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Background and Aims: Acute respiratory failure (ARF) is the most frequent cause of cardiorespiratory arrest and subsequent death in children worldwide. There have been limited studies regarding ARF in high altitude settings. The aim of this study was to calculate mortality and describe associated factors for severity and mortality in children with ARF. Methods: The study was conducted within a prospective multicentric cohort that evaluated the natural history of pediatric ARF. For this analysis three primary outcomes were studied: mortality, invasive mechanical ventilation, and pediatric intensive care unit (PICU) length of stay. Eligible patients were children older than 1 month and younger than 18 years of age with respiratory difficulty at the time of admission. Patients who developed ARF were followed at the time of ARF, 48 h later, at the time of discharge, and at 30 and 60 days after discharge. It was conducted in the pediatric emergency, in-hospital, and critical-care services in three hospitals in Bogotá, Colombia, from April 2020 to June 2021. Results: Out of a total of 685 eligible patients, 296 developed ARF for a calculated incidence of ARF of 43.2%. Of the ARF group, 90 patients (30.4%) needed orotracheal intubation, for a mean of 9.57 days of ventilation (interquartile range = 3.00-11.5). Incidence of mortality was 6.1% (n = 18). The associated factors for mortality in ARF were a history of a neurologic comorbidity and a higher fraction of inspired oxygen at ARF diagnosis. For PICU length of stay, the associated factors were age between 2 and 5 years of age, exposure to smokers, and respiratory comorbidity. Finally, for mechanical ventilation, the risk factors were obesity and being unstable at admission. Conclusions: ARF is a common cause of morbidity and mortality in children. Understanding the factors associated with greater mortality and severity of ARF might allow earlier recognition and initiation of prompt treatment strategies.
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BACKGROUND: Lung ultrasound has demonstrated its usefulness in several respiratory diseases management. One derived score, the Lung Ultrasound (LUS) score, is considered a good outcome predictor in patients with Acute Respiratory Failure (ARF). Nevertheless, it has not been tested in patients undergoing non-invasive respiratory support (NIRS). Taking this into account, the aim of this study is to evaluate LUS score as a predictor of 90-day mortality, ETI (Endotracheal intubation) and HFNC (High Flow Nasal Cannula) failure in patients with ARF due to COVID-19 admitted to a Respiratory Intermediate Care Unit (RICU) for NIRS management. RESULTS: One hundred one patients were admitted to the RICU during the study period. Among these 76% were males and the median age was 55 (45-64) years. Initial ARF management started with HFNC, the next step was the use of Continuous Positive Airway Pressure (CPAP) devices and the last intervention was ETI and Intensive Care Unit (ICU) admission. Of the total study population, CPAP was required in 40%, ETI in 26%, while 15% died. By means of a ROC analysis, a LUS ≥ 25 points was identified as the cut-off point for mortality(AUC 0.81, OR 1.40, 95% CI 1.14 to 1.71; p < 0.001), ETI (AUC 0.83, OR 1.43, 95% CI 1.20 to 1.70; p < 0.001) and HFNC failure (AUC 0.75, OR 1.25, 95% CI 1.12 to 1.41; p < 0.001). Kaplan-Meier survival curves also identified LUS ≥ 25 as a predictor of 90-days mortality (HR 4.16, 95% CI 1.27-13.6) and 30 days ETI as well. CONCLUSION: In our study, a ≥ 25 point cut-off of the Lung Ultrasound Score was identified as a good outcome prediction factor for 90-days mortality, ETI and HFNC failure in a COVID-19 ARF patients cohort treated in a RICU. Considering that LUS score is easy to calculate, a multicenter study to confirm our findings should be performed.
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Severe community-acquired pneumonia (sCAP) remains one of the leading causes of admission to the intensive care unit, thus consuming a large share of resources and is associated with high mortality rates worldwide. The evidence generated by clinical studies in the last decade was translated into recommendations according to the first published guidelines focusing on severe community-acquired pneumonia. Despite the advances proposed by the present guidelines, several challenges preclude the prompt implementation of these diagnostic and therapeutic measures. The present article discusses the challenges for the broad implementation of the sCAP guidelines and proposes solutions when applicable.
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Infecções Comunitárias Adquiridas , Pneumonia , Humanos , Pneumonia/terapia , Pneumonia/tratamento farmacológico , Infecções Comunitárias Adquiridas/terapia , Infecções Comunitárias Adquiridas/tratamento farmacológico , Unidades de Terapia Intensiva , HospitalizaçãoRESUMO
OBJECTIVE: To compare the evolution of hospitalized patients infected with SARS-CoV-2 who received corticosteroid-based treatment versus patients who received standard therapy. METHOD: Retrospective, observational, and analytical study. Clinical records were collected from the different intensive care units, and data were obtained from confirmed COVID-19 patients over 18 years of age who were hospitalized. The population was divided into two groups: patients who received corticosteroid treatment, and those who received standard therapy. RESULTS: A total of 1603 patients were admitted to hospital, and of these 984 (62.9%) were discharged due to death. The main result was the identification by odds ratio (OR: 4.68; 95% confidence interval [95% CI]: 3.75-5.83; p = 0.001) as risk for death to the use of systemic steroids, as well as the use of invasive mechanical ventilation (OR: 2.26; 95% CI: 1.80-2.82; p < 0.001). The male gender was the most affected with 1051 (65.6%) patients. Mean age was 56 years (± 14). CONCLUSIONS: Corticosteroid use was associated with poor prognosis in patients hospitalized for COVID-19 compared to those receiving standard therapy.
