Uso de BiPAP intraoperatoria en paciente con exacerbación aguda severa de EPOC y miastenia gravis / Intraoperative use of BiPAP in patients with severe acute exacerbation of COPD and myasthenia gravis

Introducción: la exacerbación aguda grave de la enfermedad pulmonar obstructiva crónica es la sexta causa de muerte a nivel mundial y su asociación a la miastenia es excepcional. Cuando ambas enfermedades coexisten en un paciente que necesita una cirugía de urgencia, plantea un reto anestésico debido a la dificultad en el mantenimiento de la ventilación y la necesidad de una extubación precoz. En situaciones de este tipo el uso de BiPAP mejora los parámetros ventilatorios e incrementa el margen de seguridad para un barotrauma, así como permite en teoría reducir el periodo de ventilación. Objetivo: mostrar la conducta ventilatoria en un caso clínico que padece enfermedad pulmonar obstructiva crónica y miastenia gravis aceptado transversostomía. Caso clínico: paciente ingresado en la unidad de cuidados intensivos por exacerbación aguda grave de EPOC asociado a crisis colinérgica que presenta una fistula recto vesical y fue intervenido de urgencia para realizar una transversostomía. Se describe la valoración preoperatoria realizada por los anestesiólogos, resultados de estudios imaginológicos y gasométricos. También se expone la medicación preanestésica y el plan anestésico elaborado con especial énfasis en la aplicación de BiPAP intraoperatoria. Conclusiones: este modo ventilatorio puede ser una alternativa eficiente en el intraoperatorio de pacientes de alto riesgo de complicaciones respiratorias postoperatorias(AU)

Introduction: severe acute exacerbation of chronic obstructive pulmonary disease is the sixth leading cause of death worldwide and its association with myasthenia is exceptional. When both conditions coexist in a patient requiring emergency surgery, it poses a challenge due to anesthetic difficulty in maintaining ventilation and the need for early extubation. In such situations, the use of BiPAP improves the ventilatory parameters and increases the safety margin for barotrauma, as well as it theoretically allows reducing the ventilation period. Objective: To show the ventilatory behavior in a clinical case with chronic obstructive pulmonary disease and myasthenia gravis accepted for transversostomy. Clinical case: A patient admitted to the intensive care unit for severe acute exacerbation of COPD associated with cholinergic crisis presented a bladder and rectal fistula and was intervened as an emergency for a transversostomy. Preoperative assessment made by the anesthesiologists is described, together with the blood gas and imaging studies. The preanesthetic medication is presented, together with the action plan developed with special emphasis on the application of intraoperative BiPAP.Conclusions: This ventilatory mode can be an efficient choice in the intraoperative time for patients at high risk for postoperative respiratory complications(AU)

Sleep quality of mother-caregivers of Duchenne muscular dystrophy patients.

BACKGROUND: Sleep disturbance is a common problem for caregivers. In general, patients with Duchenne muscular dystrophy (DMD) use noninvasive ventilation to maintain quality of life and improve survival. OBJECTIVE: The aim of this study was to evaluate the sleep quality of caregiver-mothers of sons with DMD and factors that are associated with their sleep quality. METHODS: We evaluated 32 caregiver-mothers of sons with DMD and 32 mothers of sons without any neuromuscular or chronic disease (control-CTRL group). The evaluation of quality of sleep was made using the Pittsburgh Sleep Quality Index (PSQI). RESULTS: Caregiver-mothers had poor sleep quality, specifically longer sleep latency and reduced sleep efficiency. The impaired sleep quality of the caregiver-mothers was associated with the length of time of noninvasive ventilation used by their sons. CONCLUSIONS: Our results suggest that caregiver-mothers of sons with DMD have poor quality of sleep, and the length of use of noninvasive ventilation of their sons is associated with better sleep of caregiver-mothers.

