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BACKGROUND: Bronchoscopic lung volume reduction (BLVR) with one-way endobronchial valves (EBV) has better outcomes when the target lobe has poor collateral ventilation, resulting in complete lobe atelectasis. High-inspired oxygen fraction (FIO2) promotes atelectasis through faster gas absorption after airway occlusion, but its application during BLVR with EBV has been poorly understood. We aimed to investigate the real-time effects of FIO2 on regional lung volumes and regional ventilation/perfusion by electrical impedance tomography (EIT) during BLVR with EBV. METHODS: Six piglets were submitted to left lower lobe occlusion by a balloon-catheter and EBV valves with FIO2 0.5 and 1.0. Regional end-expiratory lung impedances (EELI) and regional ventilation/perfusion were monitored. Local pocket pressure measurements were obtained (balloon occlusion method). One animal underwent simultaneous acquisitions of computed tomography (CT) and EIT. Regions-of-interest (ROIs) were right and left hemithoraces. RESULTS: Following balloon occlusion, a steep decrease in left ROI-EELI with FIO2 1.0 occurred, 3-fold greater than with 0.5 (p < 0.001). Higher FIO2 also enhanced the final volume reduction (ROI-EELI) achieved by each valve (p < 0.01). CT analysis confirmed the denser atelectasis and greater volume reduction achieved by higher FIO2 (1.0) during balloon occlusion or during valve placement. CT and pocket pressure data agreed well with EIT findings, indicating greater strain redistribution with higher FIO2. CONCLUSIONS: EIT demonstrated in real-time a faster and more complete volume reduction in the occluded lung regions under high FIO2 (1.0), as compared to 0.5. Immediate changes in the ventilation and perfusion of ipsilateral non-target lung regions were also detected, providing better estimates of the full impact of each valve in place. TRIAL REGISTRATION: Not applicable.

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ABSTRACT Objective: To assess the effect of atelectasis during mechanical ventilation on the periatelectatic and normal lung regions in a model of atelectasis in rats with acute lung injury induced by lipopolysaccharide. Methods: Twenty-four rats were randomized into the following four groups, each with 6 animals: the Saline-Control Group, Lipopolysaccharide Control Group, Saline-Atelectasis Group, and Lipopolysaccharide Atelectasis Group. Acute lung injury was induced by intraperitoneal injection of lipopolysaccharide. After 24 hours, atelectasis was induced by bronchial blocking. The animals underwent mechanical ventilation for two hours with protective parameters, and respiratory mechanics were monitored during this period. Thereafter, histologic analyses of two regions of interest, periatelectatic areas and the normally-aerated lung contralateral to the atelectatic areas, were performed. Results: The lung injury score was significantly higher in the Lipopolysaccharide Control Group (0.41 ± 0.13) than in the Saline Control Group (0.15 ± 0.51), p < 0.05. Periatelectatic regions showed higher lung injury scores than normally-aerated regions in both the Saline-Atelectasis (0.44 ± 0.06 x 0.27 ± 0.74 p < 0.05) and Lipopolysaccharide Atelectasis (0.56 ± 0.09 x 0.35 ± 0.04 p < 0.05) Groups. The lung injury score in the periatelectatic regions was higher in the Lipopolysaccharide Atelectasis Group (0.56 ± 0.09) than in the periatelectatic region of the Saline-Atelectasis Group (0.44 ± 0.06), p < 0.05. Conclusion: Atelectasis may cause injury to the surrounding tissue after a period of mechanical ventilation with protective parameters. Its effect was more significant in previously injured lungs.

RESUMO Objetivo: Avaliar o efeito da atelectasia durante a ventilação mecânica nas regiões periatelectáticas e pulmonares normais em um modelo de atelectasia em ratos com lesão pulmonar aguda induzida por lipopolissacarídeo. Métodos: Foram distribuídos aleatoriamente 24 ratos em quatro grupos, cada um com 6 animais: Grupo Salina-Controle, Grupo Lipopolissacarídeo-Controle, Grupo Salina-Atelectasia e Grupo Lipopolissacarídeo-Atelectasia. A lesão pulmonar aguda foi induzida por injeção intraperitoneal de lipopolissacarídeo. Após 24 horas, a atelectasia foi induzida por bloqueio brônquico. Os animais foram submetidos à ventilação mecânica por 2 horas com parâmetros ventilatórios protetores, e a mecânica respiratória foi monitorada durante esse período. Em seguida, foram realizadas análises histológicas de duas regiões de interesse: as áreas periatelectásicas e o pulmão normalmente aerado contralateral às áreas atelectásicas. Resultados: O escore de lesão pulmonar foi significativamente maior no Grupo Controle-Lipopolissacarídeo (0,41 ± 0,13) do que no Grupo Controle-Solução Salina (0,15 ± 0,51), com p < 0,05. As regiões periatelectásicas apresentaram escores maiores de lesão pulmonar do que as regiões normalmente aeradas nos Grupos Atelectasia-Solução Salina (0,44 ± 0,06 versus 0,27 ± 0,74, p < 0,05) e Atelectasia-Lipopolissacarídeo (0,56 ± 0,09 versus 0,35 ± 0,04, p < 0,05). O escore de lesão pulmonar nas regiões periatelectásicas foi maior no Grupo Atelectasia-Lipopolissacarídeo (0,56 ± 0,09) do que na região periatelectásica do Grupo Atelectasia-Solução Salina (0,44 ± 0,06), p < 0,05. Conclusão: A atelectasia pode causar lesão no tecido circundante após um período de ventilação mecânica com parâmetros ventilatórios protetores. Seu efeito foi mais significativo em pulmões previamente lesionados.

