Acute Respiratory Distress Syndrome Secondary to Influenza A(H1N1)pdm09: Clinical Characteristics and Mortality Predictors.

BACKGROUND: Acute respiratory distress syndrome secondary to influenza A(H1N1)pdm09 virus is the leading cause of death among this patient population. Expanding the knowledge of its course and predictors of mortality is relevant to decision making. We aimed to describe the clinical characteristics and identify factors associated with mortality in patients with acute respiratory distress syndrome secondary to influenza A(H1N1)pdm09 during the 2013-2014 influenza season. METHODS: This is an observational study of a prospective cohort of 70 patients with acute respiratory distress syndrome and influenza A(H1N1) pdm09 seen in an academic medical center. Multivariate logistic regression was used to identify the independent mortality predictors. Bootstrap was used for internal model validation. RESULTS: This cohort was represented by young adults (43 ± 11 years old). Obesity was present in 62.5% and was not associated with mortality. Mortality at 28 days and at discharge from the respiratory intensive care unit was 14 and 20%, respectively. All patients met the criteria for acute respiratory distress syndrome, 73% had vasodilatory shock, and 27.1% had acute kidney injury on respiratory intensive care unit admission. We observed a high incidence of intensive care unit-acquired weakness (81.4%). Ventilator-associated pneumonia developed in 47.1% and was not associated with mortality. In multivariate analysis, independent risk factors for intensive care unit mortality were age (odds ratio [OR] = 1.102), white blood cell count (OR = 1.22), and lactate dehydrogenase levels (OR = 1.004) on admission to the intensive care unit. CONCLUSIONS: We described the clinical characteristics and course of a cohort of patients with acute respiratory distress syndrome secondary to influenza A(H1N1)pdm09, and developed a predictive model of mortality based on the covariates age, levels of lactate dehydrogenase, and white cell count on admission to the respiratory intensive care unit.

Patología traquaal diagnosticada por fibrobroncoscopia: experiencia en 111 casos

Objetivo: Determinar la etiología benigna o maligna de las lesiones traqueales diagnosticadas por fibrobroncoscopia y el tratamiento establecido. Material y métodos: Estudio de observación clínica, retrospectivo y prospectivo, en pacientes con fibrobroncoscopia diagnóstica (octubre 2001 a septiembre 2003). Se registraron diagnóstico histopatológico benigno o maligno de las lesiones y el tratamiento. Se aplicaron las pruebas de varianza ANOVA y de comparación de proporciones con límites de confianza de la distribución binominal (Bernoulli). Resultados: De 867 fibrobroncoscopias, 153 (17.6%) fueron de vía aérea central realizadas en 111 pacientes, 62 (55.8%) hombres y 49 (44.1%) mujeres, edad promedio 52 años, desviación estándar 20.15, rango 3-82 años. Tenían patología benigna 66/111 (59.4%): las más frecuentes fueron estenosis posintubación 41/66 y granuloma inespecífico 9/66; otras causas incluyen compresión extrínseca, traqueomalacia, tuberculosis, fístula traqueoesofágica, escleroma, bridas, adenoma papilar. En 45/111 (40.5%) la patología fue maligna: primaria en 34/45 siendo más frecuente el adenocarcinoma 18/45; otros tumores fueron: cáncer epidermoide pulmonar, cáncer epidermoide laríngeo, carcinoma de células pequeñas; y metástasis: 4/45 como cáncer de próstata, cervicouterino, colangiocarcinoma y sarcoma fibromixoide retroperitoneal. Correspondieron a extensión local o infiltración tumoral 7/45 casos. Por ANOVA no se encontraron diferencias en cuanto al porcentaje de estenosis de diferente localización. Por comparación de proporciones no hubo diferencias significativas entre patología benigna y maligna; de cada 10 casos, 6 benignos y 4 malignos. De las lesiones malignas hubo diferencia significativa entre primarias y metastásicas e infiltrantes de tumores intratorácicos, 34/45 (75.5%), p<0.05. Después del tratamiento se obtuvo una mejoría inmediata de la sintomatología obstructiva. Conclusión: La fibrobroncoscopia permite determinar: localización, grado de obstrucción y tipo de lesión de laringe, tráquea y bronquios principales, benigna o maligna. Es útil para planear la terapéutica curativa o paliativa más conveniente para corregir la obstrucción. Predominó la estenosis posintubación traqueal 41/66 (62%) entre las lesiones benignas.

