RESUMEN
High-flow oxygen therapy (high flow nasal cannula, HFNC), in which an oxygen-air gas mixture is applied at flow rates between 30 and 70â¯L/min, is a technically simple and highly effective procedure for the treatment of hypoxemic respiratory insufficiency. Furthermore, HFNC can be used during bronchoscopy for oxygenation, before intubation for preoxygenation, and after extubation to avoid reintubation. The high gas flow prevents the patient from inspiring ambient air, allowing precise adjustment of an inspiratory oxygen fraction; furthermore, a positive end-expiratory pressure is built up by a resulting dynamic pressure, mucociliary clearance is improved by humidification and warming of the air breathed and the work of breathing is reduced by flushing the upper airways. Compared with conventional oxygen therapy, aerosol formation is not increased by HFNC; therefore, this procedure can also be used for patients with coronavirus disease 2019 (COVID-19). In hypercapnic respiratory failure the data are inconclusive and in this case noninvasive ventilation should currently be preferred instead of HFNC. It is important to remember that patients treated with HFNC are critically ill and therefore require continuous monitoring. It must be ensured that an escalation of therapy, e.g. to intubation and invasive ventilation, can be performed at any time.
RESUMEN
Oxygen treatment is being widely used in intensive care and emergency medicine and is required to maintain aerobic metabolism. It may be administered by nasal cannula, face mask, high-flow therapy, and by ventilation. Under clinical circumstances, blood oxygen concentration is not relevantly increased above a partial pressure of 80âmmHg. Although oxygen therapy is often life-saving, it has recently been shown that its indiscriminate administration may increase morbidity and mortality, presumably due to a formation of reactive-oxygen species.For ventilated critically ill patients the optimal targets need to be further defined but harm has been shown for mild hyperoxia. For patients with acute exacerbation of chronic obstructive lung disease hyperoxia may lead to an increase of hypercarbia. Hyperoxia may increase myocardial necrosis in myocardial infarction. For patients with stroke, data do not show any benefit or harm from oxygen administration.On the other hand, hyperoxia shall be used for treatment in patients with cardiac arrest until return of spontaneous circulation and in patients with carbon monoxide poisoning.For other conditions, no benefit has been shown for hyperoxia, but undoubtedly, hypoxemia must be avoided, as well. Therefore, a normoxic oxygenation strategy should be employed. The optimal oxygenation targets for distinct conditions need to be further defined.
Asunto(s)
Terapia por Inhalación de Oxígeno , Cuidados Críticos , Servicio de Urgencia en Hospital , Humanos , Hiperoxia , Terapia por Inhalación de Oxígeno/efectos adversos , Terapia por Inhalación de Oxígeno/métodosRESUMEN
In recent years, high-flow oxygen therapy (HFNC) has become established and proven as an oxygenation method for patients with severe respiratory restrictions in most intensive care units. Advantages of this method, which is used especially for patients with hypoxaemia, are the easy application and the compliance by the patient. Devices are used which enable individual oxygen therapy by means of humidification, warming up and gas flow regulation options.
