Peripheral microcirculatory alterations are associated with the severity of acute respiratory distress syndrome in COVID-19 patients admitted to intermediate respiratory and intensive care units.

BACKGROUND: COVID-19 is primarily a respiratory disease; however, there is also evidence that it causes endothelial damage in the microvasculature of several organs. The aim of the present study is to characterize in vivo the microvascular reactivity in peripheral skeletal muscle of severe COVID-19 patients. METHODS: This is a prospective observational study carried out in Spain, Mexico and Brazil. Healthy subjects and severe COVID-19 patients admitted to the intermediate respiratory (IRCU) and intensive care units (ICU) due to hypoxemia were studied. Local tissue/blood oxygen saturation (StO2) and local hemoglobin concentration (THC) were non-invasively measured on the forearm by near-infrared spectroscopy (NIRS). A vascular occlusion test (VOT), a three-minute induced ischemia, was performed in order to obtain dynamic StO2 parameters: deoxygenation rate (DeO2), reoxygenation rate (ReO2), and hyperemic response (HAUC). In COVID-19 patients, the severity of ARDS was evaluated by the ratio between peripheral arterial oxygen saturation (SpO2) and the fraction of inspired oxygen (FiO2) (SF ratio). RESULTS: Healthy controls (32) and COVID-19 patients (73) were studied. Baseline StO2 and THC did not differ between the two groups. Dynamic VOT-derived parameters were significantly impaired in COVID-19 patients showing lower metabolic rate (DeO2) and diminished endothelial reactivity. At enrollment, most COVID-19 patients were receiving invasive mechanical ventilation (MV) (53%) or high-flow nasal cannula support (32%). Patients on MV were also receiving sedative agents (100%) and vasopressors (29%). Baseline StO2 and DeO2 negatively correlated with SF ratio, while ReO2 showed a positive correlation with SF ratio. There were significant differences in baseline StO2 and ReO2 among the different ARDS groups according to SF ratio, but not among different respiratory support therapies. CONCLUSION: Patients with severe COVID-19 show systemic microcirculatory alterations suggestive of endothelial dysfunction, and these alterations are associated with the severity of ARDS. Further evaluation is needed to determine whether these observations have prognostic implications. These results represent interim findings of the ongoing HEMOCOVID-19 trial. Trial registration ClinicalTrials.gov NCT04689477 . Retrospectively registered 30 December 2020.

Análisis de costes y mortalidad de una unidad de cuidados intermedios respiratorios. ¿Es realmente eficiente y segura? / Cost and Mortality Analysis of an Intermediate Respiratory Care Unit. Is It Really Efficient and Safe?

Introducción: Históricamente se ha asumido que las unidades de cuidados intermedios respiratorios (UCIR) eran estructuras eficientes por los costes evitados atribuibles a la reducción de los ingresos en las unidades de cuidados intensivos (UCI) y eficaces por la especialización neumológica. Métodos: Se evaluó el número de ingresos y mortalidad en la unidad, histórica y en el año 2016. Ese año además se describieron los grupos relacionados de diagnóstico (GRD) agrupados y el coste evitado por estancia en UCI en relación con todos los capítulos presupuestarios. Se realizó un análisis multivariante para asociar costes a pesos medios y complejidad y se realizó una regresión logística múltiple sobre la totalidad de enfermos ingresados de 2004 a 2017 para describir las variables asociadas a la mortalidad en nuestra unidad. Resultados: La UCIR evita un coste al hospital de 500.000 €/año al reducir días de estancia en las UCI. El análisis sobre la cohorte de 2016 describe que los costes se asocian al peso medio y mortalidad, y por tanto, a la complejidad. El análisis de regresión logística multivariante sobre la cohorte de 2004-2017 describe la frecuencia respiratoria, la leucopenia, la anemia, la hiperpotasemia y la acidosis como las variables que mejor se asocian con la mortalidad. El área bajo la curva para el modelo logístico fue de 0,75. Conclusión: La UCIR analizada ha demostrado ser eficiente en términos de «coste evitado» y ahorro ligado a la complejidad. Nuestros resultados sugieren que las UCIR son un entorno seguro para los pacientes al tener una mortalidad menor que otras unidades similares

