Agudización grave de asma en una unidad de cuidados respiratorios intermedios: ¿realidad o controversia? / Severe Asthma Exacerbation in an Intermediate Respiratory Care Unit: Fact or Controversy?

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Evolución del uso de la ventilación mecánica no invasiva en enfermedad pulmonar obstructiva crónica en una región española, 1997-2010 / Evolution of the Use of Noninvasive Mechanical Ventilation in Chronic Obstructive Pulmonary Disease in a Spanish Region, 1997-2010

Introducción: La ventilación mecánica no invasiva (VMNI) aparece, en los 80, como alternativa a la ventilación mecánica invasiva (VMI) en pacientes con fracaso respiratorio agudo. Se pretende valorar la introducción de la VMNI y los resultados sobre los pacientes hospitalizados por agudización de enfermedad pulmonar obstructiva crónica en la Región de Murcia. Sujetos y métodos: Estudio observacional retrospectivo basado en el conjunto mínimo básico de datos al alta hospitalaria de todos los pacientes hospitalizados en todos los hospitales públicos de la región entre 1997-2010. Se realizó análisis de tendencias temporales en la frecuentación hospitalaria, el uso de cada intervención ventilatoria y la mortalidad hospitalaria mediante regresión joinpoint. Resultados: En los 14 años estudiados se identificaron 30.027 casos. Análisis joinpoint: tendencia descendente de la frecuentación (porcentaje de cambio anual [PCA] = −3,4; IC95%: 4,8; -2,0; p < 0,05) y en el grupo sin intervención ventilatoria (PCA = −4,2; −5,6;−2,8; p < 0,05), ascendente en el uso de VMNI (PCA = 16,4; 12,0;20,9; p < 0,05); el uso de la VMI presenta una tendencia descendente sin significación estadística (PCA = −4,5; −10,3;1,7). Se aprecia una tendencia ascendente sin significación estadística en la mortalidad global (PCA = 0,5; −1,3;2,4) y en el grupo sin intervención (PCA = 0,1; −1,6;1,9); decreciente con significación estadística en el grupo VMNI (PCA = −7,1; −11,7;−2,2; p < 0,05) y sin significación estadística en el grupo VMI (PCA = −0,8; −6,1;4,8). La estancia media no varía sustancialmente. Conclusiones: La introducción de la VMNI ha hecho disminuir el grupo de pacientes que no reciben ventilación asistida. No se aprecia mejora de los resultados en términos de mortalidad o estancia media global (AU)

Introduction: Noninvasive mechanical ventilation (NIV) appeared in the 1980s as an alternative to invasive mechanical ventilation (IMV) in patients with acute respiratory failure. We evaluated the introduction of NIV and the results in patients with acute exacerbation of chronic obstructive pulmonary disease in the Region of Murcia (Spain). Subjects and methods: A retrospective observational study based on the minimum basic hospital discharge data of all patients hospitalised for this pathology in all public hospitals in the region between 1997 and 2010. We performed a time trend analysis on hospital attendance, the use of each ventilatory intervention and hospital mortality through JoinPoint regression. Results: We identified 30 027 hospital discharges. JoinPoint analysis: downward trend in attendance (annual percentage change [APC]=−3.4, 95% CI : −4.8 to −2.0, P<0.05) and in the group without ventilatory intervention (APC=−4.2%, −5.6 to −2.8, P<0.05); upward trend in the use of NIV (APC=16.4, 12.0–20.9, P<0.05), and downward trend that was not statistically significant in IMV (APC=−4.5%, −10.3 to 1.7). We observed an upward trend without statistical significance in overall mortality (APC=0.5, −1.3 to 2.4) and in the group without intervention (APC=0.1, −1.6 to 1.9); downward trend with statistical significance in the NIV group (APC=−7.1, −11.7 to −2.2, P<0.05) and not statistically significant in the IMV group (APC=−0.8, −6, 1–4.8). The mean stay did not change substantially. Conclusions: The introduction of NIV has reduced the group of patients not receiving assisted ventilation. No improvement in results was found in terms of mortality or length of stay (AU)

Evolution of the use of noninvasive mechanical ventilation in chronic obstructive pulmonary disease in a Spanish region, 1997-2010.

INTRODUCTION: Noninvasive mechanical ventilation (NIV) appeared in the 1980s as an alternative to invasive mechanical ventilation (IMV) in patients with acute respiratory failure. We evaluated the introduction of NIV and the results in patients with acute exacerbation of chronic obstructive pulmonary disease in the Region of Murcia (Spain). SUBJECTS AND METHODS: A retrospective observational study based on the minimum basic hospital discharge data of all patients hospitalised for this pathology in all public hospitals in the region between 1997 and 2010. We performed a time trend analysis on hospital attendance, the use of each ventilatory intervention and hospital mortality through joinpoint regression. RESULTS: We identified 30.027 hospital discharges. Joinpoint analysis: downward trend in attendance (annual percentage change [APC]=-3.4, 95% CI: - 4.8; -2.0, P <.05) and in the group without ventilatory intervention (APC=-4.2%, -5.6; -2.8, P <.05); upward trend in the use of NIV (APC=16.4, 12.0; 20. 9, P <.05), and downward trend that was not statistically significant in IMV (APC=-4.5%, -10.3; 1.7). We observed an upward trend without statistical significance in overall mortality (APC=0.5, -1.3; 2.4) and in the group without intervention (APC=0.1, -1.6; 1.9); downward trend with statistical significance in the NIV group (APC=-7.1, -11.7; -2.2, P <.05) and not statistically significant in the IMV group (APC=-0,8, -6, 1; 4.8). The mean stay did not change substantially. CONCLUSIONS: The introduction of NIV has reduced the group of patients not receiving assisted ventilation. No improvement in results was found in terms of mortality or length of stay.

Clinical review: Helmet and non-invasive mechanical ventilation in critically ill patients.

Non-invasive mechanical ventilation (NIV) has proved to be an excellent technique in selected critically ill patients with different forms of acute respiratory failure. However, NIV can fail on account of the severity of the disease and technical problems, particularly at the interface. The helmet could be an alternative interface compared to face mask to improve NIV success. We performed a clinical review to investigate the main physiological and clinical studies assessing the efficacy and related issues of NIV delivered with a helmet. A computerized search strategy of MEDLINE/PubMed (January 2000 to May 2012) and EMBASE (January 2000 to May 2012) was conducted limiting the search to retrospective, prospective, nonrandomized and randomized trials. We analyzed 152 studies from which 33 were selected, 12 physiological and 21 clinical (879 patients). The physiological studies showed that NIV with helmet could predispose to CO2 rebreathing and increase the patients' ventilator asynchrony. The main indications for NIV were acute cardiogenic pulmonary edema, hypoxemic acute respiratory failure (community-acquired pneumonia, postoperative and immunocompromised patients) and hypercapnic acute respiratory failure. In 9 of the 21 studies the helmet was compared to a face mask during either continous positive airway pressure or pressure support ventilation. In eight studies oxygenation was similar in the two groups, while the intubation rate was similar in four and lower in three studies for the helmet group compared to face mask group. The outcome was similar in six studies. The tolerance was better with the helmet in six of the studies. Although these data are limited, NIV delivered by helmet could be a safe alternative to the face mask in patients with acute respiratory failure.