Asunto(s)
Terapia por Inhalación de Oxígeno , Humanos , Hipoxia/prevención & control , Hipoxia/terapia , Unidades de Cuidados Intensivos , Oxígeno/uso terapéutico , Terapia por Inhalación de Oxígeno/instrumentación , Terapia por Inhalación de Oxígeno/métodos , Terapia por Inhalación de Oxígeno/normasRESUMEN
BACKGROUND: The urgent treatment of ruptured abdominal aortic aneurysms (rAAA) remains a challenging condition with devastating morbidity and mortality. Available studies are often limited due to a significant selection bias. This study aims to illuminate real-world evidence using comprehensive data from electronic health records, registries, postmortem findings, and administrative data on all consecutively treated patients presenting with rAAA at a tertiary care center. METHODS: This is a retrospective cross-sectional cohort study covering consecutively treated patients with rAAA between 2009 and 2018. All noninvasive treatments, fatalities, and invasive repairs were included. Information on patient's characteristics, prehospital, and inpatient care was gathered. Short-term outcomes and long-term survival were analyzed for relevant subgroups. RESULTS: In total, 139 patients with rAAA (median age 75 years and 20.9% females, 79.9% infrarenal) were treated increasingly frequent by endovascular aortic repair (EVAR) when compared to open-surgical aortic repair (OSR) during the study period (16.7% in 2009 to 33.3% in 2018, P < 0.05). The rate of patients who had been turned down for rAAA repair was 10.8%, and the overall in-hospital mortality was 43.2%. Perioperative morbidity and mortality were similar for EVAR and OSR, although patients treated by OSR presented with a lower mean Glasgow Coma Scale during the prehospital (12.7 vs. 14.3) and inpatient care (12.7 vs. 14.4) (both P < 0.001), higher rates of intubation (12.8% vs. 10.9%, P < 0.001), lower systolic blood pressure (115 mm Hg vs. 127 mm Hg, P = 0.042), and more often had a cardiac arrest before the operation (14.1% vs. 2.3%, P < 0.001). Higher patient's age (Odds Ratio, OR 1.09; Hazard Ratio, HR 1.06), history of stroke or transient ischemic attack (OR 5.30; HR 2.64), higher serum creatinine (OR 1.81; HR 1.31), and occurrence of colonic ischemia (OR 11.31; HR 2.82) were significantly associated with higher odds of dying in hospital and in the longer term, respectively. CONCLUSIONS: We observed comparable outcomes following OSR and EVAR, although hemodynamically unstable patients were more likely to be treated by OSR. This study also confirmed the impact of colonic ischemia as a devastating complication following rAAA repair emphasizing the need for further reflection by the vascular community.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Hospitales de Alto Volumen , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Abdominal/fisiopatología , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/mortalidad , Rotura de la Aorta/fisiopatología , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Toma de Decisiones Clínicas , Estudios Transversales , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Hemodinámica , Mortalidad Hospitalaria , Humanos , Masculino , Selección de Paciente , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Centros de Atención Terciaria , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Critically ill patients with respiratory failure undergoing intubation have an increased risk of hypoxemia-related complications. Delivering oxygen via a high-flow nasal cannula (HFNC) has theoretical advantages and is increasingly used. This study was conducted to compare HFNC with bag-valve-mask (BVM) for preoxygenation and to assess oxygenation during intubation in subjects with hypoxemic respiratory failure. METHODS: This study was a randomized controlled trial including 40 critically ill subjects with hypoxemic respiratory failure who received either HFNC or BVM for preoxygenation before intubation in the ICU. The primary outcome was the mean lowest SpO2 during intubation. RESULTS: The mean lowest SpO2 during intubation was 89 ± 18% in the HFNC group and 86 ± 11% in the BVM group (P = .56). In subjects receiving HFNC, a significant increase in SpO2 after preoxygenation was only seen in those previously receiving low-flow oxygen (P = .007), whereas there was no significant difference in SpO2 in subjects previously receiving noninvasive ventilation or HFNC (P = .73). During the 1 min of apnea after the induction of anesthesia, SpO2 dropped significantly in the BVM group (P = .001), whereas there was no significant decrease in the HFNC group (P = .17). There were no significant differences between the 2 groups at any of the predefined time points before or after intubation concerning SpO2 , PaO2 /FIO2 , and PaCO2 . CONCLUSIONS: Preoxygenation using HFNC before intubation was feasible and safe compared with BVM in critically ill subjects with acute, mild to moderate hypoxemic respiratory failure. There was no significant difference in the mean lowest SpO2 during intubation between the HFNC and the BVM group. There was also no significant difference in SpO2 between the 2 groups at any of the predefined time points. However, on continuous monitoring, there was a significant decrease in SpO2 during the apnea phase before intubation in the BVM group, which was not seen in the HFNC group. (ClinicalTrials.gov registration NCT01994928.).