[Predictors of weaning and mortality in prolonged mechanical ventilation ­ surviving survival]. / Predictores de desvinculación y mortalidad en ventilación mecánica prolongada-Sobrevivir al sobrevivir.

Objetive: to describe a sample of tracheostomized patients requiring prolonged mechanical ventilation who were admitted to a weaning center, to analyze their evolution and to determine the predictors of weaning failure from mechanical ventilation and of mortality. Design: Design: an observational and retrospective cohort study was carried out, in the period between January 2005 and December 2017. Setting: weaning and rehabilitation center. Patients: all tracheostomized patients requiring mechanical ventilation who were admitted during the study period were included. Of 1027 patients admitted to the respiratory care service, a consecutive sample of 677 patients was analyzed. Main variables of interest: the main variables were mortality and weaning failure from mechanical ventilation. Results: : age older than 70 years (OR 1,461 95% CI 1,016-2,099), a cardiovascular history (OR 1,533 95% CI 1,050-2,237), admission due to respiratory disease (OR 1,538 95% CI 1,001-2,364) and presenting more than 105 days of hospitalization (OR 0,408 95% CI 0,261-0,637) were found as predictors of weaning failure. The predictors of mortality were, age over 70 years (OR 2,116 95% CI 1,491-3,004), history of cerebrovascular accident (OR 1,991 95% CI 1,255-3,158), admission to intensive care due to cardiorespiratory arrest (OR 5,821 95% CI 2,193-15,445) and presenting more than 64 days of hospitalization (OR 1, 63 95% CI 1,116-2,292). Conclusions: The data found in this study manage to describe factors associated with weaning and mortality of patients in a weaning and rehabilitation center.

Objetivos: describir una muestra de pacientes traqueostomizados con requerimiento de ventilación mecánica prolongada que ingresaron a un centro de desvinculación, analizar su evolución y determinar los predictores de fracaso de desvinculación de la ventilación mecánica y de mortalidad. Diseño: se realizó un estudio de cohorte observacional y retrospectivo, en el período comprendido entre enero del 2005 y diciembre del 2017. Ámbito: centro de desvinculación de la ventilación mecánica y de rehabilitación. Pacientes: se incluyeron a todos los pacientes traqueostomizados con requerimiento de ventilación mecánica, que ingresaron durante el periodo de estudio. De 1027 pacientes ingresados al servicio de cuidados respiratorios, se analizó una muestra consecutiva de 677 pacientes. Variables de interés principales: las variables principales fueron mortalidad y falla en la desvinculación de la ventilación mecánica. Resultados: Se encontraron como predictores del fracaso de la desvinculación la edad mayor a 70 años (OR 1.461 IC95% 1.016-2.099), tener antecedentes cardiovasculares (OR 1.533 IC95% 1.050-2.237), motivo de ingreso por afección respiratoria (OR 1.538 IC95% 1.001-2.364) y presentar más de 105 días de internación (OR 0.408 IC95% 0.261-0.637). Los predictores de mortalidad fueron, la edad mayor a 70 años (OR 2.116 IC95% 1.491-3.004), tener como antecedente un accidente cerebro-vascular (OR 1.991 IC95% 1.255-3.158), motivo de ingreso a terapia intensiva por paro cardiorrespiratorio (OR 5.821 IC95% 2.193-15.445) y presentar más de 64 días de internación (OR1.63 IC95% 1.116-2.292). Conclusión: Los datos hallados en este estudio logran describir factores asociados a la desvinculación y mortalidad de los pacientes en un centro de desvinculación.

Prevalence of and Risk Factors for Mechanical Ventilation Reinstitution in Patients Weaned From Prolonged Mechanical Ventilation.

