelectasis is common in patients undergoing laparoscopic abdominal surgery under general anaesthesia, which increases the risk of perioperative respiratory complications. Alveolar recruitment manoeuvres (ARM) are used to open up the lung parenchyma with atelectasis, although the duration of their benefit has not been clearly established. The aim of this study was to determine the effectiveness of an ARM in laparoscopic colon surgery, the duration of response over time, and its haemodynamic impact. METHODS: Twenty-five patients undergoing laparoscopic colon surgery were included. After anaesthetic induction and initiation of surgery with pneumoperitoneum, an ARM was performed, and then optimal PEEP determined. Respiratory mechanics and gas exchange variables, and haemodynamic parameters, were analysed before the manoeuvre and periodically over the following 90 min. RESULTS: Three patients were excluded for surgical reasons. The alveolar arterial oxygen gradient went from 94.3 (62.3-117.8) mmHg before to 60.7 (29.6-91.0) mmHg after the manoeuvre (P < .05). This difference was maintained during the 90 min of the study. Dynamic compliance of the respiratory system went from 31.3 ml/cmH2O (26.1-39.2) before the manoeuvre to 46.1 ml/cmH2O (37.5-53.5) after the manoeuvre (P < .05). This difference was maintained for 60 min. No significant changes were identified in any of the haemodynamic variables studied. CONCLUSION: In patients undergoing laparoscopic colon surgery, performing an intraoperative ARM improves the mechanics of the respiratory system and oxygenation, without associated haemodynamic compromise. The benefit of these manoeuvres lasts for at least one hour.

Use of thoracic fluid content for prediction of fluid balance and postoperative pulmonary complications after major abdominal surgery: an observational study.

BACKGROUND AND OBJECTIVES: The harmful effects of excess fluids frequently manifest in the lungs. Thoracic fluid content (TFC) is a variable provided by the STARLINGTM bioreactance monitor, which represents the total volume of fluid in the chest. The objective is to analyse the association between the variation in TFC values (TFCd0%) at 24 h postoperatively, postoperative fluid balance, and postoperative pulmonary complications. MATERIAL AND METHODS: Prospective and analytical observational study. Patients scheduled for major abdominal surgery at a tertiary teaching hospital were included. They were monitored during the intervention and the first 24 postoperative hours with the monitor. STARLINGTM, measuring TFC and its variation in different stages of the perioperative period. Serial lung ultrasounds were performed and postoperative pulmonary complications were recorded. Logistic regression was performed to predict the occurrence of atelectasis and pulmonary congestion. The Pearson correlation coefficient was calculated to verify the association between TFC and fluid balance. RESULTS: 50 patients were analyzed. TFCd0% measured on the morning of the first postoperative day increased by a median of 27.1% [IQR: 20.3-37.5] and was correlated at r = 0.44 with the postoperative balance of 677 ml [IQR: 125.5-1,412]. Increased TFC was related to a higher risk of atelectasis (OR = 1.24) and pulmonary congestion (OR = 1.3). CONCLUSIONS: TFCd0% measured 24 h after surgery presents a moderate correlation with postoperative fluid balance. Its increase is a risk factor for the appearance of postoperative pulmonary complications.

Uso del contenido de fluido torácico para la predicción del balance hídrico y las complicaciones pulmonares postoperatorias tras cirugía abdominal mayor / Use of thoracic fluid content for prediction of fluid balance and postoperative pulmonary complications after major abdominal surgery: An observational study

Antecedentes y objetivos: Los efectos nocivos del exceso de líquidos se manifiestan frecuentemente en los pulmones. El contenido de fluido torácico (thoracic fluid content [TFC]) es una variable que proporciona el monitor por biorreactancia STARLING™, que representa el volumen total de líquido en el tórax. El objetivo es analizar la asociación entre la variación de los valores del TFC (TFCd0%) a las 24horas postoperatorias, el balance hídrico postoperatorio y las complicaciones pulmonares postoperatorias. Material y métodos: Estudio observacional prospectivo y analítico. Se incluyeron pacientes programados para cirugía abdominal mayor en un hospital universitario de tercer nivel. Fueron monitorizados durante la intervención y las 24 primeras horas postoperatorias con el monitor STARLING™, midiendo el TFC y su variación en distintas etapas del perioperatorio. Se realizaron ecografías pulmonares seriadas y se recogieron las complicaciones pulmonares postoperatorias. Se realizó una regresión logística para predecir la aparición de atelectasias y congestión pulmonar. Se calculó el coeficiente de correlación de Pearson para comprobar la asociación entre TFC y balance hídrico. Resultados: Se analizaron 50 pacientes. El TFCd0% medido en la mañana del primer día postoperatorio aumentó una mediana del 27,1% [IQR: 20,3-37,5] y se correlacionó con una r=0,44 con el balance postoperatorio de 677ml [IQR: 125,5-1.412]. El aumento del TFC se relacionó con un mayor riesgo de sufrir atelectasias (OR=1,24) y congestión pulmonar (OR=1,3). Conclusiones: El TFCd0% medido a las 24horas de la cirugía presenta una correlación moderada con el balance hídrico postoperatorio. Su incremento es un factor de riesgo para la aparición de complicaciones pulmonares postoperatorias.(AU)