OBJETIVO: Comparar la evolución de los pacientes hospitalizados infectados por SARS-CoV-2 que recibieron tratamiento a base de corticoesteroides frente a los pacientes que recibieron la terapia estándar. MÉTODO: Estudio de tipo retrospectivo, observacional y analítico. Se recolectaron los expedientes clínicos de las diferentes unidades de terapia intensiva y se obtuvieron datos de los pacientes confirmados de COVID-19, mayores de 18 años, que estuvieron hospitalizados. Se dividió la población en dos grupos: pacientes que recibieron tratamiento con corticoesteroides y pacientes que recibieron terapia estándar. RESULTADOS: De un total de 1603 pacientes ingresados a hospitalización, 984 (62.9%) fallecieron. El resultado principal fue la identificación mediante razón de momios (odds ratio [OR]: 4.68; intervalo de confianza del 95% [IC95%]: 3.75-5.83; p = 0.001) como riesgo para defunción con uso de esteroides sistémicos, así como con uso de ventilación mecánica invasiva (OR: 2.26; IC95%: 1.80-2.82; p < 0.001). El sexo masculino fue el más afectado, con 1051 (65.6%) pacientes. La media de edad fue de 56 años (± 14). CONCLUSIONES: El uso de corticoesteroides se asoció con mal pronóstico en los pacientes hospitalizados por COVID-19, en comparación con los que recibieron la terapia estándar.
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COVID-19 , Adolescente , Adulto , Humanos , Masculino , Pessoa de Meia-Idade , Corticosteroides/uso terapêutico , Hospitais Gerais , México/epidemiologia , Respiração Artificial , Estudos Retrospectivos , SARS-CoV-2RESUMO
Background: Repurposed drugs for treatment of new onset disease may be an effective therapeutic shortcut. We aimed to evaluate the efficacy of repurposed antivirals compared to placebo in lowering SARS-CoV2 viral load of COVID-19 patients. Methods: REVOLUTIOn is a randomised, parallel, blinded, multistage, superiority and placebo controlled randomised trial conducted in 35 centres in Brazil. We include patients aged 18 years or older admitted to hospital with laboratory-confirmed SARS-CoV-2 infection, symptoms onset 9 days or less and SpO2 94% or lower at room air were eligible. All participants were randomly allocated to receive either atazanavir, daclatasvir or sofosbuvir/daclatasvir or placebo for 10 days. The primary outcome was the decay rate (slope) of the SARS-CoV-2 viral load logarithm assessed in the modified intention to-treat population. This trial was registered with ClinicalTrials.gov, number NCT04468087. Findings: Between February 09, 2021, and August 04, 2021, 255 participants were enrolled and randomly assigned to atazanavir (n = 64), daclatasvir (n = 66), sofosbuvir/daclatasvir (n = 67) or placebo (n = 58). Compared to placebo group, the change from baseline to day 10 in log viral load was not significantly different for any of the treatment groups (0.05 [95% CI, -0.03 to 0.12], -0.02 [95% CI, -0.09 to 0.06], and -0.03 [95% CI, -0.11 to 0.04] for atazanavir, daclatasvir and sofosbuvir/daclatasvir groups respectively). There was no significant difference in the occurrence of serious adverse events between treatment groups. Interpretation: No significant reduction in viral load was observed from the use of atazanavir, daclatasvir or sofosbuvir/daclatasvir compared to placebo in hospitalised COVID-19 patients who need oxygen support with symptoms onset 9 days or less. Funding: Ministério da Ciência, Tecnologia e Inovação (MCTI) - Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPQ); Cia Latino-Americana de Medicamentos (Clamed); Cia Industrial H. Carlos Schneider (Ciser); Hospital Research Foundation Incorporation, Australia, HCor São Paulo; Blanver Farmoquímica; Instituto de Tecnologia em Fármacos (Farmanguinhos) da Fundação Oswaldo Cruz (Fiocruz); Coordenação Geral de Planejamento Estratégico (Cogeplan)/Fiocruz; and Fundação de apoio a Fiocruz (Fiotec, VPGDI-054-FIO-20-2-13).
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INTRODUCTION: Histoplasmosis is a fungal disease caused by Histoplasma capsulatum. Histoplasma capsulatum var capsulatum is found in Martinique. Cluster cases following working in deserted house, have been described in Martinique. Cases of acute pulmonary histoplasmosis have been described in immunosuppressed individuals, or in case of substantial exposure to reservoirs of Histoplasma capsulatum; however, cases of acute histoplasmosis are rare in immunocompetent individuals. CASES SERIES: We report a series of 4 cases of sporadic acute pulmonary histoplasmosis in immunocompetent subjects. Investigation revealed definite exposure in one patient and 3 cases with potential exposure. The diagnosis was microbiological and histological in 3 patients and histological in one patient. All subjects had positive serology to histoplasmosis. Pulmonary involvement was in the form of nodules and micronodules in 3 cases and ground glass lesions in one case. Patients were treated with itraconazole for 3 months and all had a favourable outcome. CONCLUSION: We report a series of 4 cases of acute pulmonary histoplasmosis in immunocompetent individuals, occurring in a context where exposure was uncertain. This raises the problem of occult exposure in the Caribbean. Interventions to raise awareness and encourage caution are warranted targeting the population of the French West Indies and French Guiana.