Objective: To determine the malignant and benign etiology of tracheal lesions by fiberoptic bronchoscopy (FOB) and the results of their treatment. Material and methods: Retrospective and prospective study of patients with diagnostic FOB, from October 2001 to September 2003. Histopathologic diagnosis and treatment of all lesions were recorded. ANOVA and proportions comparison with confidence limits for binomial distribution (Bernoulli) were applied. Results: Of 867 FOB, 153 (17.6%) were performed in the main airway in a total of 111 patients. Sixty-two (55.8%) were males and 49 (44.1%) females, mean age of 52 years; SD 20.15, range 3-82 years. Of these, 66/111 (59.4%) had benign lesions, the most frequent were post-intubation stenosis (41/66) and non-specific granuloma (9/66), other lesions such as extrinsic compression, tracheomalacia, tuberculosis, tracheoesophageal fistula, scleroma, strips and papillary adenoma were found. In 45/111 (40.5%) the lesion was malignant; of these, 34/45 were primarythe most common being adenocarcinoma (18/45); other tumors were epidermoid pulmonary, epidermoid laryngeal and small cell carcinoma, and metastases, and 4/45 were prostate cancer, uterine cervix carcinoma, cholangiocarcinoma and retroperitoneal fibromixoid sarcoma. 7/45 had local infiltration or invasion from intrathoracic tumors. ANOVA did not demonstrate differences between the percentages of stenosis of different localization. There was statistical difference between primary and metastatic malignancies p <0.05. Immediate relief of respiratory difficulty was registered following treatment. Conclusion: Site, degree of obstruction and type of tracheal lesions can be evaluated by FOB to establish the most convenient treatment for the obstruction, whether curative or palliative. Among benign lesions post-endotracheal intubation structure was the most common.

La fibrobroncocoopia en medicina crítica

Objetivo: Identificar las indicaciones de la fibrobroncoscopia en pacientes hospitalizados en Unidades de Cuidados Intensivos. Material y métodos: Estudio de observación clínica, reprospectivo y prospectivo en pacientes hospitalizados en la Unidad de Cuidados Intensivos con fibrobroncoscopia de octubre de 2001 a septiembre de 2003. Se registraron diagnósticos de indicación de fibrobroncoscopia, hallazgos, complicaciones y Unidades de Cuidados Intensivos de procedencia. Se aplicó la prueba de comparación de proporciones con límites de confianza de la distribución nominal (Bernoulli) Resultados: De 867 fibrobroncoscopias, 88 se practicaron en la Unidad de Cuidados Intensivos (10.14%); de ellas hubo 51 hombres y 37 mujeres; edad promedio 52.35; desviación estándar 17.27; rango 15-86 años. Cincuenta pacientes provinieron de diferentes Unidades de Cuidados Intensivos (Central, Infectología, Oncología, Cardiología Y Neurología), y 38 de la Unidad de Cuidados Intensivos Respiratorios (Neumología). En 50 casos la indicación fue por neumonía, 16 adquirida en la comunidad, 12 por broncoaspiración, 12 asociada a ventilador, 10 nosocomial. Quince casos en Unidades de Cuidados Intensivos Respiratorios y 35 procedentes de unidades no neumológicas; la diferencia no fue estadísticamente significativa. Los diagnósticos de los 38 pacientes restantes fueron: 18 atelectasia, 6 enfermedad maligna, 5 hemoptisis, 3 revisión de traqueotomía y colocación de cánula, 2 fístula traqueoesofágica, 2 estenosis traqueal, 1 absceso pulmonar y 1 quemadura de vía aérea. En fibrobroncoscopia 65 fueron diagnósticas,11 terapéuticas y 12 ambas. Dos pacientes presentaron complicaciones. Ninguno falleció como consecuencia del procedimiento. Conclusiones: La fibrobroncoscopia es un método seguro en pacientes en estado crítico, tiene indicaciones diagnósticas y terapéuticas que facilitan la toma de decisiones para su manejo clínico, con baja morbilidad.

Objective: To identify the indications of fiberoptic bronchoscopy (FOB) in patients hospitalized in Intensive Care Units (ICU). Material and methods: Observational clinic study retrospective and prospective of patients hospitalized in ICU with FOB, from October 2001-September 2003. In all cases it was recorded diagnostic indication for FOB, findings, complications and ICU where it comes from. Test of proportions with confidence limits for binomial distribution (Bernoulli) was applied. Results: Of 867 FOB, 88 were performed in ICU (10.14%), 51 males, 37 females, mean age 52.35; SD 17.27; range 15-86 years old. Fifty patients came from different services IC units, central, infectology, oncology, cardiology and neurology, 38 were from Respiratory Intensive Care Unit (RICU). In 50 cases the indication was pneumonia, 16 communitary, 12 by aspiration, 12 ventilator associated and 10 nosocomial. 15 correspond to RICU and 35 from non-pneumologic ICU. There were no significative differences. Diagnosis of the others 38 patients were 18 atelectasis, 6 malignancies, 5 hemoptysis, 3 evaluation of tracheostomy, 2 tracheoesophageal fistula, 2 tracheal stenosis, 1 lung abscess an 1 burn of airway. 65 FOB were for diagnosis, 11 therapeutics and 12 by both. Only 2 patients presented complications. No casualties were recorded. Conclusion: FOB is a safe method for diagnostic and therapeutic indications in patients in critical conditions under intensive care and make easier the decisions for clinical management, with low morbidity.