Background and objectives: The harmful effects of excess fluids frequently manifest in the lungs. Thoracic fluid content (TFC) is a variable provided by the STARLINGTM bioreactance monitor, which represents the total volume of fluid in the chest. The objective is to analyze the association between the variation in TFC values (TFCd0%) at 24 hours postoperatively, postoperative fluid balance, and postoperative pulmonary complications. Material and methods: Prospective and analytical observational study. Patients scheduled for major abdominal surgery at a tertiary teaching hospital were included. They were monitored during the intervention and the first 24 postoperative hours with the monitor. STARLINGTM, measuring TFC and its variation in different stages of the perioperative period. Serial lung ultrasounds were performed and postoperative pulmonary complications were recorded. Logistic regression was performed to predict the occurrence of atelectasis and pulmonary congestion. The Pearson correlation coefficient was calculated to verify the association between TFC and water balance. Results: 50 patients were analyzed. TFCd0% measured on the morning of the first postoperative day increased by a median of 27.1% [IQR: 20.3-37.5] and was correlated at r=0.44 with the postoperative balance of 677 ml [IQR: 125.5-1,412]. Increased TFC was related to a higher risk of atelectasis (OR=1.24) and pulmonary congestion (OR=1.3). Conclusions: TFCd0% measured 24 hours after surgery presents a moderate correlation with postoperative fluid balance. Its increase is a risk factor for the appearance of postoperative pulmonary complications.(AU)

Efectos intraoperatorios de una maniobra de reclutamiento alveolar en pacientes sometidos a cirugía laparoscópica de colon / Intraoperative effects of an alveolar recruitment manoeuvre in patients undergoing laparoscopic colon surgery

Introducción: Las atelectasias pulmonares son habituales en pacientes sometidos a cirugía abdominal laparoscópica bajo anestesia general, aumentando el riesgo de complicaciones respiratorias perioperatorias. Las maniobras de reclutamiento alveolar (MRA) permiten la reexpansión del parénquima atelectasiado, aunque no está claramente establecida la duración de su beneficio. El objetivo de este estudio fue determinar la efectividad de una MRA en cirugía de colon laparoscópica, la duración de la respuesta en el tiempo y su repercusión hemodinámica. Métodos: Se incluyeron 25 pacientes sometidos a cirugía de colon laparoscópica. Tras la inducción anestésica e inicio de la cirugía con neumoperitoneo, se realizó una MRA y determinación posterior de la PEEP óptima. Se analizaron variables de mecánica respiratoria y de intercambio gaseoso, así como parámetros hemodinámicos, antes de la maniobra y periódicamente durante los 90 min siguientes. Resultados: Tres pacientes fueron excluidos por causas quirúrgicas. El gradiente alveoloarterial de oxígeno pasó de 94,3 (62,3-117,8) mmHg antes a 60,7 (29,6-91,0) mmHg después de la maniobra (p < 0,05). Esta diferencia se mantuvo durante los 90 min del estudio. La compliance dinámica del sistema respiratorio pasó de 31,3 mL/cmH2O (26,1-39,2) antes de la maniobra, a 46,1 mL/cmH2O (37,5-53,5) tras la misma (p < 0,05). Esta diferencia se mantuvo durante 60 min. No se identificaron cambios significativos en ninguna de las variables hemodinámicas estudiadas. Conclusión: En pacientes sometidos a cirugía laparoscópica de colon, la realización de una MRA intraoperatoria mejora la mecánica del sistema respiratorio y la oxigenación, sin apreciarse un compromiso hemodinámico asociado. El beneficio de estas maniobras se extiende al menos durante una hora.(AU)

Introduction: Pulmonary atelectasis is common in patients undergoing laparoscopic abdominal surgery under general anaesthesia, which increases the risk of perioperative respiratory complications. Alveolar recruitment manoeuvres (ARM) are used to open up the lung parenchyma with atelectasis, although the duration of their benefit has not been clearly established. The aim of this study was to determine the effectiveness of an ARM in laparoscopic colon surgery, the duration of response over time, and its haemodynamic impact. Methods: Twenty-five patients undergoing laparoscopic colon surgery were included. After anaesthetic induction and initiation of surgery with pneumoperitoneum, an ARM was performed, and then optimal PEEP determined. Respiratory mechanics and gas exchange variables, and haemodynamic parameters, were analysed before the manoeuvre and periodically over the following 90 minutes. Results: Three patients were excluded for surgical reasons. The alveolar arterial oxygen gradient went from 94.3 (62.3-117.8) mmHg before to 60.7 (29.6-91.0) mmHg after the manoeuvre (P < .05). This difference was maintained during the 90 minutes of the study. Dynamic compliance of the respiratory system went from 31.3 ml/cmH2O (26.1-39.2) before the manoeuvre to 46.1 ml/cmH2O (37.5-53.5) after the manoeuvre (P < .05). This difference was maintained for 60 minutes. No significant changes were identified in any of the haemodynamic variables studied. Conclusion: In patients undergoing laparoscopic colon surgery, performing an intraoperative ARM improves the mechanics of the respiratory system and oxygenation, without associated haemodynamic compromise. The benefit of these manoeuvres lasts for at least one hour.(AU)

Effects of atelectatic areas on the surrounding lung tissue during mechanical ventilation in an experimental model of acute lung injury induced by lipopolysaccharide / Efeitos das áreas atelectásicas no tecido pulmonar circundante durante a ventilação mecânica em um modelo experimental de lesão pulmonar aguda induzida por lipopolissacarídeo