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Histoplasmose , Humanos , Histoplasmose/diagnóstico , Histoplasmose/tratamento farmacológico , Guiana Francesa , Martinica/epidemiologia , Guadalupe , HistoplasmaRESUMO
BACKGROUND: Hospitalized patients with severe COVID-19 follow heterogeneous clinical trajectories, requiring different levels of respiratory support and experiencing diverse clinical outcomes. Differences in host immune responses to SARS-CoV-2 infection may account for the heterogeneous clinical course, but we have limited data on the dynamic evolution of systemic biomarkers and related subphenotypes. Improved understanding of the dynamic transitions of host subphenotypes in COVID-19 may allow for improved patient selection for targeted therapies. RESEARCH QUESTION: We examined the trajectories of host-response profiles in severe COVID-19 and evaluated their prognostic impact on clinical outcomes. STUDY DESIGN AND METHODS: In this prospective observational study, we enrolled 323 inpatients with COVID-19 receiving different levels of baseline respiratory support: (1) low-flow oxygen (37%), (2) noninvasive ventilation (NIV) or high-flow oxygen (HFO; 29%), (3) invasive mechanical ventilation (27%), and (4) extracorporeal membrane oxygenation (7%). We collected plasma samples on enrollment and at days 5 and 10 to measure host-response biomarkers. We classified patients by inflammatory subphenotypes using two validated predictive models. We examined clinical, biomarker, and subphenotype trajectories and outcomes during hospitalization. RESULTS: IL-6, procalcitonin, and angiopoietin 2 persistently were elevated in patients receiving higher levels of respiratory support, whereas soluble receptor of advanced glycation end products (sRAGE) levels displayed the inverse pattern. Patients receiving NIV or HFO at baseline showed the most dynamic clinical trajectory, with 24% eventually requiring intubation and exhibiting worse 60-day mortality than patients receiving invasive mechanical ventilation at baseline (67% vs 35%; P < .0001). sRAGE levels predicted NIV failure and worse 60-day mortality for patients receiving NIV or HFO, whereas IL-6 levels were predictive in all patients regardless of level of support (P < .01). Patients classified to a hyperinflammatory subphenotype at baseline (< 10%) showed worse 60-day survival (P < .0001) and 50% of them remained classified as hyperinflammatory at 5 days after enrollment. INTERPRETATION: Longitudinal study of the systemic host response in COVID-19 revealed substantial and predictive interindividual variability influenced by baseline levels of respiratory support.
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BACKGROUND: The management of acute respiratory failure during pregnancy is a poorly defined issue in the literature, especially regarding the use of the prone position and the appropriate time for delivery. This study describes our experience in treating pregnant and postpartum women with severe or critical coronavirus disease 2019 (COVID-19). MATERIALS AND METHODS: This descriptive retrospective study included 25 pregnant and 4 postpartum women admitted to an ICU due to respiratory complications from COVID-19 from June 2020 to August 2021. RESULTS: The mean maternal age was 33.6 years, and the median gestational age (GA) at admission was 33 weeks. Obesity was the most common comorbidity. The median time between symptom onset and ICU admission was 10 days, while the median length of ICU stay was 14 days. Invasive mechanical ventilation (IMV) was required in 16 (55.2%) patients for a median time of 16.5 days. Prone positioning (PP) was performed in 68.7% of the patients on IMV, and resulted in an expressive increase in arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2 ratio). Eleven (44%) pregnant women delivered during their ICU stay for obstetric or fetal reasons: of these, 2 (18%) developed postpartum hemorrhagic shock and 1 (9%) developed abdominal wall infection. None of the 25 pregnant women underwent delivery due to acute respiratory failure or in an attempt to avoid intubation. There were 2 fetal deaths, but no maternal or neonatal deaths. CONCLUSION: We observed favorable outcomes in pregnant and postpartum women with severe and critical COVID-19 admitted to our institution. This finding reinforces the effectiveness of PP in the treatment of hypoxemic respiratory failure secondary to COVID-19 in pregnant women undergoing IMV, and suggests that gestation should only be interrupted in cases of obstetric and fetal complications, provided the patient is stable, or when hypoxemia is refractory to PP.
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COVID-19 , Síndrome do Desconforto Respiratório , Insuficiência Respiratória , Gravidez , Recém-Nascido , Feminino , Humanos , Adulto , Lactente , COVID-19/terapia , Estudos Retrospectivos , Período Pós-Parto , Insuficiência Respiratória/terapiaRESUMO
Introduction: The use of high-flow nasal oxygen (HFNO) is a simple method that can reduce intubation in patients with hypoxemic acute respiratory failure (ARF). Early and prolonged prone position has demonstrated benefits on mortality in mechanically ventilated patients and on intubation in awake patients with ARF. However, strategies to achieve adherence to awake prone positioning (APP) have not been previously described. Case and outcomes: We present six patients with ARF due to COVID-19 treated with HFNO and APP. The median (p25-75) of PaFiO2 upon admission was 121 (112-175). The average duration of APP on the first day was 16 h (SD 5 h). Duration (median p25-75) in APP for the following 20 days was 13 (10-18) h/day. Several strategies such as the presence of a health care team, recreational activities, adaptation of the circadian rhythm, oral nutritional support, and analgesics were used to improve prone tolerance. None of the patients suffered from delirium, all were ambulating on discharge from the ICU and none require intubation. Conclusion: The case series presented show the feasibility of prolonged use of HFNO and APP in patients with COVID-19 and severe persistent hypoxemia and described strategies to enhance adherence.