BACKGROUND: Prolonged mechanical ventilation is increasingly common in ICUs. Although a consensus conference defined weaning success in this patient population, few studies have used this definition. A clear definition of successful weaning is useful to assess clinical and epidemiological outcomes, facilitate clinical decision making, and set goals of care. The aims of our study were to describe the prevalence of reinstitution of mechanical ventilation within 28 d in patients successfully weaned according to our institution criterion (ie, weaning success as per consensus guidelines), to describe reasons to reestablish mechanical ventilation, and to identify associated factors. METHODS: An observational, analytical, cross-sectional study was conducted at a weaning and rehabilitation center. All patients liberated from mechanical ventilation (ie, no ventilatory support for 7 d) were included as subjects. Requirement of and reasons for reinstitution of mechanical ventilation within 28 d of weaning were recorded. RESULTS: A total of 639 tracheostomized subjects were analyzed. Of these, 219 (34%) were weaned, and 15 were eliminated due to lack of data. Of the remaining 204 subjects, 42 (21%) were reconnected to mechanical ventilation within 28 d. Sepsis accounted for 64% of reconnections. In the multivariate analysis, neurological comorbidity (adjusted odds ratio 5.1 [95% CI 2.3-11.1]) and delayed weaning (> 7 d after admission) (adjusted odds ratio 2.37 [95% CI 1.1-5.3]) were independently associated with reinstitution of mechanical ventilation within 28 d of weaning. The synergistic effect of both variables showed an adjusted odds ratio of 5.35 (95% CI 2.4-11.4). CONCLUSIONS: Reinstitution of mechanical ventilation within 28 d is a common event in patients considered to be weaned: 1 in 5 of such patients requires reconnection to mechanical ventilation, with sepsis being the most prevalent cause. Neurological comorbidity and delayed weaning are risk factors associated with reestablishment of mechanical ventilation. The presence of more than one risk factor increases the association with reinstitution of mechanical ventilation within 28 d of weaning.

Encuesta sobre el procedimiento de extubación en las unidades de cuidados intensivos de Buenos Aires, Argentina / Survey on the extubation procedure in intensive care units in Buenos Aires, Argentina

RESUMEN Objetivo: Conocer la práctica habitual del manejo de la vía aérea durante el procedimiento de extubación mediante una encuesta online a profesionales de las unidades de cuidados intensivos de la Ciudad Autónoma de Buenos Aires y Provincia de Buenos, Argentina. Métodos: Estudio descriptivo transversal de tipo encuesta online del 11 de febrero al 11 de marzo de 2013. Se envió por correo electrónico una invitación voluntaria y anónima para acceder a la encuesta a 500 participantes a partir de una base de datos confeccionada por los investigadores de este estudio. Resultados: De un total de 500 participantes, 217 (44%) respondieron la encuesta. El 59,4% son kinesiólogos. Ciento noventa y cinco (89,9%) profesionales se desempeñan en atención de adultos. Con respecto al procedimiento de desinflado del balón y extubación, 203 (93,5%) realizan aspiración endotraqueal y 27 (12,5%) emplean presión positiva. El 53,5% de los participantes informó haber tenido en los últimos 3 meses complicaciones inmediatas a este procedimiento. Se informaron un total de 163 complicaciones, siendo el estridor el más prevalente (52,7%). Conclusión: La mayoría de los profesionales de unidades de cuidados intensivos de la Ciudad Autónoma de Buenos Aires y Provincia de Buenos Aires, Argentina, emplea aspiración endotraqueal sin aplicar presión positiva durante el procedimiento de extubación.

ABSTRACT Objective: To examine the usual practice of airway management during the extubation procedure through an online survey to professionals working in intensive care units in the Autonomous City of Buenos Aires and in the Province of Buenos Aires, Argentina. Methods: A cross-sectional descriptive study online survey was conducted from February 11 to March 11, 2013. A database was generated, and a voluntary and anonymous invitation to access the survey was sent by email to 500 participants. Results: Out of a total of 500 participants, 217 (44%) responded to the survey, of whom 59.4% were physical therapists. One hundred ninety-five (89.9%) professionals were working in adult care. Regarding the cuff deflation procedure and extubation, 203 (93.5%) performe endotracheal suctioning, and 27 (12.5%) use positive pressure. Approximately 53.5% of participants reported having experienced immediate complications with this procedure in the last three months. In all, 163 complications were reported, and stridor was the most prevalent (52.7%). Conclusion: Most professionals working in intensive care units in the Autonomous City of Buenos Aires and in the Province of Buenos Aires, Argentina, use endotracheal suctioning without applying positive pressure during extubation.

Survey on the extubation procedure in intensive care units in Buenos Aires, Argentina. / Encuesta sobre el procedimiento de extubación en las unidades de cuidados intensivos de Buenos Aires, Argentina.