ABSTRACT Objective: To assess the effect of atelectasis during mechanical ventilation on the periatelectatic and normal lung regions in a model of atelectasis in rats with acute lung injury induced by lipopolysaccharide. Methods: Twenty-four rats were randomized into the following four groups, each with 6 animals: the Saline-Control Group, Lipopolysaccharide Control Group, Saline-Atelectasis Group, and Lipopolysaccharide Atelectasis Group. Acute lung injury was induced by intraperitoneal injection of lipopolysaccharide. After 24 hours, atelectasis was induced by bronchial blocking. The animals underwent mechanical ventilation for two hours with protective parameters, and respiratory mechanics were monitored during this period. Thereafter, histologic analyses of two regions of interest, periatelectatic areas and the normally-aerated lung contralateral to the atelectatic areas, were performed. Results: The lung injury score was significantly higher in the Lipopolysaccharide Control Group (0.41 ± 0.13) than in the Saline Control Group (0.15 ± 0.51), p < 0.05. Periatelectatic regions showed higher lung injury scores than normally-aerated regions in both the Saline-Atelectasis (0.44 ± 0.06 x 0.27 ± 0.74 p < 0.05) and Lipopolysaccharide Atelectasis (0.56 ± 0.09 x 0.35 ± 0.04 p < 0.05) Groups. The lung injury score in the periatelectatic regions was higher in the Lipopolysaccharide Atelectasis Group (0.56 ± 0.09) than in the periatelectatic region of the Saline-Atelectasis Group (0.44 ± 0.06), p < 0.05. Conclusion: Atelectasis may cause injury to the surrounding tissue after a period of mechanical ventilation with protective parameters. Its effect was more significant in previously injured lungs.

RESUMO Objetivo: Avaliar o efeito da atelectasia durante a ventilação mecânica nas regiões periatelectáticas e pulmonares normais em um modelo de atelectasia em ratos com lesão pulmonar aguda induzida por lipopolissacarídeo. Métodos: Foram distribuídos aleatoriamente 24 ratos em quatro grupos, cada um com 6 animais: Grupo Salina-Controle, Grupo Lipopolissacarídeo-Controle, Grupo Salina-Atelectasia e Grupo Lipopolissacarídeo-Atelectasia. A lesão pulmonar aguda foi induzida por injeção intraperitoneal de lipopolissacarídeo. Após 24 horas, a atelectasia foi induzida por bloqueio brônquico. Os animais foram submetidos à ventilação mecânica por 2 horas com parâmetros ventilatórios protetores, e a mecânica respiratória foi monitorada durante esse período. Em seguida, foram realizadas análises histológicas de duas regiões de interesse: as áreas periatelectásicas e o pulmão normalmente aerado contralateral às áreas atelectásicas. Resultados: O escore de lesão pulmonar foi significativamente maior no Grupo Controle-Lipopolissacarídeo (0,41 ± 0,13) do que no Grupo Controle-Solução Salina (0,15 ± 0,51), com p < 0,05. As regiões periatelectásicas apresentaram escores maiores de lesão pulmonar do que as regiões normalmente aeradas nos Grupos Atelectasia-Solução Salina (0,44 ± 0,06 versus 0,27 ± 0,74, p < 0,05) e Atelectasia-Lipopolissacarídeo (0,56 ± 0,09 versus 0,35 ± 0,04, p < 0,05). O escore de lesão pulmonar nas regiões periatelectásicas foi maior no Grupo Atelectasia-Lipopolissacarídeo (0,56 ± 0,09) do que na região periatelectásica do Grupo Atelectasia-Solução Salina (0,44 ± 0,06), p < 0,05. Conclusão: A atelectasia pode causar lesão no tecido circundante após um período de ventilação mecânica com parâmetros ventilatórios protetores. Seu efeito foi mais significativo em pulmões previamente lesionados.

Aspergilosis invasiva de vías aéreas

Es poco común encontrar en la literatura casos de traqueobronquitis invasiva por aspergillus que se manifiesten como tumores endobronquiales que produzcan atelectasia pulmonar total. Aunque relatada en inmunocomprometidos, la morbimortalidad es considerable aun en pacientes sin enfermedad de base.

It is rare to find in the literature cases of invasive aspergillus tracheobronchitis that manifest as endobronchial tumors that produce total pulmonary atelectasis. Although reported in immunocompromised patients, morbidity and mortality are considerable even in patients without underlying disease.

Aspergilosis invasiva de vías aéreas / Airway invasive aspergillosis

Es poco común encontrar en la literatura casos de traqueobronquitis invasiva por aspergillus que se manifiesten como tumores endobronquiales que produzcan atelectasia pulmonar total. Aunque relatada en inmunocomprometidos, la morbimortalidad es considerable aun en pacientes sin enfermedad de base.

It is rare to find in the literature cases of invasive aspergillus tracheobronchitis that manifest as endobronchial tumors that produce total pulmonary atelectasis. Although reported in immunocompromised patients, morbidity and mortality are considerable even in patients without underlying disease.

Silent sinus syndrome: A case report.

A 65-year-old patient was referred to the Faculty of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran, with left facial pain and numbness in the upper lip. Based on clinical examinations and radiographic investigations, the patient was diagnosed with silent sinus syndrome. This study discusses oral findings associated with silent sinus syndrome.