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Es poco común encontrar en la literatura casos de traqueobronquitis invasiva por aspergillus que se manifiesten como tumores endobronquiales que produzcan atelectasia pulmonar total. Aunque relatada en inmunocomprometidos, la morbimortalidad es considerable aun en pacientes sin enfermedad de base.

It is rare to find in the literature cases of invasive aspergillus tracheobronchitis that manifest as endobronchial tumors that produce total pulmonary atelectasis. Although reported in immunocompromised patients, morbidity and mortality are considerable even in patients without underlying disease.

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Es poco común encontrar en la literatura casos de traqueobronquitis invasiva por aspergillus que se manifiesten como tumores endobronquiales que produzcan atelectasia pulmonar total. Aunque relatada en inmunocomprometidos, la morbimortalidad es considerable aun en pacientes sin enfermedad de base.

It is rare to find in the literature cases of invasive aspergillus tracheobronchitis that manifest as endobronchial tumors that produce total pulmonary atelectasis. Although reported in immunocompromised patients, morbidity and mortality are considerable even in patients without underlying disease.

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Mechanical ventilation is a life-saving therapy in several clinical situations, promoting gas exchange and providing rest to the respiratory muscles. However, mechanical ventilation may cause hemodynamic instability and pulmonary structural damage, which is known as ventilator-induced lung injury (VILI). The four main injury mechanisms associated with VILI are as follows: barotrauma/volutrauma caused by overstretching the lung tissues; atelectrauma, caused by repeated opening and closing of the alveoli resulting in shear stress; and biotrauma, the resulting biological response to tissue damage, which leads to lung and multi-organ failure. This narrative review elucidates the mechanisms underlying the pathogenesis, progression, and resolution of VILI and discusses the strategies that can mitigate VILI. Different static variables (peak, plateau, and driving pressures, positive end-expiratory pressure, and tidal volume) and dynamic variables (respiratory rate, airflow amplitude, and inspiratory time fraction) can contribute to VILI. Moreover, the potential for lung injury depends on tissue vulnerability, mechanical power (energy applied per unit of time), and the duration of that exposure. According to the current evidence based on models of acute respiratory distress syndrome and VILI, the following strategies are proposed to provide lung protection: keep the lungs partially collapsed (SaO2 > 88%), avoid opening and closing of collapsed alveoli, and gently ventilate aerated regions while keeping collapsed and consolidated areas at rest. Additional mechanisms, such as subject-ventilator asynchrony, cumulative power, and intensity, as well as the damaging threshold (stress-strain level at which tidal damage is initiated), are under experimental investigation and may enhance the understanding of VILI.

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BACKGROUND: Robotic-Assisted Hysterectomies (RAH) require Trendelenburg positioning and pneumoperitoneum, which further accentuate alteration in respiratory mechanics induced by general anesthesia. The role of Recruitment Maneuver (RM) as a lung-protective strategy during intraoperative surgical settings has not been much studied. We planned this study to evaluate the effect of RM on perioperative oxygenation and postoperative spirometry using PaO2/FiO2 and FEV1/FVC, respectively in patients undergoing RAH. METHODS: Sixty-six ASA I‒II female patients scheduled for elective RAH were randomized into group R (recruitment maneuver, n = 33) or group C (control, n = 33). Portable spirometry was done one day before surgery. Patients were induced with general anesthesia, and mechanical ventilation started with volume control mode, with Tidal Volume (TV) of 6-8 mL.kg-1, Respiratory Rate (RR) of 12 min, inspiratory-expiratory ratio (I: E ratio) of 1:2, FiO2 of 0.4, and Positive End-Expiratory Pressure (PEEP) of 5 cmH2O. Patients in group R received recruitment maneuvers of 30 cmH2O every 30 minutes following tracheal intubation. The primary objectives were comparison of oxygenation and ventilation between two groups intraoperatively and portable spirometry postoperatively. Postoperative pulmonary complications, like desaturation, pulmonary edema, pneumonia, were monitored. RESULTS: Patients who received RM had significantly higher PaO2 (mmHg) (203.2+-24.3 vs. 167.8+-27.3, p < 0.001) at T2 (30 min after the pneumoperitoneum). However, there was no significant difference in portable spirometry between the groups in the postoperative period (FVC, 1.40 ± 0.5 L vs. 1.32 ± 0.46 L, p = 0.55). CONCLUSION: This study concluded that intraoperative recruitment did not prevent deterioration of postoperative spirometry values; however, it led to improved oxygenation intraoperatively.

