Tos ineficaz y técnicas mecánicas de aclaramiento mucociliar / Ineffective cough and mechanical mucociliary clearance techniques

La tos es un mecanismo de defensa fundamental para mantener la vía respiratoria libre de elementos extraños. Cuando la tos es ineficaz, por debilidad muscular o por alteración del normal funcionamiento del sistema mucociliar, se puede dar lugar a situaciones que pongan en riesgo la vida. Cuando un paciente no es capaz de producir tos eficaz es cuando está indicada la aplicación de técnicas que, o bien potencien la tos del paciente, o bien la sustituyan. Actualmente el uso de sistemas mecánicos facilitadores o sustitutivos de la tos es creciente en las unidades de cuidados intensivos, donde con relativa frecuencia encontramos pacientes en esta situación por diversas causas clínicas. Esta revisión se centra en las recomendaciones de práctica clínica actuales con respecto a la indicación y aplicación de la tos asistida mecánica y de la ventilación percutora intrapulmonar (AU)

Cough is a fundamental defense mechanism for keeping the airway free of foreign elements. Life-threatening situations may arise when cough proves ineffective as a result of muscle weakness or altered mucociliary function. When a patient is unable to cough effectively, techniques are required to either reinforce or replace cough capacity. The use of mechanical systems that facilitate or substitute cough function is increasingly common in Intensive Care Units, where it is relatively frequent to find situations of ineffective cough due to different clinical causes. This review examines the current clinical practice recommendations referred to the indication and use of mechanical cough assist and intrapulmonary percussive ventilation systems (AU)

Advancing frontiers in anaesthesiology with laparoscopy.

The introduction of laparoscopy in the surgeon's armamentarium was in fact a "revolution in the history of surgery". Since this technique involves insufflation of carbon dioxide it produces several pathophysiological changes which have to be understood by the anaesthesiologist who can modify the anaesthesia technique accordingly. Advantages of laparoscopy include reduced pain, small scars and early return to work. Certain complications specific to laparoscopic surgery are due to carboperitoneum and increased intra-abdominal pressure. Venous air embolism, although very rare, can be lethal if not managed promptly. Other complications include subcutaneous emphysema, haemodynamic compromise and arrhythmias. Although associated with minimal postoperative morbidity, postoperative pain, nausea and vomiting can be quite problematic. The limitations of laparoscopy have been overcome by the introduction of robotic surgery. There are important implications for the anaesthesiologist during robotic surgeries which have to be practiced accordingly. Robotic surgery has a learning curve for both the surgeon and the anaesthesiologist. The robot is bulky, and cannot be disengaged after docking. Therefore it is important that the anaesthetized patient remains immobile throughout surgery and anaesthesia is reversed only after the robot has been disengaged at the end of surgery. Advances in laparoscopy and robotic surgery have modified anaesthetic techniques too.

A historical perspective on expiratory muscle aids and their impact on home care.

Mechanically assisted coughing is the combination of mechanical insufflation-exsufflation to the airways in conjunction with an exsufflation-timed abdominal thrust. It has permitted in-home long-term survival of respirator-dependent users of continuous noninvasive intermittent positive pressure ventilatory support in the United States since shortly after it became available in 1952. By contrast, the first European patients to benefit from continuous noninvasive intermittent positive pressure ventilatory support were not described until institutionalized continuous noninvasive intermittent positive pressure ventilatory support users with Duchenne muscular dystrophy were described in Belgium in 2006, 2 yrs after mechanically assisted coughing was approved for sale by the European Union. Domiciliary management with continuous noninvasive intermittent positive pressure ventilatory support and mechanically assisted coughing has subsequently been described in Europe. This work describes the historical development of mechanically assisted coughing in the framework of aiding the respiratory muscles to prevent respiratory failure and avoid invasive airway intubation. Some current mechanical in-exsufflators include oscillation as a surrogate for physiologic mucociliary transport along with their assisted coughing function. Noninvasive management prolongs life while promoting cost containment and preserving quality-of-life for patients with respiratory muscle impairment.