Introduction: Historically, it has been assumed that Intermediate Respiratory Care Units (IRCU) were efficient, because they saved costs by reducing the number of admissions to intensive care units (ICU), and effective, because they specialized in respiratory diseases. Methods: The number of IRCU admissions and mortality rate, historically and in 2016, were evaluated. For 2016, the grouped Related Diagnostic Groups (DRGs) were also described, and the savings achieved under all budgetary headings by avoiding UCI stays were calculated. A multivariate analysis was performed to associate costs with mean weights and complexity, and multiple logistic regression was performed on all patients admitted from 2004 to 2017 to describe the variables associated with mortality in our unit. Results: An IRCU generates savings of 500,000 €/year by reducing length of ICU stay. Analysis of the 2016 cohort shows that costs correlate with mean weight and mortality, and consequently complexity. The multivariate logistic regression analysis of the 2004-2017 cohort found respiratory frequency, leukopenia, anemia, hyperkalemia, and acidosis to be the variables best associated with mortality. The area under the curve for the logistic model was 0.75. Conclusion: The IRCU analyzed in our study was efficient in terms of "avoided costs" and savings associated with complexity. Our results suggest that IRCUs have a lower mortality rate than other similar units, and are therefore a safe environment for patients

[Non-invasive respiratory unit in the Hungarian health care system]. / Nem invazív légzési osztály a hazai ellátórendszerben.

Treating patients with acute or chronic respiratory insufficiency still poses a major load on the healthcare system. Though there is evidence that treating these patients in high dependency respiratory units results in a shortening of hospital stay, reduces the need of intubation, and decreases mortality. In the Hungarian routine these patients are treated in general wards until the development of global respiratory insufficiency, when they are transferred to intensive care units. The authors present their first year experience on their novel Non-invasive Respiratory Unit established at Semmelweis University.

Creation of an intermediate respiratory care unit to decrease intensive care utilization.

Patients requiring specialized respiratory care often have lengthy stays in the intensive/critical care settings. Financial constraints, patient flow, unit management, and limited resources make finding alternative sites for the care of patients on long-term ventilator (LTV) essential. The authors discuss the efforts of a multidisciplinary team that created, implemented, and evaluated an evidence-based respiratory care unit for LTV patients. The nursing staff development required as part of this initiative is described.

Actividad de una unidad de cuidados respiratorios intermedios dependiente de un servicio de neumología / Activity of an Intermediate Respiratory Care Unit Attached to a Respiratory Medicine Department

Introducción y objetivo: El desarrollo de la ventilación no invasiva (VNI) ha aumentado la complejidad de los pacientes ingresados en los servicios de neumología. Por ello, en España y Europa se están incorporando unidades especiales para el seguimiento y tratamiento de pacientes con enfermedades respiratorias graves: las unidades de cuidados respiratorios intermedios (UCRI). El objetivo del presente estudio ha sido describir la actividad de una UCRI dependiente de un servicio de neumología. Esta información puede ser un punto de referencia útil que facilite la implementación de las UCRI en otros hospitales del Sistema Nacional de Salud español. Métodos: De enero a diciembre de 2006, ambos inclusive, se recogió de forma prospectiva y sistemática la actividad realizada en la UCRI del Hospital Universitario Son Dureta. Resultados: Ingresaron 206 pacientes, cuya edad media (±desviación estándar) era de 65±14 años. Los Servicios de Urgencias y Neumología y la Unidad de Cuidados Intensivos (UCI) aportaron, respectivamente, el 67, el 14 y el 12% de todos los ingresos. Los principales diagnósticos de ingreso fueron: agudización de la enfermedad pulmonar obstructiva crónica (EPOC, con 97 casos; 47,1%), neumonía (n=39; 18,9%) e insuficiencia cardíaca (n=17; 8,2%). Del total de pacientes, 121 (59%) precisaron VNI. La estancia media fue de 5±5 días. El 79,1% recibió el alta a camas de hospitalización convencional del propio Servicio de Neumología, el 7,8% requirió ingreso posterior en la UCI y el 9,7% falleció. De los pacientes con agudización de la EPOC (edad media: 66,5±10 años; estancia media: 4,6±4,5 días), el 67% precisó VNI, el 7,2% requirió un ingreso posterior en la UCI y el 8,2% falleció(AU)