Utilización de ventilación percusiva intrapulmonar como terapia de higiene bronquial mecánica en pacientes pediátricos críticos / Use of Intrapulmonary Percussive Ventilation as Mechanical Bronchial Hygiene Therapy in Critical Pediatric Patients

La ventilación percusiva intrapulmonar (VPI) es una técnica de higiene bronquial mecánica (THBM) de alta frecuencia, que favorece la movilización de secreciones y es considerada como alternativa para la resolución de atelectasias. Estudio de serie de casos, prospectivo, observacional y descriptivo que se llevó a cabo entre el 1 de agosto del 2019 y el 31 de diciembre del 2019. Se incluyeron todos los pacientes menores de 18 años, con soporte ventilatorio que recibieron al menos una sesión de VPI dentro de terapia intensiva. El objetivo primario de nuestro estudio es describir las características de la población en la que se utilizó un equipo domiciliario de VPI como THBM en la UCIP. De manera secundaria describiremos la metodología de implementación del dispositivo y sus resultados. Resultados: Se incluyeron 18 pacientes y se realizaron 48 sesiones de VPI. El principal motivo para la realización de VPI fue el diagnóstico de atelectasia (83,3%). El tratamiento se realizó tanto en pacientes con VMI (ventilación mecánica invasiva) (55,6%) como en pacientes con soporte no invasivo (44,4%), ya sea VMNI (ventilación mecánica no invasiva) o CNAF (cánula nasal de alto flujo). En el 53,3% de los pacientes, se evidenció resolución radiográfica de la atelectasia, entre los cuales, el 75% solo requirió entre una y dos sesiones para resolverlas. No se observaron complicaciones graves. Conclusión: Este estudio permite describir la población en la cual se implementa VPI a la vez que presenta una herramienta que podría ser de utilidad para la resolución de atelectasias.

Intrapulmonary percussive ventilation (IPV) is a high-frequency mechanical bronchial hygiene technique (MBHT) that favors secretion clearance and is considered an alterna tive to the resolution of atelectasis. This is a prospective, observational and descriptive case series study conducted be tween August 1st, 2019 and December 31st, 2019. The study included patients younger than 18 years on ventilatory support who received at least one session of IPV in the intensive care unit. The primary objective of our study was to describe the characteristics of the population in whom we used a home IPV device as MBHT in the PICU. On a secondary level, we will describe the methodology for using this device and its results. Results: 18 patients were included; 48 IPV sessions were done. The main reason for doing IPV was the atelectasis diagnosis (83.3%). The treatment was carried out both in patients on IMV (invasive mechanical ventilation) (55.6%) and in patients with non-invasive support (44.4%), whether it was NIMV (non-invasive mechanical ventilation) or HFNC (high-flow nasal cannula). 53.3% of the patients showed radiographic resolution of atelectasis, where 75% only required between one and two sessions to resolve it. No severe complications were observed. Conclusion: This study allows us to describe the population receiving IPV and presents a tool that could be useful for the resolution of atelectasis.

Use of Intrapulmonary Percussive Ventilation as Mechanical Bronchial Hygiene Therapy in Critical Pediatric Patients / Utilización de ventilación percusiva intrapulmonar como terapia de higiene bronquial mecánica en pacientes pediátricos críticos

ABSTRACT Intrapulmonary percussive ventilation (IPV) is a high-frequency mechanical bronchial hygiene technique (MBHT) that favors secretion clearance and is considered an alternative to the resolution of atelectasis. This is a prospective, observational and descriptive case series study conducted between August 1st, 2019 and December 31st, 2019. The study included patients younger than 18 years on ventilatory support who received at least one session of IPV in the intensive care unit. The primary objective of our study was to describe the characteristics of the population in whom we used a home IPV device as MBHT in the PICU. On a secondary level, we will describe the methodology for using this device and its results. Results: 18 patients were included; 48 IPV sessions were done. The main reason for doing IPV was the atelectasis diagnosis (83.3%). The treatment was carried out both in patients on IMV (invasive mechanical ventilation) (55.6%) and in patients with non-invasive support (44.4%), whether it was NIMV (non-invasive mechanical ventilation) or HFNC (high-flow nasal cannula). 53.3% of the patients showed radiographic resolution of atelectasis, where 75% only required between one and two sessions to resolve it. No severe complications were observed. Conclusion: This study allows us to describe the population receiving IPV and presents a tool that could be useful for the resolution of atelectasis.

RESUMEN La ventilación percusiva intrapulmonar (VPI) es una técnica de higiene bronquial mecánica (THBM) de alta frecuencia, que favorece la movilización de secreciones y es considerada como alternativa para la resolución de atelectasias. Estudio de serie de casos, prospectivo, observacional y descriptivo que se llevó a cabo entre el 1 de agosto del 2019 y el 31 de diciembre del 2019. Se incluyeron todos los pacientes menores de 18 años, con soporte ventilatorio que recibieron al menos una sesión de VPI dentro de terapia intensiva. El objetivo primario de nuestro estudio es describir las características de la población en la que se utilizó un equipo domiciliario de VPI como THBM en la UCIP. De manera secundaria describiremos la metodología de implementación del dispositivo y sus resultados. Resultados: Se incluyeron 18 pacientes y se realizaron 48 sesiones de VPI. El principal motivo para la realización de VPI fue el diagnóstico de atelectasia (83,3%). El tratamiento se realizó tanto en pacientes con VMI (ventilación mecánica invasiva) (55,6%) como en pacientes con soporte no invasivo (44,4%), ya sea VMNI (ventilación mecánica no invasiva) o CNAF (cánula nasal de alto flujo). En el 53,3% de los pacientes, se evidenció resolución radiográfica de la atelectasia, entre los cuales, el 75% solo requirió entre una y dos sesiones para resolverlas. No se observaron complicaciones graves. Conclusión: Este estudio permite describir la población en la cual se implementa VPI a la vez que presenta una herramienta que podría ser de utilidad para la resolución de atelectasias.