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Background: Pulmonary atelectasis is a commonly occurs during anesthesia. In these cases, mechanical ventilation (MV) associated with alveolar recruitment maneuvers (ARMs) and positive end-expiratory pressure (PEEP) is indicated to reverse the condition, ensure adequate gas exchange and improve oxygenation. ARMs can trigger volutrauma, barotrauma, and atelectrauma. Therefore, computed tomography (CT) is the gold-standard method for monitoring lung aeration after ARM. Objective: To evaluate lung volume distribution after stepwise ARMs using computed tomography (CT). Methods: Twelve dogs weighing 24.0 ± 6.0 kg, aged 3 ± 1 years, of both sexes and different breeds, underwent orchiectomy or ovariohysterectomy. The animals were anesthetized and ventilated in volume-controlled mode. ARMs were then initiated by positive end-expiratory pressure (PEEP) titration (5, 10, 15, and 20 cmH2O). CT scans, cardiovascular parameters, and ventilatory mechanics were evaluated at all time points. Data were assessed for normality using the Shapiro-Wilk test and a two-way analysis of variance, followed by a post-hoc Bonferroni test to identify differences between time points. Statistical significance was attributed to a value of p of <0.05. Results: CT demonstrated that the ARMs increased ventilation throughout the lung, including the dependent regions, with volumes that increased and decreased proportionally with PEEP titration. When they reached PEEP 10 and 5 cmH2O descending (d), they remained significantly higher than those in PEEP 0 cmH2O (baseline). Static compliance improved about 40% at PEEP 10d and PEEP 5d compared to baseline. There was an increase in heart rate (HR) from PEEP 15 increasing (i) (74.5%) to PEEP 10d (54.8%) compared to baseline. Mean arterial blood pressure (MABP) decreased approximately 9% from PEEP 15i to PEEP 15d compared to baseline. Conclusion: Lung attenuation and regional and global volumes assessed by CT showed that maximum pulmonary aeration distribution followed by PEEP titration occurred at PEEP 20 cmH2O, maintaining the lungs normoaerated and without hyperaeration.

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Abstract Background Robotic-Assisted Hysterectomies (RAH) require Trendelenburg positioning and pneumoperitoneum, which further accentuate alteration in respiratory mechanics induced by general anesthesia. The role of Recruitment Maneuver (RM) as a lung-protective strategy during intraoperative surgical settings has not been much studied. We planned this study to evaluate the effect of RM on perioperative oxygenation and postoperative spirometry using PaO2/FiO2 and FEV1/FVC, respectively in patients undergoing RAH. Methods Sixty-six ASA I‒II female patients scheduled for elective RAH were randomized into group R (recruitment maneuver, n = 33) or group C (control, n = 33). Portable spirometry was done one day before surgery. Patients were induced with general anesthesia, and mechanical ventilation started with volume control mode, with Tidal Volume (TV) of 6-8 mL.kg−1, Respiratory Rate (RR) of 12 min, inspiratory-expiratory ratio (I: E ratio) of 1:2, FiO2 of 0.4, and Positive End-Expiratory Pressure (PEEP) of 5 cmH2O. Patients in group R received recruitment maneuvers of 30 cmH2O every 30 minutes following tracheal intubation. The primary objectives were comparison of oxygenation and ventilation between two groups intraoperatively and portable spirometry postoperatively. Postoperative pulmonary complications, like desaturation, pulmonary edema, pneumonia, were monitored. Results Patients who received RM had significantly higher PaO2 (mmHg) (203.2+-24.3 vs. 167.8+-27.3, p < 0.001) at T2 (30 min after the pneumoperitoneum). However, there was no significant difference in portable spirometry between the groups in the postoperative period (FVC, 1.40 ± 0.5 L vs. 1.32 ± 0.46 L, p= 0.55). Conclusion This study concluded that intraoperative recruitment did not prevent deterioration of postoperative spirometry values; however, it led to improved oxygenation intraoperatively.

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Background: Electrical impedance tomography (EIT) has been an essential tool for assessing pulmonary ventilation in several situations, such as the alveolar recruitment maneuver (ARM) in PEEP titration to maintain the lungs open after atelectasis reversion. In the same way as in humans and dogs, in horses, this tool has been widely used to assess pulmonary aeration undergoing anesthesia, mechanical ventilation, recruitment maneuver, standing horses, or specific procedures. Objectives: The present study aimed to evaluate the distribution of regional ventilation during ARM based on lung monitoring assessment by EIT, with a focus on better recruitment associated with less or no overdistention. Methods: Fourteen horses of 306 ± 21 kg undergoing isoflurane anesthesia in dorsal recumbency were used. The animals were mechanically ventilated with a tidal volume of 14 ml kg-1 and a respiratory rate of 7-9. An alveolar recruitment maneuver was instituted, increasing the PEEP by five cmH2O every 5 min until 32 cmH2O and decreasing it by five cmH2O every 5 min to 7 cmH2O. At each step of PEEP, arterial blood samples were collected for blood gas analysis, EIT images, hemodynamic, and respiratory mechanics. Results: Associated with the CoV-DV increase, there was a significant decrease in the DSS during the ARM and a significant increase in the NSS when PEEP was applied above 12 cmH2O compared to baseline. The ComplROI showed a significant increase in the dependent area and a significant decrease in the non-dependent area during ARM, and both were compared to their baseline values. The driving pressure decreased significantly during the ARM, and Cst, PaO2, and PaO2/FiO2 ratio increased significantly. The VD/VT decreased significantly at DEPEEP17 and DEPEEP12. There was an HR increase at INPEEP27, INPEEP 32, and DEPEEP17 (p < 0.0001; p < 0.0001; and p < 0.05, respectively), those values being above the normal reference range for the species. The SAP, MAP, DAP, CI, and DO2I significantly decreased INPEEP32 (p < 0.05). Conclusion: The ARM by PEEP titration applied in the present study showed better ventilation distribution associated with better aeration in the dependent lung areas, with minimal overdistention between PEEP 17 and 12 cmH2O decreasing step. Those changes were also followed by improvements in static and regional compliance associated with increased oxygenation and pulmonary ventilation. ARM promoted a transitory decrease in arterial blood pressure and depression in CI with a concomitant drop in oxygen delivery, which should be best investigated before its routine use in clinical cases.