Conclusiones: En nuestro país es viable la creación de una UCRI dependiente del servicio de neumología. Estas unidades permiten desarrollar una alta actividad asistencial con un bajo porcentaje de fracasos terapéuticos. La agudización de la EPOC fue el diagnóstico de ingreso más habitual en nuestra UCRI, y la necesidad de tratamiento con VNI, el criterio de ingreso más frecuente(AU)

Background and objectiveWith the development of noninvasive ventilation (NIV), patients with increasingly complex needs have been admitted to respiratory medicine departments. For this reason, such departments in Spain and throughout Europe have been adding specialized respiratory intermediate care units (RICUs) for monitoring and treating patients with severe respiratory diseases. The aim of the present study was to describe the activity of such a RICU. The description may be of use in facilitating the setting up of RICUs in other hospitals of the Spanish National Health Service. MethodsA systematic record of activity carried out in the RICU of the Hospital Universitario Son Dureta between January and December 2006 was kept prospectively. ResultsOf 206 patients with a mean (SD) age of 65 (14) years admitted to the unit, 67% came from the emergency department, 14% from the respiratory medicine department, and 12% from the intensive care unit (ICU). The most common admission diagnoses were exacerbated chronic obstructive pulmonary disease (COPD) (n=97, 47.1%), pneumonia (n=39, 18.9%), heart failure (n=17, 8.2%), and pulmonary vascular diseases (n=18, 8.7%). One hundred twenty-one patients (59%) required NIV. Mean length of stay in the RICU was 5 (5) days. Patients were discharged to the conventional respiratory ward in 79.1% of the cases; 7.8% required subsequent admission to the ICU, and 9.7% died. Of the patients with exacerbated COPD (mean age, 66.5 [10] years; mean length of stay, 4.6 [4.5] days), 67% required NIV, 7.2% required subsequent admission to the ICU, and 8.2% died. ConclusionsThe creation of a RICU by a respiratory medicine department is viable in Spain. Such units make it possible to treat a large number of patients with a low rate of therapeutic failures. Exacerbated COPD was the most common diagnosis on admission to our RICU, and the need for NIV the most common criterion for admission(AU)

Changing patterns of inpatient respiratory care services over a decade at the Cleveland Clinic: challenges posed and proposed responses.

INTRODUCTION: Changing characteristics of hospitalized patients over the last decade have created challenges for all health-care providers in delivering optimal care. In the specific case of respiratory care, trends that hospitalized patients have generally become sicker over time and that average lengths of stay have generally become shorter have posed the challenge of meeting demands for more services delivered with greater immediacy. We undertook the current analysis to assess how the delivery of respiratory care services at a tertiary-care academic medical center, the Cleveland Clinic Foundation Hospital, has evolved over the decade 1991 to 2001. In this observational study, we examined concurrent departmental trends and speculated that the capability to increase clinical activity with maintained or improved clinical outcomes, preserved costs, and a lower turnover rate among respiratory therapists reflects features of the professional environment within our Section of Respiratory Therapy. METHODS: This analysis compares patterns of respiratory care service delivery in two 5-year intervals: from 1991 to 1996 and from 1996 to 2001. Data were collected using a respiratory care information-management system and an inpatient hospital information system, which track the volume and actual cost of services provided. These analyses accounted for the actual time-based cost of the services, including labor (with benefits), necessary equipment and supplies, medications, and equipment maintenance and depreciation. Hospital case-mix index values were determined according to guidelines from the Centers for Medicare and Medicaid Services, as the weighted average of resource allocation scores assigned to diagnosis-related-group categories of hospitalized patients. RESULTS: From 1991 to 2001, there were important expansions in the scope of respiratory care practice by our Section of Respiratory Care, while the volume of respiratory care services delivered per year increased 1.96-fold (from 339,600 to 665,921 services/y). The number of respiratory therapy consults performed yearly, beginning in 1992 when the service was first implemented, rose to over 10,000/y by 2001. At the same time, the cost of respiratory therapy services delivered per patient decreased by 4.2%. Regarding staffing trends, the number of full-time-equivalent employees increased by 50% (from 65 to 97.5). However, the percent turnover rate among respiratory therapists decreased by 2.3-fold (from 11.5% to 5%). In the face of these trends, the hospital mortality rate for patients with diagnosis-related group 088 (high users of respiratory care services) decreased by 53%, and the length of hospital stay for all patients receiving respiratory treatments decreased by 30%. CONCLUSIONS: This analysis shows that trends of growing demands for respiratory care services have been accompanied by generally improving clinical outcomes and favorable retention of respiratory therapists in our section. We believe that a focus on the process of care, including enhanced professionalism, communication, and participation, has permitted a favorable response to these rising demands.