Lung ultrasonography as a tool to guide perioperative atelectasis treatment bundle in head and neck cancer patients undergoing free flap reconstructive surgeries: a preliminary observational study / Ultrassonografia pulmonar como ferramenta para orientar o tratamento perioperatório de atelectasia em pacientes com câncer de cabeça e pescoço submetidos a cirurgia reconstrutiva com retalho livre: um estudo observacional preliminar

Abstract Introduction: General anesthesia causes pulmonary atelectasis within few minutes of induction. This can have significant impact on postoperative outcome of cancer patients undergoing prolonged reconstructive surgeries. Objective: The purpose of this study was to evaluate the impact of sonographically detected perioperative atelectasis on the need for postoperative oxygen supplementation, bronchodilator therapy and assisted chest physiotherapy in patients undergoing free flap surgeries for head and neck carcinoma. Methods: Twenty eight head and neck cancer patients underwent bilateral pulmonary ultrasonographic assessments before and after lung surgery. Lung ultrasound scores, serum lactate, and PaO2/FiO2 ratio were measured both at the beginning and at end of the surgery. Patients were scanned in the supine position and the number of single and confluent B lines was noted. These values were correlated with the need for oxygen therapy, requirement of bronchodilators and total weaning time to predict the postoperative outcome. Other factors affecting weaning were also studied. Results: Among twenty eight patients, seven had mean lung ultrasound score of ≥10.5 which correlated with prolonged weaning time (144.56±33.5min vs. 66.7±15.7min; p = 0.005). The change in lung ultrasound score significantly correlated with change in PaO2/FiO2 ratio (r = −0.56, p = 0.03). Elevated total leukocyte count >8200 ΜL and serum lactate >2.1 mmoL/L also predicted prolonged postoperative mechanical ventilation. Conclusion: This preliminary study detected significant levels of perioperative atelectasis using point of care lung ultrasonography in head and neck cancer patients undergoing long duration surgical reconstructions. Higher lung ultrasound scores highlighted the need for frequent bronchodilator nebulizations as well as assisted chest physiotherapy and were associated with delayed weaning. We propose more frequent point of care lung ultrasonographic evaluations and use of recruitment maneuvers to reduce the impact of perioperative pulmonary atelectasis.

Resumo Introdução: A anestesia geral causa atelectasia pulmonar poucos minutos após sua indução. Isso pode ter um impacto significativo no resultado pós-operatório de pacientes com câncer submetidos a cirurgias reconstrutivas prolongadas. Objetivo: Avaliar o impacto das atelectasias perioperatórias detectadas por ultrassonografia na necessidade de suplementação pós-operatória de oxigênio, terapia broncodilatadora e fisioterapia respiratória assistida em pacientes com carcinoma de cabeça e pescoço submetidos a cirurgias com uso de retalho livre. Método: Foram submetidos a avaliações ultrassonográficas pulmonares bilaterais antes e após a cirurgia 28 pacientes com câncer de cabeça e pescoço. Os escores de ultrassonografia pulmonar, lactato sérico, razão PaO2/FiO2 foram medidos no início e no fim da cirurgia. Os pacientes foram avaliados na posição supina e o número de linhas B confluentes e únicas foi observado. Esses valores foram correlacionados com a necessidade de oxigenoterapia, necessidade de broncodilatadores e tempo total de desmame para predizer o resultado pós-operatório. Outros fatores que afetam o desmame também foram estudados. Resultados: Entre os 28 pacientes, sete apresentaram escore médio de ultrassonografia pulmonar ≥ 10,5, que se correlacionou com o tempo de desmame prolongado (144,56 ± 33,5 minutos vs. 66,7 ± 15,7 minutos; p = 0,005). A mudança no escore de ultrassonografia pulmonar correlacionou-se significantemente com a mudança na razão PaO2/FiO2 (r = −0,56, p = 0,03). A contagem total elevada de leucócitos > 8200 uLe o nível de lactato sérico >2,1 mmoL/L também previram ventilação mecânica pós-operatória prolongada. Conclusão: Este estudo preliminar detectou um nível significante de atelectasia perioperatória com ultrassonografia pulmonar no local de atendimento em pacientes com câncer de cabeça e pescoço submetidos a reconstruções cirúrgicas de longa duração. Escores mais altos de ultrassonografia pulmonar enfatizaram a necessidade de nebulizações broncodilatadoras frequentes e fisioterapia respiratória assistida e foram associados a desmame tardio. Propomos avaliações ultrassonográficas pulmonares mais frequentes no local de atendimento e o uso de manobras de recrutamento para reduzir o impacto das atelectasias pulmonares perioperatórias.