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Background: Noninvasive ventilation (NIV) is an important component of respiratory therapy for a range of cardiopulmonary conditions. The World Health Organization recommends NIV use to decrease the use of intensive care unit resources and improve outcomes among patients with respiratory failure during periods of high patient capacity from coronavirus disease (COVID-19). However, healthcare providers in many low- and middle-income countries, including Haiti, do not have experience with NIV. We conducted NIV training and evaluation in Port-au-Prince, Haiti. Objectives: To design and implement a multimodal NIV training program in Haiti that would improve confidence and knowledge of NIV use for respiratory failure. Methods: In January 2021, we conducted a 3-day multimodal NIV training consisting of didactic sessions, team-based learning, and multistation simulation for 36 Haitian healthcare workers. The course included 5 didactic session and 10 problem-based and simulation sessions. All course material was independently created by the study team on the basis of Accreditation Council for Continuing Medical Education-approved content and review of available evidence. All participants completed pre- and post-training knowledge-based examinations and confidence surveys, which used a 5-point Likert scale. Results: A total of 36 participants were included in the training and analysis, mean age was 39.94 years (standard deviation [SD] = 9.45), and participants had an average of 14.32 years (SD = 1.21) of clinical experience. Most trainees (75%, n = 27) were physicians. Other specialties included nursing (19%, n = 7), nurse anesthesia (3%, n = 1), and respiratory therapy (3%, n = 1). Fifty percent (n = 18) of participants stated they had previous experience with NIV. The majority of trainees (77%) had an increase in confidence survey score; the mean confidence survey score increased significantly after training from 2.75 (SD = 0.77) to 3.70 (SD = 0.85) (P < 0.05). The mean knowledge examination score increased by 39.63% (SD = 15.99%) after training, which was also significant (P < 0.001). Conclusion: This multimodal NIV training, which included didactic, simulation, and team-based learning, was feasible and resulted in significant increases in trainee confidence and knowledge with NIV. This curriculum has the potential to provide NIV training to numerous low- and middle-income countries as they manage the ongoing COVID-19 pandemic and rising burden of noncommunicable disease. Further research is necessary to ensure the sustainability of these improvements and adaptability to other low- and middle-income settings.
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Resumen El uso de terapia nasal de alto flujo (TNAFO) en pacientes con insuficiencia respiratoria aguda grave (IRAG) por neumonía COVID-19 (NCOVID-19) es debatido. Ante la falta de camas en Unidades de Cuidados Intensivos en el Sistema de Salud Pública de la Provincia del Neuquén, se implementó su uso en salas generales. Con el objetivo de describir la experiencia de uso de la TNAFO en pacientes con IRAG por NCOVID-19, se llevó a cabo este estudio retrospectivo multicéntrico. El resultado primario fue la frecuencia de destete exitoso de TNAFO y la mortalidad intrahospitalaria (MIH). Se analizaron 299 pacientes, de éstos, 120 (40.1%) fueron retirados con éxito de la TNAFO. Esta fracasó en 59.8% (179), 44.1% (132) requirió ventilación mecánica invasiva (VMI) y 15.7% (47) no eran candidatos a la intubación. Un índice ROX ≥ 5 a las 6 h después del inicio, se asoció con el éxito de la TNAFO (OR 0.26 [IC 95% 0.15-0.46] p<0.0001). La MIH general fue del 48.5% (145/299), 70.4% (93/132) en aquellos con VMI, 4.2% (5/120) falleció post destete exitoso de la TNAFO y 100% (47/47) en el grupo no candidatos a la intubación. Los pacientes con TNAFO tuvieron una disminución estadísticamente significativa en la MIH y en días de internación. El uso de TNAFO en salas generales logró una reducción en la utilización de VMI, con una reducción de la mortalidad y días de estada en los internados por NCOVID-19 con IRAG.
Abstract The use of high-flow nasal therapy (HFNT) in patients with severe acute respiratory failure (SARF) due to COVID-19 pneu monia (NCOVID-19) is debated. Given the lack of beds in Intensive Care Units in the Public Health System of the Province of Neuquén, their use was implemented in general wards. This restrospective multicenter study was carried out to describe the experience of using HNFT in patients with SARF due to NCOVID-19. The primary outcome was the frequency of successful weaning from HFNT and in-hospital mortality (IHM). Two hundred ninety-nine patients were analyzed; 120 (40.1%) were successfully withdrawn from HFNT. This failed in 59.8% (179), 44.1% (132) required invasive mechanical ventilation (IMV), and 15.7% (47) was not candidates for intubation. A ROX index ≥ 5 at 6 h after initiation was associated with the success of HFNT (OR 0.26 [IC 95% 0.15-0.46] p<0.0001). The general IHM was 48.5% (145/299), 70.4% (93/132) in patients with IMV, 4.2% (5/120) died after successful weaning from HFNT and 100% (47/47) in the group not candidates for intubation. Patients with TNAFO had a statistically significant decrease in MIH and days of hospitalization. TNAFO in general wards achieved a decrease in the use of IMV, with a reduction in mortality and days of stay in hospitalized for NCOVID-19 with SARF.