Estudio comparativo de dos modos de ventilación no invasiva para retirar la asistencia respiratoria mecánica en lactantes post-operatorios de cirugía cardiovascular / Comparative study of two modalities of non-invasive ventilation for the weaning from mechanical ventilation of post-cardiovascular surgery infants

La mejor estrategia en el post-quirúrgico de cardiopatías congénitas para promover la extubación precoz y destete de asistencia respiratoria mecánica (ARM) con ventilación no invasiva (VNI) todavía no ha sido establecida. El objetivo es comparar eficacia de la presión positiva continua en la vía aérea (CPAP) vs presión positiva con dos niveles en la vía aérea (BIPAP) en la extubación electiva de estos pacientes. Es un estudio prospectivo entre el 1 de junio de 2008 y 31 marzo de 2010. Se randomizaron los pacientes para extubación electiva: modo CPAP o BIPAP. Se registraron datos demográficos y del procedimiento quirúrgico, entre otros. El fracaso de VNI fue definido como reintubación dentro de las 72 hs posteriores a la extubación o más de un criterio de intubación. Durante el periodo de estudio 1438 pacientes fueron admitidos en UCI35. En el grupo BIPAP se randomizaron 53 pacientes, de los cuales se extubaron exitosamente 49 (92%), pero 4 se reintubaron debido a falla cardiaca. En el grupo CPAP se randomizaron 46 y fallaron en la extubación 18 (39%) debido a múltiples episodios de desaturación y apneas. De éstos, 11 requirieron reintubación endotraqueal y ARM. En 7 pacientes, se pasó a modo BIPAP y permanecieron extubados, aunque el cruzamiento no fue parte del diseño de este estudio. En el destete de ARM de los pacientes post-quirúrgicos de cardiopatías congénitas, el uso de BIPAP fue más efectivo que CPAP. En esta última modalidad se presentaron mayor número de fracasos de VNI (AU)

The best strategy for early extubation and weaning from mechanical respiration (MV) with non-invasive ventilation (NIV) in post-surgical congenital heart defect patients has not been established yet. The aim of this study was to compare the efficacy of continuous positive airway pressure CPAP) vs bi-level positive airway pressure (BIPAP) in the elective extubation of these patients. A prospective study was conducted between June 1, 2008 and March 31, 2010. Patients that were candidates for elective extubation were randomized to CPAP or BIPAP. Data on demographics and surgical procedure, among others, were recorded. Failure of NIV was defined as the need for reintubation within 72 hours after extubation or more than one criterion for intubation. Over the study period, 1438 patients were admitted to ICU 35. Fifty-three patients were randomized to BIPAP, of whom 49 (92%) were successfully extubated; however, four were reintubated due to heart failure. Forty-six patients were randomized to CPAP. Extubation failed in 18 (39%) due to multiple episodes of desaturation and apneas. Eleven of 18 required endotracheal reintubation and mechanical ventilation. Seven patients were switched to BIPAP and remained extubated, although the switch was not part of the study design. In the weaning of post-surgical congenital heart defect patients from MV, BIPAP was more effective than CPAP. In the latter modality, the incidence of NIV failure was higher (AU)

Um anjo para ELA: arquitetura baseada em visão computacional aplicada ao monitoramento on-line de parâmetros respiratórios de pacientes com Esclerose Lateral Amiotrófica (ELA) em ambiente hospitalar / An angel for ALS: architecture based on computer vision applied for on-line monitoring respiratory parameters of patients with Amyotrophic Lateral Sclerosis (ALS) in hospital environment