Factores asociados con hospitalización prolongada en lactantes con bronquiolitis moderada

RESUMEN Introducción: La bronquiolitis es una entidad clínica que se presenta antes de los dos años y constituye una causa frecuente de hospitalización en ese grupo de edad. La hospitalización prolongada se define como un tiempo hospitalario mayor a 5 días. Esta situación demanda uso de recursos y tiene un impacto económico sobre el sistema de salud. En el contexto peruano no se ha abordado los factores asociados con la hospitalización prolongada en pacientes con bronquiolitis. Objetivo: Determinar los factores asociados con hospitalización prolongada en pacientes con bronquiolitis moderada. Métodos: Estudio descriptivo, transversal, retrospectivo. La unidad de análisis fue la historia clínica de lactantes hospitalizado por bronquiolitis moderada atendidos en el Instituto Nacional de Salud del Niño-Breña, entre los años 2018 y 2019. Se consideraron 160 lactantes. Para establecer la relación entre los factores asociados a la hospitalización prolongada tanto de la madre como los aspectos clínicos del lactante, se utilizó la prueba JI-cuadrada con un nivel de significancia de 0,05. Resultados: La hospitalización prolongada se asoció con un mayor número de días con oxígeno suplementario con p= 0,000; además de presentarse con mayor frecuencia en lactantes que no recibieron lactancia materna exclusiva con p= 0,000; finalmente, también se asoció con atelectasia y neumonía, ambos casos con p= 0,040. Conclusiones: La hospitalización prolongada en los lactantes con bronquiolitis se asocia con el número de días con oxígeno suplementario, con el no disfrute de la lactancia materna exclusiva y con la aparición de complicaciones como bronquiectasias y neumonías.

ABSTRACT Introduction: Bronchiolitis is a clinical entity that occurs before the age of two and is a frequent cause of hospitalization in this age group. Prolonged hospitalization is defined as a hospital time greater than 5 days. This situation demands the use of resources and has an economic impact on the health system. In the Peruvian context, the factors associated with prolonged hospitalization in patients with bronchiolitis have not been addressed. Objective : etermine the factors associated with prolonged hospitalization in patients with moderate bronchiolitis. Method : Descriptive, cross-sectional, retrospective study. The unit of analysis was the clinical history of infants hospitalized due to moderate bronchiolitis treated at Niño -Breña National Institute of Health, between 2018 and 2019. 160 infants were included. To establish the relationship between the factors associated with prolonged hospitalization of both the mother and the clinical aspects of the infant, the JI-square test with a significance level of 0.05 was used. Results : rolonged hospitalization was associated with a greater number of days with supplemental oxygen with p= 0.000; in addition to presenting more frequently in infants who did not receive exclusive breastfeeding with p = 0.000 . Finally, it was also associated with atelectasis and pneumonia, both cases with p= 0.040. Conclusions: Prolonged hospitalization in infants with bronchiolitis is associated with the number of days on supplemental oxygen, with the non-enjoyment of exclusive breastfeeding and with the appearance of complications such as bronchiectasis and pneumonia.

Amiloidose pulmonar com apresentação traqueobrônquica: relato de caso clínico / Pulmonary amyloidosis with tracheobronchial presentation: clinical case report

Introdução: Amiloidose é o termo utilizado para designar doenças que fazem deposição extracelular de proteínas fibrilares patológicas em órgãos e tecidos, podendo ser sistêmica ou restrita a um único órgão. As manifestações clínicas são diversas, como cardiomiopatia, falência renal, esplenomegalia, problemas intestinais, neuropatias, problemas pulmonares, entre outros. Objetivo: relatar um caso clínico de paciente com amiloidose traqueobrônquica. Metodologia: revisão de bibliografias em comparação ao relato de caso, o qual foi descrito a partir de dados retirados do prontuário e de exames complementares da paciente. Caso clínico: paciente do sexo feminino, 70 anos, procurou assistência médica por dorsalgia, apresentando também chiado, tosse seca, dispneia paroxística noturna e ortopneia. Realizou-se investigação diagnóstica durante a internação, na qual biópsia da mucosa traqueobrônquica e coleta de lavado alveolar foram positivos para o teste Vermelho Congo, o que confirmou o diagnóstico de amiloidose. A paciente, então, foi encaminhada para terapia de ablação a laser. Conclusão: portanto, diante de um paciente com quadro clínico inespecífico e suspeita diagnóstica principal de amiloidose pulmonar, é imprescindível investigar e descartar diagnósticos diferenciais como neoplasia ou discrasia de células plasmáticas. Para isso, é necessário que haja alta precisão na análise dos exames de imagem, de modo a sugerir esse diagnóstico, o qual deve ser confirmado através da fibrobroncoscopia com biópsia de tecido brônquico, que através da coloração Vermelho do Congo, evidenciará presença de substância amorfa e birrefringente, compatível com substância amiloide [au]

Introduction: Amyloidosis is the term used to describe diseases that cause extracellular deposition of pathological fibrillar proteins in organs and tissues, which can be systemic or restricted to a single organ. The clinical manifestations are diverse, such as cardiomyopathy, renal failure, splenomegaly, intestinal problems, neuropathies, lung problems, among others. Objective: to report a clinical case of a patient with pulmonary amioloidosis. Methodology: review of bibliographies in comparison to the case report, which was described based on data taken from the patient's record and complementary exams. Clinical case: a seventy-year-old female patient sought medical assistance because of back pain, also presenting wheezing, dry cough, paroxysmal nocturnal dyspnea and orthopnea. Diagnostic investigation was carried out during hospitalization, in which biopsy of the tracheobronchial mucosa and collection of alveolar lavage were positive for the Congo Red test,wich confirmed the amyloidosis diagnosis. The patient was then referred for laser ablation therapy.Conclusion: hence, in a patient with a nonspecific clinical presentation and main diagnostic suspicion of pulmonary amyloidosis, it is essential to investigate and rule out differential diagnoses such as malignancy or plasma cell dyscrasia. Therefore, it is necessary to use high precision in the analysis of image exams in order to suggest this diagnosis, which should be confirmed through fibrobronchoscopy with bronchial tissue biopsy, that through the Congo Red dye, will show the presence of amorphous and birefringent substance, compatible with amyloid substance [au]

All You Need Is Evidence: What We Know About Pneumonia in Children With Neuromuscular Diseases.