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The use of high-flow nasal therapy (HFNT) in patients with severe acute respiratory failure (SARF) due to COVID-19 pneumonia (NCOVID-19) is debated. Given the lack of beds in Intensive Care Units in the Public Health System of the Province of Neuquén, their use was implemented in general wards. This restrospective multicenter study was carried out to describe the experience of using HNFT in patients with SARF due to NCOVID-19. The primary outcome was the frequency of successful weaning from HFNT and in-hospital mortality (IHM). Two hundred ninety-nine patients were analyzed; 120 (40.1%) were successfully withdrawn from HFNT. This failed in 59.8% (179), 44.1% (132) required invasive mechanical ventilation (IMV), and 15.7% (47) was not candidates for intubation. A ROX index = 5 at 6 h after initiation was associated with the success of HFNT (OR 0.26 [IC 95% 0.15-0.46] p < 0.0001). The general IHM was 48.5% (145/299), 70.4% (93/132) in patients with IMV, 4.2% (5/120) died after successful weaning from HFNT and 100% (47/47) in the group not candidates for intubation. Patients with TNAFO had a statistically significant decrease in MIH and days of hospitalization. TNAFO in general wards achieved a decrease in the use of IMV, with a reduction in mortality and days of stay in hospitalized for NCOVID-19 with SARF.
El uso de terapia nasal de alto flujo (TNAFO) en pacientes con insuficiencia respiratoria aguda grave (IRAG) por neumonía COVID-19 (NCOVID-19) es debatido. Ante la falta de camas en Unidades de Cuidados Intensivos en el Sistema de Salud Pública de la Provincia del Neuquén, se implementó su uso en salas generales. Con el objetivo de describir la experiencia de uso de la TNAFO en pacientes con IRAG por NCOVID-19, se llevó a cabo este estudio retrospectivo multicéntrico. El resultado primario fue la frecuencia de destete exitoso de TNAFO y la mortalidad intrahospitalaria (MIH). Se analizaron 299 pacientes, de éstos, 120 (40.1%) fueron retirados con éxito de la TNAFO. Esta fracasó en 59.8% (179), 44.1% (132) requirió ventilación mecánica invasiva (VMI) y 15.7% (47) no eran candidatos a la intubación. Un índice ROX = 5 a las 6 h después del inicio, se asoció con el éxito de la TNAFO (OR 0.26 [IC 95% 0.15-0.46] p < 0.0001). La MIH general fue del 48.5% (145/299), 70.4% (93/132) en aquellos con VMI, 4.2% (5/120) falleció post destete exitoso de la TNAFO y 100% (47/47) en el grupo no candidatos a la intubación. Los pacientes con TNAFO tuvieron una disminución estadísticamente significativa en la MIH y en días de internación. El uso de TNAFO en salas generales logró una reducción en la utilización de VMI, con una reducción de la mortalidad y días de estada en los internados por NCOVID-19 con IRAG.
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COVID-19 , Insuficiência Respiratória , Humanos , Oxigenoterapia , Respiração Artificial , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/terapia , SARS-CoV-2RESUMO
BACKGROUND: In patients with COVID-19-related acute respiratory failure (ARF), awake prone positioning (AW-PP) reduces the need for intubation in patients treated with high-flow nasal oxygen (HFNO). However, the effects of different exposure times on clinical outcomes remain unclear. We evaluated the effect of AW-PP on the risk of endotracheal intubation and in-hospital mortality in patients with COVID-19-related ARF treated with HFNO and analyzed the effects of different exposure times to AW-PP. METHODS: This multicenter prospective cohort study in six ICUs of 6 centers in Argentine consecutively included patients > 18 years of age with confirmed COVID-19-related ARF requiring HFNO from June 2020 to January 2021. In the primary analysis, the main exposure was awake prone positioning for at least 6 h/day, compared to non-prone positioning (NON-PP). In the sensitivity analysis, exposure was based on the number of hours receiving AW-PP. Inverse probability weighting-propensity score (IPW-PS) was used to adjust the conditional probability of treatment assignment. The primary outcome was endotracheal intubation (ETI); and the secondary outcome was hospital mortality. RESULTS: During the study period, 580 patients were screened and 335 were included; 187 (56%) tolerated AW-PP for [median (p25-75)] 12 (9-16) h/day and 148 (44%) served as controls. The IPW-propensity analysis showed standardized differences < 0.1 in all the variables assessed. After adjusting for other confounders, the OR (95% CI) for ETI in the AW-PP group was 0.36 (0.2-0.7), with a progressive reduction in OR as the exposure to AW-PP increased. The adjusted OR (95% CI) for hospital mortality in the AW-PP group ≥ 6 h/day was 0.47 (0.19-1.31). The exposure to prone positioning ≥ 8 h/d resulted in a further reduction in OR [0.37 (0.17-0.8)]. CONCLUSION: In the study population, AW-PP for ≥ 6 h/day reduced the risk of endotracheal intubation, and exposure ≥ 8 h/d reduced the risk of hospital mortality.