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La ventilación percusiva intrapulmonar (VPI) es una técnica de higiene bronquial mecánica (THBM) de alta frecuencia, que favorece la movilización de secreciones y es considerada como alternativa para la resolución de atelectasias. Estudio de serie de casos, prospectivo, observacional y descriptivo que se llevó a cabo entre el 1 de agosto del 2019 y el 31 de diciembre del 2019. Se incluyeron todos los pacientes menores de 18 años, con soporte ventilatorio que recibieron al menos una sesión de VPI dentro de terapia intensiva. El objetivo primario de nuestro estudio es describir las características de la población en la que se utilizó un equipo domiciliario de VPI como THBM en la UCIP. De manera secundaria describiremos la metodología de implementación del dispositivo y sus resultados. Resultados: Se incluyeron 18 pacientes y se realizaron 48 sesiones de VPI. El principal motivo para la realización de VPI fue el diagnóstico de atelectasia (83,3%). El tratamiento se realizó tanto en pacientes con VMI (ventilación mecánica invasiva) (55,6%) como en pacientes con soporte no invasivo (44,4%), ya sea VMNI (ventilación mecánica no invasiva) o CNAF (cánula nasal de alto flujo). En el 53,3% de los pacientes, se evidenció resolución radiográfica de la atelectasia, entre los cuales, el 75% solo requirió entre una y dos sesiones para resolverlas. No se observaron complicaciones graves. Conclusión: Este estudio permite describir la población en la cual se implementa VPI a la vez que presenta una herramienta que podría ser de utilidad para la resolución de atelectasias.

Intrapulmonary percussive ventilation (IPV) is a high-frequency mechanical bronchial hygiene technique (MBHT) that favors secretion clearance and is considered an alterna tive to the resolution of atelectasis. This is a prospective, observational and descriptive case series study conducted be tween August 1st, 2019 and December 31st, 2019. The study included patients younger than 18 years on ventilatory support who received at least one session of IPV in the intensive care unit. The primary objective of our study was to describe the characteristics of the population in whom we used a home IPV device as MBHT in the PICU. On a secondary level, we will describe the methodology for using this device and its results. Results: 18 patients were included; 48 IPV sessions were done. The main reason for doing IPV was the atelectasis diagnosis (83.3%). The treatment was carried out both in patients on IMV (invasive mechanical ventilation) (55.6%) and in patients with non-invasive support (44.4%), whether it was NIMV (non-invasive mechanical ventilation) or HFNC (high-flow nasal cannula). 53.3% of the patients showed radiographic resolution of atelectasis, where 75% only required between one and two sessions to resolve it. No severe complications were observed. Conclusion: This study allows us to describe the population receiving IPV and presents a tool that could be useful for the resolution of atelectasis.

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ABSTRACT Intrapulmonary percussive ventilation (IPV) is a high-frequency mechanical bronchial hygiene technique (MBHT) that favors secretion clearance and is considered an alternative to the resolution of atelectasis. This is a prospective, observational and descriptive case series study conducted between August 1st, 2019 and December 31st, 2019. The study included patients younger than 18 years on ventilatory support who received at least one session of IPV in the intensive care unit. The primary objective of our study was to describe the characteristics of the population in whom we used a home IPV device as MBHT in the PICU. On a secondary level, we will describe the methodology for using this device and its results. Results: 18 patients were included; 48 IPV sessions were done. The main reason for doing IPV was the atelectasis diagnosis (83.3%). The treatment was carried out both in patients on IMV (invasive mechanical ventilation) (55.6%) and in patients with non-invasive support (44.4%), whether it was NIMV (non-invasive mechanical ventilation) or HFNC (high-flow nasal cannula). 53.3% of the patients showed radiographic resolution of atelectasis, where 75% only required between one and two sessions to resolve it. No severe complications were observed. Conclusion: This study allows us to describe the population receiving IPV and presents a tool that could be useful for the resolution of atelectasis.

RESUMEN La ventilación percusiva intrapulmonar (VPI) es una técnica de higiene bronquial mecánica (THBM) de alta frecuencia, que favorece la movilización de secreciones y es considerada como alternativa para la resolución de atelectasias. Estudio de serie de casos, prospectivo, observacional y descriptivo que se llevó a cabo entre el 1 de agosto del 2019 y el 31 de diciembre del 2019. Se incluyeron todos los pacientes menores de 18 años, con soporte ventilatorio que recibieron al menos una sesión de VPI dentro de terapia intensiva. El objetivo primario de nuestro estudio es describir las características de la población en la que se utilizó un equipo domiciliario de VPI como THBM en la UCIP. De manera secundaria describiremos la metodología de implementación del dispositivo y sus resultados. Resultados: Se incluyeron 18 pacientes y se realizaron 48 sesiones de VPI. El principal motivo para la realización de VPI fue el diagnóstico de atelectasia (83,3%). El tratamiento se realizó tanto en pacientes con VMI (ventilación mecánica invasiva) (55,6%) como en pacientes con soporte no invasivo (44,4%), ya sea VMNI (ventilación mecánica no invasiva) o CNAF (cánula nasal de alto flujo). En el 53,3% de los pacientes, se evidenció resolución radiográfica de la atelectasia, entre los cuales, el 75% solo requirió entre una y dos sesiones para resolverlas. No se observaron complicaciones graves. Conclusión: Este estudio permite describir la población en la cual se implementa VPI a la vez que presenta una herramienta que podría ser de utilidad para la resolución de atelectasias.