Neuromuscular diseases may involve all major respiratory muscles groups including inspiratory, expiratory, and bulbar muscles. Respiratory complications are the major cause of morbidity and mortality. Pneumonia represents a frequent cause of morbidity in children with neuromuscular disease. The aim of this review is to collect knowledge about pneumonia in children with neuromuscular diseases. Pneumonia usually follows viral respiratory infections of the upper respiratory tract, due to the combination of an increased amount of nasal and oral secretions and an impairment of the cough efficiency and of the clearance of secretions due to the muscle weakness, further compromised by the infection itself. The accumulation of bronchial secretions leads to atelectasis and promote bacterial infection. Moreover, dysfunction of swallowing mechanism exposes these children to the risk of developing aspiration pneumonia. However, etiology of viral and bacterial respiratory infection in these patients is still poorly studied.

Initial findings in chest X-rays as predictors of worsening lung infection in patients with COVID-19: correlation in 265 patients.

BACKGROUND AND AIMS: We aimed to analyze the relationship between the initial chest X-ray findings in patients with severe acute respiratory syndrome due to infection with SARS-CoV-2 and eventual clinical worsening and to compare three systems of quantifying these findings. MATERIAL AND METHODS: This retrospective study reviewed the clinical and radiological evolution of 265 adult patients with COVID-19 attended at our center between March 2020 and April 2020. We recorded data related to patients' comorbidities, hospital stay, and clinical worsening (admission to the ICU, intubation, and death). We used three scoring systems taking into consideration 6 or 8 lung fields (designated 6A, 6B, and 8) to quantify lung involvement in each patient's initial pathological chest X-ray and to classify its severity as mild, moderate, or severe, and we compared these three systems. We also recorded the presence of alveolar opacities and linear opacities (fundamentally linear atelectasis) in the first chest X-ray with pathologic findings. RESULTS: In the χ2 analysis, moderate or severe involvement in the three classification systems correlated with hospital admission (P = .009 in 6A, P = .001 in 6B, and P = .001 in 8) and with death (P = .02 in 6A, P = .01 in 6B, and P = .006 in 8). In the regression analysis, the most significant associations were 6B with alveolar involvement (OR 2.3; 95%CI 1.1.-4.7; P = .025;) and 8 with alveolar involvement (OR 2.07; 95% CI 1.01.-4.25; P = .046). No differences were observed in the ability of the three systems to predict clinical worsening by classifications of involvement in chest X-rays as moderate or severe. CONCLUSION: Moderate/severe extension in the three chest X-ray scoring systems evaluating the extent of involvement over 6 or 8 lung fields and the finding of alveolar opacities in the first pathologic X-ray correlated with mortality and the rate of hospitalization in the patients studied. No significant difference was found in the predictive ability of the three classification systems proposed.

Neumonía por COVID-19 en niña con síndrome de Down / COVID-19 pneumonia in a girl with Down syndrome

Actualmente, no existe información estadística ni evidencias sobre cómo está afectando el SARS-CoV-2 en el síndrome de Down. Sin embargo, es frecuente que estas personas tengan comorbilidades asociadas a su síndrome como cardiopatías, enfermedad pulmonar crónica, hipertensión, diabetes u otras patologías que les hacen ser un colectivo más vulnerable. Presentamos el caso clínico de una niña de 7 meses con diagnóstico de síndrome de Down con una comunicación interauricular asociada, que padeció una neumonía por COVID-19 con una evolución tórpida y que requirió ingreso hospitalario. Es pertinente tenerlo en cuenta en nuestras consultas, dado el ambiente epidemiológico del SARS-CoV-2, puesto que son pacientes con múltiples comorbilidades que determinan factores de riesgo y mal pronóstico para esta infección.(AU)

Currently, there is no statistical information or evidence on how SARS-CoV-2 is affecting Down syndrome. However, it is common for these people to have comorbidities associated with their syndrome such as heart disease, chronic lung disease, hypertension, diabetes, or other pathologies that make them a more vulnerable group. We report the case study of a seven-month-old girl with a personal history of Down syndrome with an associated interatrial communication, who suffered from COVID-19 pneumonia with torpid clinical course and who required hospital admission. It is relevant to take this into account in our consultations, given the epidemiological environment of SARS-CoV-2, since they are patients with multiple comorbidities that determine risk factors and a poor prognosis for this infection.(AU)

Impact of two methods of pulmonary re-expansion in patients undergoing bariatric surgery by videolaparoscopy / Impacto de dois métodos de reexpansão pulmonar em pacientes submetidos a cirurgia bariátrica por videolaparoscopia

Evaluating the impact of lung re-expansion methods on the postoperative pulmonary function and respiratory complications such as atelectasis, pneumonia and hypoxemia in videolaparoscopy-based bariatric surgery. Prospective clinical study conducted with 105 patients randomly divided into three groups: control (conventional postoperative physical therapy), recruitment (intraoperative alveolar recruitment) and decompression (postoperative chest compression and decompression maneuver). Spirometry, respiratory and hemodynamic variables were analyzed. All groups have presented worsened values in spirometry measurements within the postoperative period (p < 0.00) and there was significant decrease in respiratory rates in comparison to the immediate preoperative period (p = 0,01). Mean end-expiratory carbon dioxide pressure in the recruitment group was higher than in the control in all assessed time intervals (p = 0.03). Chest compression and decompression maneuver and alveolar recruitment were beneficial to pulmonary function recovery. There were no differences in postoperative pulmonary complications and function in the three assessed groups, except for significant decrease in respiratory rates and in the end-expiratory carbon dioxide pressure level in the recruitment group. (AU)