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COVID-19 , Oxigenoterapia , Insuficiência Respiratória , Administração Intranasal , COVID-19/complicações , Humanos , Oxigênio/administração & dosagem , Oxigenoterapia/métodos , Decúbito Ventral , Estudos Prospectivos , Insuficiência Respiratória/terapia , Insuficiência Respiratória/virologia , Fatores de Tempo , Resultado do Tratamento , VigíliaRESUMO
BACKGROUND: Noninvasive ventilation (NIV) and High-flow nasal cannula (HFNC) are the main forms of treatment for acute respiratory failure. This study aimed to evaluate the effect, safety, and applicability of the NIV and HFNC in patients with acute hypoxemic respiratory failure (AHRF) caused by COVID-19. METHODS: In this retrospective study, we monitored the effect of NIV and HFNC on the SpO2 and respiratory rate before, during, and after treatment, length of stay, rates of endotracheal intubation, and mortality in patients with AHRF caused by COVID-19. Additionally, data regarding RT-PCR from physiotherapists who were directly involved in assisting COVID-19 patients and non-COVID-19. RESULTS: 62.2 % of patients were treated with HFNC. ROX index increased during and after NIV and HFNC treatment (P < 0.05). SpO2 increased during NIV treatment (P < 0.05), but was not maintained after treatment (P = 0.17). In addition, there was no difference in the respiratory rate during or after the NIV (P = 0.95) or HFNC (P = 0.60) treatment. The mortality rate was 35.7 % for NIV vs 21.4 % for HFNC (P = 0.45), while the total endotracheal intubation rate was 57.1 % for NIV vs 69.6 % for HFNC (P = 0.49). Two adverse events occurred during treatment with NIV and eight occurred during treatment with HFNC. There was no difference in the physiotherapists who tested positive for SARS-COV-2 directly involved in assisting COVID-19 patients and non-COVID-19 ones (P = 0.81). CONCLUSION: The application of NIV and HFNC in the critical care unit is feasible and associated with favorable outcomes. In addition, there was no increase in the infection of physiotherapists with SARS-CoV-2.
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COVID-19/terapia , Cânula , Intubação Intratraqueal , Ventilação não Invasiva , Avaliação de Processos e Resultados em Cuidados de Saúde , Oxigênio/administração & dosagem , Respiração com Pressão Positiva , Insuficiência Respiratória/terapia , Taxa Respiratória/efeitos dos fármacos , Doença Aguda , Administração por Inalação , Adulto , Idoso , Idoso de 80 Anos ou mais , Brasil , COVID-19/complicações , COVID-19/mortalidade , Cânula/efeitos adversos , Cânula/normas , Cânula/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Humanos , Unidades de Terapia Intensiva , Intubação Intratraqueal/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Ventilação não Invasiva/efeitos adversos , Ventilação não Invasiva/métodos , Ventilação não Invasiva/normas , Ventilação não Invasiva/estatística & dados numéricos , Avaliação de Processos e Resultados em Cuidados de Saúde/estatística & dados numéricos , Fisioterapeutas , Respiração com Pressão Positiva/efeitos adversos , Respiração com Pressão Positiva/normas , Respiração com Pressão Positiva/estatística & dados numéricos , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/mortalidade , Estudos RetrospectivosRESUMO
Background: Acute respiratory failure is a life-threatening medical condition, associated with a variety of conditions and risk factors, including acute respiratory diseases which are a frequent cause of pediatric morbidity and mortality worldwide. In Colombia, the literature related to ARF is scarce. Objective: To determine the incidence, causes, and sociodemographic and clinical characteristics of ARF in three hospitals in Bogota, a high-altitude city located in Colombia, during the COVID-19 pandemic. Methods: A multicenter prospective cohort study called the FARA cohort was developed between April 2020 - December 2021. Patients older than one month and younger than 18 years with respiratory distress who developed ARF were included. Results: 685 patients with respiratory distress were recruited in 21 months. The incidence density of ARF was found to be 41.7 cases per 100 person-year CI 95%, (37.3-47.7). The median age was 4.5 years.. Most of the patients consulted during the first 72â h after the onset of symptoms. Upon admission, 67.2% were potentially unstable. The most frequent pathologies were asthma, bronchiolitis, pneumonia, and sepsis. At admission, 75.6% of the patients required different oxygen delivery systems, 29,5% a low-flow oxygen system, 36,8% a high-flow oxygen system, and 9,28% invasive mechanical ventilation. SARS-COV-2, respiratory syncytial virus, rhinovirus/enterovirus, and adenovirus were the most frequently isolated viral agents. The coinfection cases were scarce. Conclusions: This multicenter study, the FARA cohort, developed at 2,600 meters above sea level, shows the first data on incidence, etiology, sociodemographic and clinical characterization in a pediatric population with ARF that also concurs with the COVID-19 pandemic. These results, not only have implications for public health but also contribute to the scientific and epidemiological literature on a disease developed at a high altitude.