Comparación entre la insuflación con aire ambiente o con dióxido de carbono durante la colonoscopia en pacientes sedados con propofol / Comparison between insufflation with air or carbon dioxide during the colonoscopy in sedated patients with propofol

Objetivos: comparar la intensidad del dolor experimentado tras una colonoscopia con aire ambiente o con dióxido de carbono (CO2) y evaluar la seguridad del CO2 en pacientes con sedación moderada o profunda. Materiales y métodos: individuos sometidos a una colonoscopia ambulatoria, sin enfermedad respiratoria severa ni obesidad mórbida, randomizados a grupo "aire" o "CO2". Se recogieron diferentes variables antes, durante y tras la colonoscopia. Todos los pacientes fueron monitorizados mediante capnografía y pulsioximetría. Posteriormente cada paciente puntuó mediante una escala visual numérica la intensidad del dolor experimentado en diferentes momentos tras la colonoscopia. Resultados: 141 pacientes incluidos en grupo "aire" (hombres/ mujeres 63/78, rango edad 24-83) y 129 en "CO2" (hombres/mujeres 59/70, rango edad 24-82). No existieron diferencias significativas entre ambos grupos a excepción del mayor número de exploraciones realizadas por un endoscopista en formación en el grupo "aire" en comparación con las realizadas por endoscopistas experimentados. El CO2 en aire espirado, los episodios de desaturación de oxígeno y las dosis de propofol o midazolam empleadas fueron similares en ambos grupos. No existieron episodios de hipercapnia severos ni complicaciones clínicamente relevantes. El dolor experimentado en el grupo "aire" fue significativamente mayor a los 15 minutos, 1, 3 y 6 horas tras la colonoscopia, igualándose a las 24 horas. Tras la realización de un análisis multivariante según el tipo de endoscopista (experimentado o en formación) las diferencias observadas en la intensidad del dolor en cada grupo se mantuvieron. Conclusiones: a) el uso de CO2 en la colonoscopia causa significativamente menos dolor en las siguientes 6 horas; b) su uso en pacientes con sedación moderada o profunda es seguro; y c) la realización de la técnica no se ve modificada ni sus tiempos reducidos(AU)

Objectives: compare the intensity of pain experienced after colonoscopy with air or with CO2 and evaluate the safety of CO2 in colonoscopies performed with moderate/deep sedation. Materials and methods: individuals undergoing ambulatory colonoscopy without exclusion criteria (severe respiratory disease, morbid obesity) were randomized in air or CO2 group. We recorded different variables prior to, during and upon completion of the colonoscopy, performing monitoring using pulse oximetry and capnography. Each patient rated, using a visual numeric scale, the intensity of post-colonoscopy pain at different moments. Results: 141 individuals in the air group (sex M/F 63/78, age 24-83) and 129 in the CO2 group (sex M/F 59/70, age 24-82). No significant differences existed in the recorded variables in both groups except for the greater number of explorations performed by an endoscopist in training (TE) in the air group compared to those by a more experienced endoscopist (SE). CO2 in expired air, episodes of oxygen desaturation and of apnoea and dose of propofol, of midazolam were similar in both groups. No episodes of hypercapnea or any complication requiring cardiopulmonary resuscitation measures were recorded. The pain in the air group was significantly higher at 15 minutes and at 1, 3 and 6 hours after the endoscopy, equalising at 24 hours. After multivariant adjustment for type of doctor (TE vs. SE) the differences observed in pain intensity for each group were maintained. Conclusions: a) the use of CO2 in colonoscopy causes significantly less pain in the first 6 hours after the procedure; b) its use in patients with moderate/deep sedation is safe; and c) performance of the endoscopic technique is not modified, nor are times reduced(AU)

Insuflación de CO2 vs. aire en íleo-colonoscopia y en gastroscopia más íleo-colonoscopia: estudio comparativo / Carbon dioxide vs. air insufflation in ileo-colonoscopy and in gastroscopy plus ileo-colonoscopy: a comparative study