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Abstract Introduction: General anesthesia causes pulmonary atelectasis within few minutes of induction. This can have significant impact on postoperative outcome of cancer patients undergoing prolonged reconstructive surgeries. Objective: The purpose of this study was to evaluate the impact of sonographically detected perioperative atelectasis on the need for postoperative oxygen supplementation, bronchodilator therapy and assisted chest physiotherapy in patients undergoing free flap surgeries for head and neck carcinoma. Methods: Twenty eight head and neck cancer patients underwent bilateral pulmonary ultrasonographic assessments before and after lung surgery. Lung ultrasound scores, serum lactate, and PaO2/FiO2 ratio were measured both at the beginning and at end of the surgery. Patients were scanned in the supine position and the number of single and confluent B lines was noted. These values were correlated with the need for oxygen therapy, requirement of bronchodilators and total weaning time to predict the postoperative outcome. Other factors affecting weaning were also studied. Results: Among twenty eight patients, seven had mean lung ultrasound score of ≥10.5 which correlated with prolonged weaning time (144.56±33.5min vs. 66.7±15.7min; p = 0.005). The change in lung ultrasound score significantly correlated with change in PaO2/FiO2 ratio (r = −0.56, p = 0.03). Elevated total leukocyte count >8200 ΜL and serum lactate >2.1 mmoL/L also predicted prolonged postoperative mechanical ventilation. Conclusion: This preliminary study detected significant levels of perioperative atelectasis using point of care lung ultrasonography in head and neck cancer patients undergoing long duration surgical reconstructions. Higher lung ultrasound scores highlighted the need for frequent bronchodilator nebulizations as well as assisted chest physiotherapy and were associated with delayed weaning. We propose more frequent point of care lung ultrasonographic evaluations and use of recruitment maneuvers to reduce the impact of perioperative pulmonary atelectasis.

Resumo Introdução: A anestesia geral causa atelectasia pulmonar poucos minutos após sua indução. Isso pode ter um impacto significativo no resultado pós-operatório de pacientes com câncer submetidos a cirurgias reconstrutivas prolongadas. Objetivo: Avaliar o impacto das atelectasias perioperatórias detectadas por ultrassonografia na necessidade de suplementação pós-operatória de oxigênio, terapia broncodilatadora e fisioterapia respiratória assistida em pacientes com carcinoma de cabeça e pescoço submetidos a cirurgias com uso de retalho livre. Método: Foram submetidos a avaliações ultrassonográficas pulmonares bilaterais antes e após a cirurgia 28 pacientes com câncer de cabeça e pescoço. Os escores de ultrassonografia pulmonar, lactato sérico, razão PaO2/FiO2 foram medidos no início e no fim da cirurgia. Os pacientes foram avaliados na posição supina e o número de linhas B confluentes e únicas foi observado. Esses valores foram correlacionados com a necessidade de oxigenoterapia, necessidade de broncodilatadores e tempo total de desmame para predizer o resultado pós-operatório. Outros fatores que afetam o desmame também foram estudados. Resultados: Entre os 28 pacientes, sete apresentaram escore médio de ultrassonografia pulmonar ≥ 10,5, que se correlacionou com o tempo de desmame prolongado (144,56 ± 33,5 minutos vs. 66,7 ± 15,7 minutos; p = 0,005). A mudança no escore de ultrassonografia pulmonar correlacionou-se significantemente com a mudança na razão PaO2/FiO2 (r = −0,56, p = 0,03). A contagem total elevada de leucócitos > 8200 uLe o nível de lactato sérico >2,1 mmoL/L também previram ventilação mecânica pós-operatória prolongada. Conclusão: Este estudo preliminar detectou um nível significante de atelectasia perioperatória com ultrassonografia pulmonar no local de atendimento em pacientes com câncer de cabeça e pescoço submetidos a reconstruções cirúrgicas de longa duração. Escores mais altos de ultrassonografia pulmonar enfatizaram a necessidade de nebulizações broncodilatadoras frequentes e fisioterapia respiratória assistida e foram associados a desmame tardio. Propomos avaliações ultrassonográficas pulmonares mais frequentes no local de atendimento e o uso de manobras de recrutamento para reduzir o impacto das atelectasias pulmonares perioperatórias.

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RESUMEN Introducción: La bronquiolitis es una entidad clínica que se presenta antes de los dos años y constituye una causa frecuente de hospitalización en ese grupo de edad. La hospitalización prolongada se define como un tiempo hospitalario mayor a 5 días. Esta situación demanda uso de recursos y tiene un impacto económico sobre el sistema de salud. En el contexto peruano no se ha abordado los factores asociados con la hospitalización prolongada en pacientes con bronquiolitis. Objetivo: Determinar los factores asociados con hospitalización prolongada en pacientes con bronquiolitis moderada. Métodos: Estudio descriptivo, transversal, retrospectivo. La unidad de análisis fue la historia clínica de lactantes hospitalizado por bronquiolitis moderada atendidos en el Instituto Nacional de Salud del Niño-Breña, entre los años 2018 y 2019. Se consideraron 160 lactantes. Para establecer la relación entre los factores asociados a la hospitalización prolongada tanto de la madre como los aspectos clínicos del lactante, se utilizó la prueba JI-cuadrada con un nivel de significancia de 0,05. Resultados: La hospitalización prolongada se asoció con un mayor número de días con oxígeno suplementario con p= 0,000; además de presentarse con mayor frecuencia en lactantes que no recibieron lactancia materna exclusiva con p= 0,000; finalmente, también se asoció con atelectasia y neumonía, ambos casos con p= 0,040. Conclusiones: La hospitalización prolongada en los lactantes con bronquiolitis se asocia con el número de días con oxígeno suplementario, con el no disfrute de la lactancia materna exclusiva y con la aparición de complicaciones como bronquiectasias y neumonías.