RESUMO
INTRODUCTION: noninvasive ventilation (NIV) can be a useful resource to treat acute respiratory failure (ARF), which occurs in patients with COVID-19. However, it is important to consider that there are still no clinical studies that have verified the safety of its use in increase of contamination. AREAS COVERED: Given the potential benefits and simultaneous concerns over the use of NIV in patients with COVID-19, further inquiry is necessary to reach a clinical consensus and provide recommendations for safe use, avoiding contamination. In this context, this narrative review, which included articles published in the Embase, SciELO, PEDro, PubMed and Cochrane up to August 2021, is focused to evaluate available studies related to interfaces, types of circuits, recommended filters, cares for the environment and protective factors for NIV use in patients with COVID-19. EXPERT OPINION: The studies analyzed recommend that the use of NIV can be safe: 1) with equipment that allows the use of the helmet as a safer interface; 2) with double circuit and antimicrobial filter in the expiratory branch; 3) in an environment that allows negative pressure, reducing the dispersion of aerosol particles in the environment; 4) the health team must use the recommended PPE to avoid contamination.
Assuntos
COVID-19 , Ventilação não Invasiva , Síndrome do Desconforto Respiratório , Insuficiência Respiratória , Humanos , Ventilação não Invasiva/efeitos adversos , Respiração Artificial , Insuficiência Respiratória/terapia , SARS-CoV-2RESUMO
The management of acute respiratory failure may require, among other measures, airway control, mechanical ventilation, and hemodynamic stabilization. About 60% of critically ill patients will require some type of respiratory support. For these reasons, an understanding of respiratory pathophysiology is important. The aim of this review is to establish an up-to-date of the concepts and fundamentals for acute respiratory failure.
El manejo de la falla respiratoria aguda puede requerir, entre otras medidas, control de la vía aérea, ventilación mecánica y estabilización hemodinámica. Alrededor del 60% de los pacientes graves requerirán de algún tipo de soporte respiratorio. Por estas razones es importante el entendimiento de la fisiopatología respiratoria. El objetivo de esta revisión es establecer conceptos y fundamentos actualizados sobre la falla respiratoria aguda.
Assuntos
Humanos , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/fisiopatologia , Insuficiência Respiratória/terapia , Respiração Artificial , Insuficiência Respiratória/classificação , Troca Gasosa Pulmonar , Doença Aguda , Hipercapnia/diagnóstico , Hipercapnia/fisiopatologia , Hipercapnia/terapia , Hipóxia/diagnóstico , Hipóxia/fisiopatologia , Hipóxia/terapiaRESUMO
Resumen: La insuficiencia respiratoria hipoxémica aguda (IRHA) es una de las principales causas de ingreso en la Unidad de Terapia Intensiva en los pacientes adultos, alrededor de 40% de estos pacientes ameritan intubación endotraqueal. La escala HACOR fue diseñada y validada como una puntuación de predicción clínica para el fracaso de la ventilación no invasiva (VNI) en pacientes con IRHA de diferentes etiologías. Objetivo: Analizar la capacidad predictiva de la escala HACOR en relación al fracaso de las puntas nasales de alto flujo (PNAF). Material y métodos: Se realizó un estudio retrospectivo, observacional en la Terapia Intensiva del Hospital Ángeles Mocel, las PNAF se iniciaron cuando el paciente presentaba IRHA, se calculó la escala HACOR a la hora y a las dos horas de colocación de PNAF, la capacidad de predecir el fracaso de las PNAF de la escala HACOR se determinó calculando el área bajo la curva de «característica operativa del receptor¼ (ROC). Resultados: La escala HACOR con mayor poder discriminatorio se obtuvo a las dos horas de inicio de las PNAF con un punto de corte de 5 puntos con un área bajo la curva (AUC): 0.82 (IC 95% 0.67-0.98), se obtuvo una sensibilidad 84% IC 95% (56.6-89.9%), especificidad 81% IC 95% (40.9-92.9%). Conclusiones: Un puntaje mayor o igual a 5 puntos en la escala HACOR predice fracaso de las PNAF y mayor mortalidad con una sensibilidad y especificidad mayor de 80% en los pacientes con neumonía por COVID-19.
Abstract: Acute hypoxemic respiratory failure (AHRF) is one of the main causes of admission to the intensive care unit in adult patients, around 40% of these patients require endotracheal intubation. The HACOR scale was designed and validated as a clinical prediction score for non-invasive ventilation (NIV) failure in patients with HAI of different etiologies. Objective: To analyze the predictive capacity of the HACOR scale in relation to the failure of the PNAF. Material and methods: A retrospective, observational study was carried out in the Intensive Care Unit at Hospital Ángeles Mocel, the PNAF was started when the patient had AHRF, the HACOR scale was calculated at one hour and 2 hours after the placement of the PNAF, the ability to predict HACOR scale PNAF failure was determined by calculating the area under the «receiver operating characteristic¼ (ROC) curve. Results: The HACOR scale with the highest discriminatory power was obtained 2 hours after the start of the PNAF with a cut-off point of 5 points with an area under the curve (AUC): 0.82 (CI 95% 0.67-0.98), it was obtained a sensitivity 84% CI 95% (56.6-89.9%), specificity 81% CI 95% (40.9-92.9%). Conclusions: A score greater than or equal to 5 points on the HACOR scale predicts failure of the PNAF and higher mortality with a sensitivity and specificity greater than 80% in patients with COVID-19 pneumonia.
