Mortality in a swiftly repurposed hospital in northeast Brazil during the first and second COVID-19 waves: A retrospective cohort study.

Background: The first months of the coronavirus disease 2019 (COVID-19) pandemic demanded rapid re-organization of available local resources. This study evaluated the performance of a private hospital in the Brazilian state of Ceará that was swiftly repurposed into a public tertiary COVID-19 centre during the first wave of the COVID-19 pandemic, and how it improved in the second wave. Methods: This retrospective cohort study included 2492 patients with COVID-19 at Hospital Estadual Leonardo da Vinci (HELV) during the first and second waves. Demographic, clinical and laboratory data were collected using a dedicated web platform (ResCOVID). A Poisson regression model was used to estimate factors associated with in-hospital mortality. Results: Differences in demographics and clinical features were found between the two waves. There was reduced in-hospital mortality during the second wave (36.2%) in comparison with the first wave (48.8%). Invasive mechanical ventilation showed the strongest association with increased risk of death in both waves {first wave: relative risk (RR) 4.28 [95% confidence interval (CI) 2.86-6.41], P<0.001; second wave: RR 12.94 (95% CI 3.4-49.12), P<0.001}. Conclusions: HELV was a pillar in the strategic public health plan to respond to COVID-19 in Ceará, helping to assist a group of moderate-to-severe cases and reduce the pressure on emergency and primary care facilities. Although mortality in intubated individuals remained high, there was an overall decrease in the in-hospital mortality rate in the second wave.

Assessment of functional status by the Duke Activity Status Index in stable bronchiectasis.

INTRODUCTION: Bronchiectasis is a growing global health problem. OBJECTIVE AND METHODS: To evaluate the functional status of stable bronchiectasis patients recruited from a terciary hospital in Fortaleza, Brazil.The patients were submitted to spirometry, six minute walking test (6MWT), step test (6MST),   measurement of fibrinogen,E-FACED scores(incorporates FEV1 ,age,colonisation by Pseudomonas,radiological extension, dyspnoea and exarcebation) and Duke Activity Status Index(DASI) test.Each item of DASI scored proportionally to the metabolic equivalentes(METs). The sum of DASI scores was applied for an estimation of oxygen consumption(VO2). RESULTS: The sample comprised 101 patients.Patients with post-tuberculosis bronchiectsis had the lowest level of functional parameters than those with others etiologies[DASI(19.9 ±10.9 vs 31.2±14.4 p<0.001); VO2 (18.1 ± 4.7 vs 23.1 ± 6.1 p< 0.001 respectively)]. DASI scores and estimated VO2 correlated with E-FACED(r= -0.44 p=0.001; and  r= -0.44 p=0.001 respectively) and 6MST r= 0.37 p<0.001 and r=0.40 p<0.001 respectively). CONCLUSION: After multivariate analysis , bronchiectasis post-TB , E-FACED and 6MWT explained the impact on performance in bronchiectasis patients.

Short-term effects of non-invasive ventilation on cerebral blood flow and cognitive function in COPD.

OBJECTIVES: Investigate the acute effects of non-invasive ventilation (NIV) on cerebral blood flow (CBF) and on cognitive functions in COPD. METHODS: Nine non-hypercapnic stable COPD and twelve healthy controls were enrolled. CBF (transcranial Doppler), cognitive tests and cardiorespiratory response were performed at baseline, during one hour of NIV and after 30 min. RESULTS: Both groups had an increase in tidal volume and reduction in respiratory rate during NIV, but only controls showed PaCO2 reductions (41.2 ±â€¯4.6 to 36.5 ±â€¯7.3 in controls vs. 40.9 ±â€¯4.5 to 42.9 ±â€¯5.9 in COPD). During NIV CBF was significantly reduced in healthy controls and COPD, although this effect was less pronounced in the latter. At the same time, healthy controls demonstrated an improvement in cognitive executive function compared to COPD in the Trail Making Test part B (90.5 vs. 180s; respectively). CONCLUSION: NIV application for one hour reversibly reduced CBF in healthy controls and non-hypercapnic stable COPD patients, despite no significant reductions of the PaCO2 in the latter group. It was associated with minor cognitive improvements in the executive function in healthy volunteers, but not in COPD.

Influences of Duration of Inspiratory Effort, Respiratory Mechanics, and Ventilator Type on Asynchrony With Pressure Support and Proportional Assist Ventilation.