INTRODUÇÃO: A Esclerose Lateral Amiotrófica (ELA) é uma doença neurodegenerativa, caracterizada por uma progressiva e fatal perda de neurônios motores do córtex cerebral, tronco encefálico e medula espinhal, mas que mantém preservada a atividade intelectual e cognitiva do paciente. Pacientes acometidos por essa doença irão invariavelmente necessitar do auxílio de ventiladores mecânicos. MÉTODOS: Foi utilizado um conjunto de hardware e software para realizar o monitoramento dos parâmetros respiratórios dos pacientes em leitos hospitalares como forma de auxiliar à equipe de saúde. O monitoramento desses parâmetros deu-se por meio de uma webcam, que capturava os valores exibidos na tela do ventilador mecânico, e do emprego de técnicas de visão computacional e Optical Character Recognition (OCR). Neste sentido, o sistema foi testado sob três condições de luminosidade diferentes para verificar a eficácia do mesmo. RESULTADOS: O sistema apresentou uma média geral de acertos de 94.90%. Além disso, quando a interferência luminosa foi mínima, o sistema obteve uma média geral de acertos de 97,76%. CONCLUSÃO: A adoção de um sistema computacional baseado em visão computacional para auxílio da equipe de saúde no monitoramento hospitalar de pacientes com ELA mostrou-se satisfatória. No entanto, a pesquisa mostrou que a adoção de um sistema com maior imunidade à interferências luminosas externas tende a apresentar melhores resultados.

INTRODUCTION: Amyotrophic Lateral Sclerosis (ALS) is a neurodegenerative disease characterized by a progressive and fatal loss of motor neurons in the cerebral cortex, brainstem and spinal cord. In spite of that, the patient's intellectual and cognitive activity remains preserved. Patients affected by this disease will invariably need the help of mechanical ventilators. METHODS: A set of hardware and software was used to perform the monitoring of respiratory parameters of patients in hospital beds as a means of assisting the healthcare team. The monitoring of these parameters was performed by a webcam that captured the values displayed on the screen of the ventilator, and the employment of computer vision techniques and Optical Character Recognition (OCR). In this sense, the system was tested under three different lighting conditions to verify its effectiveness. RESULTS:The system presented an overall average of 94.90% of correct answers. Furthermore, when the luminous interference was minimum, it achieved an overall average of success of 97.76%. CONCLUSION: The adoption of a computational system based on computer vision to aid the healthcare team in hospital monitoring of patients with ALS was satisfactory. However, the research has shown that the adoption of a system with greater immunity to external light interference tends to achieve better results.

Ventilação não-invasiva no edema agudo de pulmão cardiogênico: [revisão] / Noninvasive ventilation in acute cardiogenic pulmonary edema: [review]

O uso da continuous positive airway pressure (CPAP) no tratamento do edema agudo de pulmão (EAP) cardiogênico tem sido estudado por alguns autores. Recentemente, a utilização da ventilação não-invasiva com dois níveis de pressão (BiPAP) vem sendo estudada nessa situação clínica; entretanto, os resultados são controversos. Dessa forma, foi realizado, através do MEDLINE, um levantamento dos ensaios clínicos randomizados publicados em língua inglesa que analisaram a utilização do BiPAP em pacientes com EAP cardiogênico, obtendo-se um total de 11 trabalhos. O BiPAP mostrou-se útil no manuseio do EAP, apresentando benefícios similares à CPAP. Nos pacientes hipercápnicos, o BiPAP surge como uma importante estratégia de suporte ventilatório não-invasivo. Porém, faz-se necessário um estudo com grande número de pacientes para esclarecer certas dúvidas ainda persistentes.

The use of continuous positive airway pressure (CPAP) in the treatment of acute cardiogenic pulmonary edema (CPE) has been studied by some authors. Recently, the use of bi-level positive airway pressure (BiPAP) has been studied in this clinical situation, although the results have been controversial. We searched MEDLINE in order to find randomized trials published in English that analyzed the use of BiPAP in patients with CPE. Eleven trials were found. BiPAP was useful in the management of CPE, showing similar benefits to those of CPAP. In hypercapnic patients, BiPAP appears to be an important strategy of noninvasive ventilatory support. However, large trials are necessary to clarify certain doubts that still remain.

Ventilación mecánica prolongada con BiPAP a través de traqueostomía / Long-term noninvasive ventilation via tracheostomy

No existen reportes que describan el uso de equipos generadores de flujo con presión diferencial en 2 niveles (BiPAP) a través de traqueostomía para entregar ventilación mecánica prolongada (VMP) en niños. Este documento describe los criterios de selección, modalidad de uso y requerimientos tecnológicos como guía para implementar esta estrategia ventilatoria.