OBJECTIVE: To examine the usual practice of airway management during the extubation procedure through an online survey to professionals working in intensive care units in the Autonomous City of Buenos Aires and in the Province of Buenos Aires, Argentina. METHODS: A cross-sectional descriptive study online survey was conducted from February 11 to March 11, 2013. A database was generated, and a voluntary and anonymous invitation to access the survey was sent by email to 500 participants. RESULTS: Out of a total of 500 participants, 217 (44%) responded to the survey, of whom 59.4% were physical therapists. One hundred ninety-five (89.9%) professionals were working in adult care. Regarding the cuff deflation procedure and extubation, 203 (93.5%) performe endotracheal suctioning, and 27 (12.5%) use positive pressure. Approximately 53.5% of participants reported having experienced immediate complications with this procedure in the last three months. In all, 163 complications were reported, and stridor was the most prevalent (52.7%). CONCLUSION: Most professionals working in intensive care units in the Autonomous City of Buenos Aires and in the Province of Buenos Aires, Argentina, use endotracheal suctioning without applying positive pressure during extubation.

OBJETIVO: Conocer la práctica habitual del manejo de la vía aérea durante el procedimiento de extubación mediante una encuesta online a profesionales de las unidades de cuidados intensivos de la Ciudad Autónoma de Buenos Aires y Provincia de Buenos, Argentina. MÉTODOS: Estudio descriptivo transversal de tipo encuesta online del 11 de febrero al 11 de marzo de 2013. Se envió por correo electrónico una invitación voluntaria y anónima para acceder a la encuesta a 500 participantes a partir de una base de datos confeccionada por los investigadores de este estudio. RESULTADOS: De un total de 500 participantes, 217 (44%) respondieron la encuesta. El 59,4% son kinesiólogos. Ciento noventa y cinco (89,9%) profesionales se desempeñan en atención de adultos. Con respecto al procedimiento de desinflado del balón y extubación, 203 (93,5%) realizan aspiración endotraqueal y 27 (12,5%) emplean presión positiva. El 53,5% de los participantes informó haber tenido en los últimos 3 meses complicaciones inmediatas a este procedimiento. Se informaron un total de 163 complicaciones, siendo el estridor el más prevalente (52,7%). CONCLUSIÓN: La mayoría de los profesionales de unidades de cuidados intensivos de la Ciudad Autónoma de Buenos Aires y Provincia de Buenos Aires, Argentina, emplea aspiración endotraqueal sin aplicar presión positiva durante el procedimiento de extubación.

Prevalence and Characteristics of Tracheal Lesions Observed in Tracheostomized Patients.

BACKGROUND: Our objective was to describe the prevalence and characteristics of tracheal lesions observed in flexile bronchoscopies of tracheostomized patients, and to determine those factors associated with severe injuries. METHODS: This is an analytical, observational, and transversal study. The flexible bronchoscopies of tracheostomized patients from our database were reviewed to assess their lesions. The tracheal lesions were classified according to their severity; lesions obstructing above 50% of the lumen were interpreted as severe and those obstructing <50% as mild. The lesions were also classified according to location as glottic, subglottic, at the level of the tracheal ostomy, tracheal, and bronchial. The types of lesions found were granuloma, stenosis, and excessive central airway collapse. Possible predictors of severe lesions were assessed. RESULTS: A total of 414 patients were included in the study, the mean age being 65 years (±16.2 y). Of all the bronchoscopies assessed, 202 (49%) showed mild lesions, and 91 (22%) were severe. We found granulomas in 230 patients (55%), and 32 (26%) were severe. Of the 27 patients with stenosis (7%), 17 (63%) were severe. Excessive central airway collapse was seen in 120 patients (31.8%), and 65 (54%) were severe. There were statistically significant differences related to age in the group that developed severe lesions (mean age, 73 y; Q1 to Q3, 58 to 81) compared with the group free of lesions (mean age, 69 y; Q1 to Q3, 55.7 to 75; P = 0.001) and also in the duration requiring an artificial airway (mean, 84.5 d; Q1 to Q3, 49 to 135.5) compared with the group free of lesions (mean of 59.5 d; Q1 to Q3, 42 to 98; P = 0.035). CONCLUSION: There was a high prevalence of tracheal lesions, mainly subglottic granulomas. Age and the duration for which the patient required an artificial airway were related to the presence of severe lesions.