Avaliar o impacto de métodos de re-expansão pulmonar na função pulmonar e incidência de complicações respiratórias como as atelectasias, pneumonias e hipoxemia no pós-operatório de cirurgia bariátrica por videolaparoscopia. Estudo clínico, prospectivo realizado com 105 pacientes, randomizado em três grupos: grupo controle (fisioterapia convencional no pós-operatório), grupo recrutamento (recrutamento alveolar no intraoperatório) e grupo descompressão (manobra de compressão e descompressão torácica no pós-operatório). Foram analisadas variáveis espirométricas, respiratórias e hemodinâmicas. No pós-operatório todos os grupos apresentaram piora nas medidas espirométricas (p < 0,00) e redução significativa da frequência respiratória quando comparado o período pré e pós-operatório imediato em todos os grupos (p = 0,01). As médias de pressão expiratória final de gás carbônico no grupo recrutamento foram maiores que no grupo controle em todos os intervalos de tempos avaliados (p = 0,03). A manobra de compressão e descompressão torácica e o recrutamento alveolar foram benéficos para a recuperação da função pulmonar. Nos três grupos avaliados não houve diferença nas complicações e função pulmonar no pós-operatório, exceto redução significativa da frequência respiratória e da pressão expiratória final de dióxido de carbono no grupo recrutamento alveolar. (AU)

Usando a técnica de fisioterapia respiratória insuflação seletiva para reversão de Atelectasia em um recém-nascido / Use of the respiratory physiotherapy technique selective insuflation to revert the Atelectasia in a newborn

INTRODUÇÃO: A atelectasia pulmonar é comum em pacientes internados em unidades de terapia intensiva neonatais, principalmente pela anatomia do recém-nascido e pelas condições clínicas e patológicas a que estão expostos. OBJETIVO: Descrever a eficácia da técnica de fisioterapia respiratória de insuflação seletiva para reverter atelectasia em um único atendimento. RELATO DE CASO: Prematuro de 35 semanas de idade gestacional no sétimo dia de ventilação mecânica invasiva, apresentando quadro de atelectasia pulmonar em lobo superior direito, recebia atendimentos diários de fisioterapia respiratória. CONCLUSÃO: A reversão total da atelectasia em apenas um atendimento foi comprovada por meio radiografia de tórax imediatamente antes e depois da manobra. A paciente foi acompanhada até a alta hospitalar, não ocorrendo nenhum evento posterior de atelectasia, mesmo após a extubação.

INTRODUCTION: Pulmonary atelectasis is common among neonatal intensive care patients, mainly due to the anatomy of the newborn and the clinical and pathological conditions that are being exposed. OBJECTIVE: Describing the effectiveness of the selective insufflation technique to reverse atelectasis in a single visit. CASE REPORT: Premature, who present pulmonary atelectasis in the upper right lobe, with a gestational age of 35 weeks, on the seventh day of invasive mechanical ventilation received daily respiratory therapy. CONCLUSION: The total reversal of atelectasis in one single visit was confirmed utilizing a chest X-ray immediately before and after the maneuver. The patient was followed up until hospital discharge, with no subsequent atelectasis event, even after extubation.

Sarcoma sinovial primario pulmonar: un caso inusual en pediatría / Primary pulmonary synovial sarcoma: an unusual case in pediatrics

El sarcoma sinovial primario de pulmón (SSPP) localizado en bronquio, es una entidad no reportada en la edad pediátrica. Se presenta el caso de un niño de siete años con antecedente de aparentes neumonías recurrentes derechas de siete meses de evolución; en la evaluación por neumología pediátrica se destaca en las radiografías de tórax, la presencia de atelectasias recurrentes en lóbulo medio e inferior derecho, por lo que se realiza broncoscopia, donde se observa una masa obstruyendo el 100% de la luz del bronquio fuente derecho y se sospecha tumor carcinoide. Se realiza extirpación de masa endobronquial con fines diagnósticos y terapéuticos, incluyendo resección segmentaria bronquial y anastomosis término-terminal. El respectivo análisis inmunohistoquímico muestra hallazgos sugestivos de sarcoma sinovial monofásico. Se descarta compromiso tumoral extrapulmonar, por lo que se diagnostica como tumor primario de bronquio. Se administraron 7 ciclos de quimioterapia y 31 sesiones de radioterapia. Actualmente en control, sin evidencia de metástasis, tumores residuales o recidivas.

Primary Synovial Sarcoma of Lung (PSSL) located in the bronchus is an unreported entity in pediatric age. We present the case of a 7-year-old child with a history of apparent recurrent right pneumonia of 7 months of evolution; in the evaluation by pediatric pulmonology, the presence of recurrent atelectasis in the middle and lower right lobe is highlighted on chest X-rays, so bronchoscopy is performed, where a mass is observed obstructing 100% of the right bronchus lumen and carcinoid tumor is suspected. Endobronchial mass resection is performed for diagnostic and therapeutic purposes, including bronchial segmental resection and termino-terminal anastomosis. The respective immunohistochemical analysis shows suggestive findings of monophasic synovial sarcoma. Extrapulmonary tumor involvement is ruled out, so it is diagnosed as a primary bronchial tumor. 7 cycles of chemotherapy and 31 sessions of radiation therapy are given. Currently in control, with no evidence of metastasis, residual tumors, or recurrence.