ABSTRACT Introduction: Bronchiolitis is a clinical entity that occurs before the age of two and is a frequent cause of hospitalization in this age group. Prolonged hospitalization is defined as a hospital time greater than 5 days. This situation demands the use of resources and has an economic impact on the health system. In the Peruvian context, the factors associated with prolonged hospitalization in patients with bronchiolitis have not been addressed. Objective : etermine the factors associated with prolonged hospitalization in patients with moderate bronchiolitis. Method : Descriptive, cross-sectional, retrospective study. The unit of analysis was the clinical history of infants hospitalized due to moderate bronchiolitis treated at Niño -Breña National Institute of Health, between 2018 and 2019. 160 infants were included. To establish the relationship between the factors associated with prolonged hospitalization of both the mother and the clinical aspects of the infant, the JI-square test with a significance level of 0.05 was used. Results : rolonged hospitalization was associated with a greater number of days with supplemental oxygen with p= 0.000; in addition to presenting more frequently in infants who did not receive exclusive breastfeeding with p = 0.000 . Finally, it was also associated with atelectasis and pneumonia, both cases with p= 0.040. Conclusions: Prolonged hospitalization in infants with bronchiolitis is associated with the number of days on supplemental oxygen, with the non-enjoyment of exclusive breastfeeding and with the appearance of complications such as bronchiectasis and pneumonia.

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To determine whether end-expiratory lung volume measured with volumetric capnography (EELVCO2) can individualize positive end-expiratory pressure (PEEP) setting during laparoscopic surgery. We studied patients undergoing laparoscopic surgery subjected to Fowler (F-group; n = 20) or Trendelenburg (T-group; n = 20) positions. EELVCO2 was measured at 0° supine (baseline), during capnoperitoneum (CP) at 0° supine, during CP with Fowler (head up + 20°) or Trendelenburg (head down - 30°) positions and after CP back to 0° supine. PEEP was adjusted to preserve baseline EELVCO2 during and after CP. Baseline EELVCO2 was statistically similar to predicted FRC in both groups. At supine and CP, EELVCO2 decreased from baseline values in F-group [median and IQR 2079 (768) to 1545 (725) mL; p = 0.0001] and in T-group [2164 (789) to 1870 (940) mL; p = 0.0001]. Change in body position maintained EELVCO2 unchanged in both groups. PEEP adjustments from 5.6 (1.1) to 10.0 (2.5) cmH2O in the F-group (p = 0.0001) and from 5.6 (0.9) to 10.0 (2.6) cmH2O in T-group (p = 0.0001) were necessary to reach baseline EELVCO2 values. EELVCO2 increased close to baseline with PEEP in the F-group [1984 (600) mL; p = 0.073] and in the T-group [2175 (703) mL; p = 0.167]. After capnoperitoneum and back to 0° supine, PEEP needed to maintain EELVCO2 was similar to baseline PEEP in F-group [5.9 (1.8) cmH2O; p = 0.179] but slightly higher in the T-group [6.5 (2.2) cmH2O; p = 0.006]. Those new PEEP values gave EELVCO2 similar to baseline in the F-group [2039 (980) mL; p = 0.370] and in the T-group [2150 (715) mL; p = 0.881]. Breath-by-breath noninvasive EELVCO2 detected changes in lung volume induced by capnoperitoneum and body position and was useful to individualize the level of PEEP during laparoscopy.Trial registry: Clinicaltrials.gov NCT03693352. Protocol started 1st October 2018.

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INTRODUCTION: General anesthesia causes pulmonary atelectasis within few minutes of induction. This can have significant impact on postoperative outcome of cancer patients undergoing prolonged reconstructive surgeries. OBJECTIVE: The purpose of this study was to evaluate the impact of sonographically detected perioperative atelectasis on the need for postoperative oxygen supplementation, bronchodilator therapy and assisted chest physiotherapy in patients undergoing free flap surgeries for head and neck carcinoma. METHODS: Twenty eight head and neck cancer patients underwent bilateral pulmonary ultrasonographic assessments before and after lung surgery. Lung ultrasound scores, serum lactate, and PaO2/FiO2 ratio were measured both at the beginning and at end of the surgery. Patients were scanned in the supine position and the number of single and confluent B lines was noted. These values were correlated with the need for oxygen therapy, requirement of bronchodilators and total weaning time to predict the postoperative outcome. Other factors affecting weaning were also studied. RESULTS: Among twenty eight patients, seven had mean lung ultrasound score of ≥10.5 which correlated with prolonged weaning time (144.56±33.5min vs. 66.7±15.7min; p=0.005). The change in lung ultrasound score significantly correlated with change in PaO2/FiO2 ratio (r=-0.56, p=0.03). Elevated total leukocyte count >8200µL and serum lactate >2.1mmoL/L also predicted prolonged postoperative mechanical ventilation. CONCLUSION: This preliminary study detected significant levels of perioperative atelectasis using point of care lung ultrasonography in head and neck cancer patients undergoing long duration surgical reconstructions. Higher lung ultrasound scores highlighted the need for frequent bronchodilator nebulizations as well as assisted chest physiotherapy and were associated with delayed weaning. We propose more frequent point of care lung ultrasonographic evaluations and use of recruitment maneuvers to reduce the impact of perioperative pulmonary atelectasis.