Resumo: A insuficiência respiratória hipoxêmica aguda (IRHA) é uma das principais causas de admissão em unidade de Terapia Intensiva em Pacientes Adultos, cerca de 40% desses pacientes requerem intubação endotraqueal. A escala HACOR foi desenhada e validada como um escore de predição clínica para falha da ventilação não invasiva (VNI) em pacientes com IRHA de diferentes etiologias. Objetivo: Analisar a capacidade preditiva da escala HACOR em relação à falha das PNAF. Material e métodos: Foi realizado um estudo retrospectivo e observacional na Unidade de Terapia Intensiva do Hospital Ángeles Mocel, a PNAF foi iniciada quando o paciente tinha IRHA, a escala HACOR foi calculada uma hora e 2 horas após a colocação da PNAF, a capacidade de previsão do fracasso das PNAF da escala HACOR foi determinada pelo cálculo da área sob a curva «receiver operating characteristics¼ (ROC). Resultados: A escala HACOR com maior poder discriminatório foi obtida 2 horas após o início das PNAF com ponto de corte de 5 pontos com área sob a curva (AUC): 0.82 (IC 95% 0.67-0.98), foi obtida uma sensibilidade de 84% IC 95% (56.6%-89.9%), especificidade 81% IC 95% (40.9%-92.9%). Conclusões: Uma pontuação maior ou igual a 5 pontos na escala HACOR prediz falha das PNAF e maior mortalidade com sensibilidade e especificidade maior à 80% em pacientes com pneumonia COVID-19.
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Resumen: La traqueostomía percutánea es un procedimiento generalmente seguro, aunque no exento de complicaciones, se considera el procedimiento de elección en el paciente crítico con ventilación mecánica prolongada. Se presenta el caso de una mujer con síndrome de insuficiencia respiratoria aguda secundario a neumonía COVID-19 que requirió traqueostomía percutánea por ventilación prolongada. La paciente desarrolló complicaciones que requirieron intervención quirúrgica.
Abstract: Percutaneous tracheostomy is a generally safe procedure, although not without risk of complications, it is considered the procedure of choice in critically ill patients with prolonged mechanical ventilation. We present the case of a woman with acute respiratory failure syndrome secondary to COVID-19 pneumonia who required percutaneous tracheostomy due to prolonged ventilation. The patient developed significant complications that required surgical intervention.
Resumo: A traqueostomia percutânea é um procedimento geralmente seguro, sem ser isenta de complicações, é o procedimento de escolha em pacientes críticos com ventilação mecânica prolongada. Apresentamos o caso de uma mulher com síndrome de insuficiência respiratória aguda por pneumonia por COVID-19 que necessitou de traqueostomia percutânea devido à ventilação prolongada, evoluindo com complicações, resolvidas com intervenção cirúrgica. A adequação dos métodos guiados por ultrassom para evitar a emissão e exposição a aerossóis é analisada.
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OBJECTIVES: Hyper- and hypoinflammatory subphenotypes discovered in patients with acute respiratory distress syndrome predict clinical outcomes and therapeutic responses. These subphenotypes may be important in broader critically ill patient populations with acute respiratory failure regardless of clinical diagnosis. We investigated subphenotyping with latent class analysis in an inclusive population of acute respiratory failure, derived a parsimonious model for subphenotypic predictions based on a small set of variables, and examined associations with clinical outcomes. DESIGN: Prospective, observational cohort study. SETTING: Single-center, academic medical ICU. PATIENTS: Mechanically ventilated patients with acute respiratory failure. MEASUREMENTS AND MAIN RESULTS: We included 498 patients with acute respiratory failure (acute respiratory distress syndrome: 143, at-risk for acute respiratory distress syndrome: 198, congestive heart failure: 37, acute on chronic respiratory failure: 23, airway protection: 61, and multifactorial: 35) in our derivation cohort and measured 10 baseline plasma biomarkers. Latent class analysis considering clinical variables and biomarkers determined that a two-class model offered optimal fit (23% hyperinflammatory subphenotype). Distribution of hyperinflammatory subphenotype varied among acute respiratory failure etiologies (acute respiratory distress syndrome: 31%, at-risk for acute respiratory distress syndrome: 27%, congestive heart failure: 22%, acute on chronic respiratory failure 0%, airway protection: 5%, and multifactorial: 14%). Hyperinflammatory patients had higher Sequential Organ Failure Assessment scores, fewer ventilator-free days, and higher 30- and 90-day mortality (all p < 0.001). We derived a parsimonious model consisting of angiopoietin-2, soluble tumor necrosis factor receptor-1, procalcitonin, and bicarbonate and classified subphenotypes in a validation cohort (n = 139). Hyperinflammatory patients (19%) demonstrated higher levels of inflammatory biomarkers not included in the model (p < 0.01) and worse outcomes. CONCLUSIONS: Host-response subphenotypes are observable in a heterogeneous population with acute respiratory failure and predict clinical outcomes. Simple, biomarker-based models can offer prognostic enrichment in patients with acute respiratory failure. The differential distribution of subphenotypes by specific etiologies of acute respiratory failure indicates that subphenotyping may be more relevant in patients with hypoxemic causes of acute respiratory failure and not in patients intubated for airway protection or acute on chronic decompensation.