Asistencia ventilatoria no invasiva domiciliaria nocturna en pediatría / Pediatric nocturnnal noninvasive ventilation assistance at home

The nocturnal noninvasive ventilation (NNIV) at home is often used in chronic respiratory failure (CRF) and obstructive sleep apnea (OSA) and, less frequently, in central hypoventilation and cystic fibrosis. We present a 6 year period (1996-2002) retrospective review of 10 children treated with noninvasive respiratory support describing indications, type of NNIV and the follow-up. Patient's age ranged from 1 to 13 years old; 6 were females and 4 males. Six had a neuromuscular disease, three a cerebral palsy and one an Arnold Chiari Syndrome Type II. Nine children presented kyphoscoliosis. NNIV was indicated in the following conditions: compensated CRF (n = 3), decompensated CRF (n = 1), acute respiratory failure with underlying neuromuscular diseases and unclear diagnosis of CRF (n = 2); OSA with pharyngeal collapse (n = 3) and central hypoventilation (n = 1). Two patients had moderate to severe pulmonary restriction and subnormal maximal airway pressures. Six patients were discharged with CPAP and four with BiPAP after being hospitalized during 3 to 90 days. In average, the follow-up lasted 2 years. Three children had training of their respiratory muscles. One patient needed a tracheostomy, the other nine improved: five without re-admissions and four reduced them. Five patients went back to school. One patient with congenital myopathy and kyphoscoliosis, surgically treated, improved her pulmonary function and the 6 minutes walking test. Two patients used NNIV irregularly and other two stopped it after one year. No deaths were reported. In our experience NNIV at home lessens admissions and promotes a better social and school re-integration. BiPAP is useful in restrictive conditions meanwhile CPAP is helpful in upper airway obstruction with OSA.

La asistencia ventilatoria no invasiva domiciliaria nocturna (AVNIDN) se indica en insuficiencia respiratoria crónica (IRC), síndrome de apnea obstructiva del sueño (SAOS) y ocasionalmente por hipoventilación central y fibrosis quística. Se hace una revisión retrospectiva de 10 pacientes sometidos a esta técnica de soporte ventilatorio no invasivo durante un periodo de 6 años (1996-2002), describiendo las indicaciones, tipo de AVNIDN y el seguimiento. Sus edades fluctuaron entre 1 a 13 años; 6 mujeres y 4 hombres. Seis pacientes tenían enfermedad neuromuscular; 3 parálisis cerebral y uno Arnold Chiari tipo II. Nueve presentaban xifoescoliosis. Las indicaciones fueron: IRC estable 3 pacientes; posterior a IRC descompensada 1; luego de insuficiencia respiratoria aguda en enfermos neuromusculares sin diagnóstico claro de IRC, 2 pacientes. SAOS secundaria a faringomalacia en 3 y por hipoventilación central uno. Dos presentaban restricción pulmonar moderada a severa y presiones máximas de vía aérea subnormales. Seis pacientes recibieron CPAP y 4 Bipap. El tiempo de hospitalización previo al alta fue de 3 a 90 días y la duración promedio del seguimiento fue 2 años. Tres recibieron entrenamiento muscular respiratorio. No hubo mortalidad; un paciente fue traqueostomizado. Nueve mejoraron, 5 no tuvieron rehospitalizaciones y 4 las disminuyeron. Cinco pacientes asisten al colegio. Un paciente con miopatía congénita y artrodesis mejoró sus pruebas funcionales respiratorias y la distancia recorrida en 6 minutos. Dos usaron irregularmente la AVNIDN y dos suspendieron tratamiento luego de un año. En nuestra experiencia, la AVNID minimizó las hospitalizaciones y promovió la reinserción social y escolar. La modalidad Bipap fue útil en patologías restrictivas y el CPAP en obstrucción de vía aérea superior/SAOS.