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Introdução: Amiloidose é o termo utilizado para designar doenças que fazem deposição extracelular de proteínas fibrilares patológicas em órgãos e tecidos, podendo ser sistêmica ou restrita a um único órgão. As manifestações clínicas são diversas, como cardiomiopatia, falência renal, esplenomegalia, problemas intestinais, neuropatias, problemas pulmonares, entre outros. Objetivo: relatar um caso clínico de paciente com amiloidose traqueobrônquica. Metodologia: revisão de bibliografias em comparação ao relato de caso, o qual foi descrito a partir de dados retirados do prontuário e de exames complementares da paciente. Caso clínico: paciente do sexo feminino, 70 anos, procurou assistência médica por dorsalgia, apresentando também chiado, tosse seca, dispneia paroxística noturna e ortopneia. Realizou-se investigação diagnóstica durante a internação, na qual biópsia da mucosa traqueobrônquica e coleta de lavado alveolar foram positivos para o teste Vermelho Congo, o que confirmou o diagnóstico de amiloidose. A paciente, então, foi encaminhada para terapia de ablação a laser. Conclusão: portanto, diante de um paciente com quadro clínico inespecífico e suspeita diagnóstica principal de amiloidose pulmonar, é imprescindível investigar e descartar diagnósticos diferenciais como neoplasia ou discrasia de células plasmáticas. Para isso, é necessário que haja alta precisão na análise dos exames de imagem, de modo a sugerir esse diagnóstico, o qual deve ser confirmado através da fibrobroncoscopia com biópsia de tecido brônquico, que através da coloração Vermelho do Congo, evidenciará presença de substância amorfa e birrefringente, compatível com substância amiloide [au]

Introduction: Amyloidosis is the term used to describe diseases that cause extracellular deposition of pathological fibrillar proteins in organs and tissues, which can be systemic or restricted to a single organ. The clinical manifestations are diverse, such as cardiomyopathy, renal failure, splenomegaly, intestinal problems, neuropathies, lung problems, among others. Objective: to report a clinical case of a patient with pulmonary amioloidosis. Methodology: review of bibliographies in comparison to the case report, which was described based on data taken from the patient's record and complementary exams. Clinical case: a seventy-year-old female patient sought medical assistance because of back pain, also presenting wheezing, dry cough, paroxysmal nocturnal dyspnea and orthopnea. Diagnostic investigation was carried out during hospitalization, in which biopsy of the tracheobronchial mucosa and collection of alveolar lavage were positive for the Congo Red test,wich confirmed the amyloidosis diagnosis. The patient was then referred for laser ablation therapy.Conclusion: hence, in a patient with a nonspecific clinical presentation and main diagnostic suspicion of pulmonary amyloidosis, it is essential to investigate and rule out differential diagnoses such as malignancy or plasma cell dyscrasia. Therefore, it is necessary to use high precision in the analysis of image exams in order to suggest this diagnosis, which should be confirmed through fibrobronchoscopy with bronchial tissue biopsy, that through the Congo Red dye, will show the presence of amorphous and birefringent substance, compatible with amyloid substance [au]

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Resumen: El modo ventilatorio asistido durante un procedimiento laparoscópico aún es controversial. Objetivo: Comparar la dinámica ventilatoria según el modo de ventilación asistida: por ventilación controlada por volumen (VCV), controlada por presión (VCP) o por presión con garantía de volumen (VCP-GV), en anestesia para colecistectomía laparoscópica. Material y métodos: 21 pacientes adultos manejados con una de las tres modalidades (7 por grupo). Se analizó durante el procedimiento (a la intubación, la insuflación de CO2 intraabdominal y resolución), su frecuencia respiratoria, el volumen espiratorio, CO2 al final de la espiración (EtCO2), presión pico vía aérea, presión media pulmonar, distensibilidad, saturación de oxígeno y volumen minuto respiratorio. Resultados: Posterior a la intubación, no hubo diferencias clínicas importantes en las mediciones entre los modos de ventilación. A la insuflación los pacientes con modo VCP incrementaron su frecuencia respiratoria, pero conservaron su presión pico; contra aquéllos en modo VCV y VCP-GV que incrementaron su presión pico con escasa reducción de su frecuencia respiratoria. Las otras variables no se modificaron durante el procedimiento y no hubo diferencias entre los modos ventilatorios. Conclusión: Los tres modos de ventilación permitieron un buen control ventilatorio con pocas diferencias respecto a parámetros basales, pero sugerimos que el modo VCP previene mejor los aumentos en la presión pico.

Abstract: The assisted ventilatory mode during a laparoscopic procedure is still controversial. Objective: To compare ventilatory dynamics according to the assisted ventilation mode: by volume-controlled ventilation (VCV), pressure-controlled (PCV) or by pressure with volume guarantee (PVC-VG), in general anesthesia for laparoscopic cholecystectomy. Material and methods: 21 adult patients managed with one of the three modalities (seven per group). Their respiratory rate, minute expiratory volume, end tidal CO2 (EtCO2), peak airway pressure, mean pulmonary pressure, compliance, oxygen saturation and minute respiratory volume were analyzed during the procedure (at intubation, abdominal CO2 insufflation and resolution). Results: After intubation there were no clinical differences in measurements between ventilation modes. On insufflation, patients with PCV mode increased their respiratory rate, but kept their peak pressure; against those in VCV and PCV-VG mode who increased their peak pressure with little reduction in their respiratory rate. The other variables were not modified during the procedure and there were no differences between the ventilatory modes. Conclusion: The three modes of ventilation allowed a good ventilatory control, but we suggest the PCV since it prevents an increase in peak pressure.