Introducción: la insuflación con dióxido de carbono (CO2) durante las endoscopias digestivas comparado con el aire, se asocia a una disminución de las molestias abdominales después de la exploración, ya que el CO2 es fácilmente absorbido por el intestino delgado y eliminado por los pulmones. Objetivo: el objetivo de este ensayo clínico aleatorizado fue valorar el efecto de la insuflación de CO2 sobre el dolor y la distensión abdominal después de una ileo-colonoscopia (I) y después de una íleo-colonoscopia + gastroscopia (I+G). Material y métodos: se incluyeron un total de 309 pacientes en el estudio y todas las endoscopias fueron realizadas bajo sedación con propofol. A 214 pacientes se les realizó una I (132 con CO2 / 82 con aire) y a 95 se les realizó una I+G (53 con CO2 / 42 con aire). Se estudió el dolor abdominal a los 10, 30 y 120 min de la exploración y la diferencia de perímetro abdominal antes y después del procedimiento. Resultados: tanto en el grupo I como en el grupo I+G, se objetivó una media de dolor abdominal en los pacientes en los que se utilizó CO2 significativamente menor que en los que se utilizó aire (p < 0,05). Y de igual modo se objetivó un menor incremento en el perímetro abdominal para el grupo I y para el I+G en los pacientes en que se utilizó CO2 frente a los que se utilizó aire (p < 0,05). Conclusión: la insuflación de CO2 en vez de aire durante la realización de la exploración endoscópica, reduce significativamente el disconfort y el dolor abdominal después de una íleo-colonoscopia y después de una íleo-colonoscopia + gastroscopia(AU)

Introduction: insufflation with carbon dioxide (CO2) during endoscopies compared to air is associated with a decrease in abdominal discomfort after the examination, because CO2 is readily absorbed through the small intestine and eliminated by the lungs. Aim: the objective of this randomized clinical trial was to assess the effect of CO2 insufflation on pain and abdominal distension after an ileo-colonoscopy (I) and after an ileo-colonoscopy plus gastroscopy (I+G). Material and methods: we included a total of 309 patients in the study and all endoscopies were performed under sedation with propofol. Two hundred fourteen patients underwent an I (132 with CO2 / 82 with air) and 95 underwent an I+G (53 with CO2 / 42 with air). Abdominal pain was studied at 10, 30 and 120 minutes of exploration and abdominal perimeter difference before and after the procedure. Results: both in group I and in group I+G, the use of CO2 translated into an average of abdominal pain significantly lower (p < 0.05). Similarly, a smaller increase in waist circumference was found among group I and group I+G, in patients where CO2 was used (p < 0.05). Conclusion: the insufflation of CO2 instead of air during the performance of endoscopy significantly reduces the discomfort and abdominal pain after an ileo-colonoscopy and after a gastroscopy + ileo-colonoscopy(AU)

Survey of use of the insufflator-exsufflator in patients with spinal cord injury.

BACKGROUND/OBJECTIVE: The insufflator-exsufflator has been shown to be effective in assisting cough in individuals with spinal cord injury. However, many institutions do not use this device. The study was performed to assess use of the device and attitudes among health care providers. METHODS: We developed a questionnaire with 4 categories of questions: knowledge of the device, type of facility, clinical practice with the device, and patient and provider satisfaction. The questionnaire was mailed to members of the American Paraplegia Society. RESULTS: Eighty-six questionnaires (16%) were returned. The device was being used in 49% of the institutions. The device was most commonly used with a tracheostomy; use did not correlate with size or type of facility. Patient and provider satisfaction with the insufflator-exsufflator was high. CONCLUSIONS: The insufflator-exsufflator is used as a means of removal of secretions in approximately one half of institutions polled. Satisfaction with the device is high.

Use of high-frequency and nonconventional ventilation for respiratory failure.

Over the past several years, many new strategies have evolved for improving the care of patients with acute lung injury and respiratory failure. Although many of these new modalities remain unproven, some show much promise for decreasing the morbidity and mortality seen in critically ill patients who need assisted ventilation. In this review, we discuss recent data concerning four of these modalities: high frequency ventilation, prone positioning, tracheal gas insufflation, and partial liquid ventilation.