Respiratory high dependency care units (RHDCU) in France.

The concept of intermediary intensive care units appeared in France with the progress of respiratory intensive care in the 1970s and an increment of the percentage of patients who were surviving an acute respiratory episode. It then became necessary to provide them with an optimal transition between the medical intensive care unit (ICU) and the home, thus explaining the emerging need for units of post-intensive care. At the present time, French health regulations recognize medical and surgical ICUs with a specific budget for equipment and nurses, and the specialized ICU which exists through a means share with the medical units (pulmonology, cardiology, etc.) inside which they are located. New regulations should make official the separation between medical and surgical intensive care units, intermediate (specialized) intensive care units and wards of reinforced follow-up, in a general perspective of improvement of the health network between the patient, home, and the different sectors of hospitalization (acute/chronic, public and private).

El paciente respiratorio crítico en una sala de hospitalización de emergencia / Critical respiratory patient in an emergency unit

Durante el año 1989 registramos próspectivamente los casos graves con compromiso respiratorio evaluados en el Servicio de Emergencia del Hospital Nacional Guillermo Almenara Irigoyen. La población evaluada incluye 72 pacientes adultos sin enfermedad gíneco-obstétrica. Fueron 56 hombres (78 por ciento) con edad promedio de 52 (15-69) años. Las causas más frecuentes de compromiso respiratorio fueron: enfermedad vascular cerebral 17 (24 por ciento), traumatismo encéfalo craneano 10 (14 por ciento), neumonía 10 (14 por ciento), sepsis 9 (13 por ciento) y asma bronquial 7 (10 por ciento). El status asmático y la neumonía nosocomial fueron primera causa de Insuficiencia Respiratoria Ventilatoria y Oxigenatoria respectivamente. Sepsis fue el factor que con más frecuencia desencadenó el SDRA. El valor APACHE II promedio fué 21 (18-23) y el TISS 24 (20-26). La mortalidad global fué 49 por ciento (35/72) y estuvo por encima de la esperada de acuerdo al puntaje APACHE II. Las causas de este hallazgo deben ser investigadas. Todos los enfermos con SDRA fallecieron. El Hospital Guillermo Almenara Irigoyen requiere una Unidad de Cuidados Intensivos

The pediatric bronchopneumonologic consultation centres (dispensaries) for children and adolescents suffering from chronic nonspecific respiratory diseases (CNSRD) in the G.D.R.

A survey is given of the three-level health service for young patient with chronic nonspecific respiratory diseases (CNSRD) in the GDR. The expected prevalence of the diseases in the young population (0-18 years) is 2-3% and still higher in regions with heavy air pollution. The pediatric working group of bronchopneumonology (in the Pediatric Society of the GDR) has organized a country-wide system of pediatric bronchopneumonologic consultation centres in the form of district (2nd level) and county dispensaries (3rd level) helping the local primary care pediatricians and general practitioners (1st level) in diagnostics, therapy and surveillance of such patients. The bronchopneumonologic county centres with all modern diagnostic and therapeutic facilities have a capacity which is sufficient for our country. However the function of the primary care doctors (to spot such children and refer them to the dispensaries), that of the district dispensaries (so far only 50-65% of expected patients in control!), and the availability of lung function test equipment and special bronchoscopic aids for infants and small children (in the county centres) needs to be improved.

Respiratory intensive care--past, present, future.

Major advances have been made in respiratory intensive care over the past three decades. The poliomyelitis epidemics provided the first major impetus for the development of techniques to maintain respiratory support via mechanical means. Principles of bronchial toilet were also established at that time. Development of blood gas electrodes permitted the application of physiologic principles to the management of acute respiratory failure. Recognition of the role of oxygen toxicity and fluid retention allowed a more rational approach to the management of acute respiratory failure. This management in turn was advanced with the introduction of PEEP. Because of the advances made over the last three decades, technology is no longer the limiting factor in survival from acute respiratory failure. If major advances are to be made in the future, a greater understanding of the basic anatomy, biochemistry, and physiology of the lung is necessary.