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BACKGROUND: Postoperative pulmonary complications are the main cause of morbidity and mortality after pulmonary resection. This study was undertaken to determine the risk factors associated with postoperative pulmonary complications (PPCs) and length of hospital stay (LOS) in pulmonary resection patients in a tertiary teaching hospital in Brazil. METHODS: A retrospective data gathering from 196 patients who underwent pulmonary resection between 2012 and 2016 was conducted. Demographic and hospital admission data were collected from patients with complete medical records. Univariate analysis was performed, followed by Poisson's regression for predicting the prevalence of postoperative pulmonary complications and length of hospital stay. RESULTS: Thirty-nine patients (20%) displayed pulmonary complications in the postoperative period. The risk factors associated with an increased prevalence of postoperative pulmonary complications in a multivariate analysis were: American Society of Anesthesiologists physical status (ASA) ≥ 3 (PR 4.77, p = 0.03, 95% CI: 1.17 to 19.46), predicted diffusion capacity of the lungs for carbon monoxide - corrected single breath (PR 0.98, p < 0.001, 95% CI: 0.96 to 0.99) and age of the patient (PR 1.04; p = 0.01; 95% CI: 1.01 to 1.06). Those associated with an increased prevalence of prolonged hospital stay were: duration of surgical procedure longer than five hours (PR 6.94, p = 0.01, 95% CI: 1.66 to 12.23), male sex (PR 5.72, p < 0.001, 95% CI: 1.87 to 9.58), and presence of postoperative pulmonary complications (PR 11.92, p < 0.001, 95% CI: 7.42 to 16.42). CONCLUSIONS: The rate of postoperative pulmonary complications in the study population is in line with the world average. Recognizing risk factors for the development of PPCs may help optimize allocation resources and preventive efforts.

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Evaluating the impact of lung re-expansion methods on the postoperative pulmonary function and respiratory complications such as atelectasis, pneumonia and hypoxemia in videolaparoscopy-based bariatric surgery. Prospective clinical study conducted with 105 patients randomly divided into three groups: control (conventional postoperative physical therapy), recruitment (intraoperative alveolar recruitment) and decompression (postoperative chest compression and decompression maneuver). Spirometry, respiratory and hemodynamic variables were analyzed. All groups have presented worsened values in spirometry measurements within the postoperative period (p < 0.00) and there was significant decrease in respiratory rates in comparison to the immediate preoperative period (p = 0,01). Mean end-expiratory carbon dioxide pressure in the recruitment group was higher than in the control in all assessed time intervals (p = 0.03). Chest compression and decompression maneuver and alveolar recruitment were beneficial to pulmonary function recovery. There were no differences in postoperative pulmonary complications and function in the three assessed groups, except for significant decrease in respiratory rates and in the end-expiratory carbon dioxide pressure level in the recruitment group. (AU)

Avaliar o impacto de métodos de re-expansão pulmonar na função pulmonar e incidência de complicações respiratórias como as atelectasias, pneumonias e hipoxemia no pós-operatório de cirurgia bariátrica por videolaparoscopia. Estudo clínico, prospectivo realizado com 105 pacientes, randomizado em três grupos: grupo controle (fisioterapia convencional no pós-operatório), grupo recrutamento (recrutamento alveolar no intraoperatório) e grupo descompressão (manobra de compressão e descompressão torácica no pós-operatório). Foram analisadas variáveis espirométricas, respiratórias e hemodinâmicas. No pós-operatório todos os grupos apresentaram piora nas medidas espirométricas (p < 0,00) e redução significativa da frequência respiratória quando comparado o período pré e pós-operatório imediato em todos os grupos (p = 0,01). As médias de pressão expiratória final de gás carbônico no grupo recrutamento foram maiores que no grupo controle em todos os intervalos de tempos avaliados (p = 0,03). A manobra de compressão e descompressão torácica e o recrutamento alveolar foram benéficos para a recuperação da função pulmonar. Nos três grupos avaliados não houve diferença nas complicações e função pulmonar no pós-operatório, exceto redução significativa da frequência respiratória e da pressão expiratória final de dióxido de carbono no grupo recrutamento alveolar. (AU)

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INTRODUCTION: To determine predictors of length of stay (LOS) in the intensive care unit (ICU) after coronary artery bypass grafting (CABG) and to develop a risk scoring system were the objectives of this study. METHODS: In this retrospective study, 1202 patients' medical records after CABG were evaluated by a research-made checklist. Tarone-Ware test was used to determine the predictors of patients' LOS in the ICU. Cox regression model was used to determine the risk factors and risk ratios associated with ICU LOS. RESULTS: The mean ICU LOS after CABG was 55.27±17.33 hours. Cox regression model showed that having more than two chest tubes (95% confidence interval [CI] 1.005-1.287, Relative Risk [RR]=1.138), occurrence of atelectasis (95% CI 1.000-3.007, RR=1.734), and occurrence of atrial fibrillation after CABG (95% CI 1.428-2.424, RR=1.861) were risk factors associated with longer ICU LOS. The discrimination power of this set of predictors was demonstrated with an area under the receiver operating characteristic curve and it was 0.69. A simple risk scoring system was developed based on three identified predictors that can raise ICU LOS. CONCLUSION: The simple risk scoring system developed based on three identified predictors can help to plan more accurately a patient's LOS in hospital for CABG and can be useful in managing human and financial resources.

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