BACKGROUND: Pressure support ventilation (PSV) is often associated with patient-ventilator asynchrony. Proportional assist ventilation (PAV) offers inspiratory assistance proportional to patient effort, minimizing patient-ventilator asynchrony. The objective of this study was to evaluate the influence of respiratory mechanics and patient effort on patient-ventilator asynchrony during PSV and PAV plus (PAV+). METHODS: We used a mechanical lung simulator and studied 3 respiratory mechanics profiles (normal, obstructive, and restrictive), with variations in the duration of inspiratory effort: 0.5, 1.0, 1.5, and 2.0 s. The Auto-Trak system was studied in ventilators when available. Outcome measures included inspiratory trigger delay, expiratory trigger asynchrony, and tidal volume (VT). RESULTS: Inspiratory trigger delay was greater in the obstructive respiratory mechanics profile and greatest with a effort of 2.0 s (160 ms); cycling asynchrony, particularly delayed cycling, was common in the obstructive profile, whereas the restrictive profile was associated with premature cycling. In comparison with PSV, PAV+ improved patient-ventilator synchrony, with a shorter triggering delay (28 ms vs 116 ms) and no cycling asynchrony in the restrictive profile. VT was lower with PAV+ than with PSV (630 mL vs 837 mL), as it was with the single-limb circuit ventilator (570 mL vs 837 mL). PAV+ mode was associated with longer cycling delays than were the other ventilation modes, especially for the obstructive profile and higher effort values. Auto-Trak eliminated automatic triggering. CONCLUSIONS: Mechanical ventilation asynchrony was influenced by effort, respiratory mechanics, ventilator type, and ventilation mode. In PSV mode, delayed cycling was associated with shorter effort in obstructive respiratory mechanics profiles, whereas premature cycling was more common with longer effort and a restrictive profile. PAV+ prevented premature cycling but not delayed cycling, especially in obstructive respiratory mechanics profiles, and it was associated with a lower VT.

Effect of an automatic triggering and cycling system on comfort and patient-ventilator synchrony during pressure support ventilation.

BACKGROUND: The digital Auto-Trak™ system is a technology capable of automatically adjusting the triggering and cycling mechanisms during pressure support ventilation (PSV). OBJECTIVE: To compare Auto-Trak with conventional settings in terms of patient-ventilator synchrony and discomfort. METHODS: Twelve healthy volunteers underwent PSV via the mouth by breathing through an endotracheal tube. In the conventional setting, a pressure support of 8 cm H2O with flow cycling (25% peak inspiratory flow) and a sensitivity of 1 cm H2O was adjusted. In Auto-Trak the triggering and cycling were automatically set. Discomfort, effort of breathing, and the asynchrony index (AI) were assessed. In a complementary bench study, the inspiratory and expiratory time delays were quantified for both settings in three mechanical models: 'normal', obstructive (COPD), and restrictive (ARDS), using the ASL 5000 simulator. RESULTS: In the volunteer study the AI and the discomfort scores did not differ statistically between the two settings. In the bench investigation the use of Auto-Trak was associated with a greater triggering delay in the COPD model and earlier expiratory cycling in the ARDS model but with no asynchronic events. CONCLUSIONS: Use of the Auto-Trak system during PSV showed similar results in comparison to the conventional adjustments with respect to patient-ventilator synchrony and discomfort in simulated conditions of invasive mechanical ventilation.

Enfrentando desafios na DPOC: gerenciamento na UTI / Facing challenges in COPD: ICU Management of Patients

A exacerbação da DPOC é causa frequente de admissão em UTI e de necessidade de ventilação mecânica. Critérios para o diagnóstico da insuficiência respiratória devem ser prontamente avaliados. O uso de oxigenoterapia é imperativo à admissão. Se possível, a ventilação não invasiva deve ser o suporte ventilatório de primeira escolha; no contrário, deve-se considerar a intubação orotraqueal. A estratégia ventilatória mecânica deve priorizar a reversão da hiperinsuflação dinâmica. A fase de transição para o desmame requer uso judicioso da pressure support ventilatione, novamente, o emprego da ventilação não invasiva em casos com desmame difícil e hipercapnia persistente. Em paralelo, recomenda-se o uso liberal de broncodilatadores por via inalatória, administração de corticosteroides sistêmicos e antibioticoterapia de amplo espectro. Nos casos de falha de desmame, uma abordagem multifatorial é obrigatória com a investigação e o tratamento da doença de base e de múltiplas comorbidades. O prognóstico é reservado e o acompanhamento sequencial por especialista é recomendado ante a alta taxa de recidivas do quadro

Exacerbations of COPD constitute a common cause of ICU admission and of a need of mechanical ventilation. Criteria for the diagnosis of acute respiratory failure should be promptly evaluated in the emergency room. The use of oxygen is imperative at admission. If not contra-indicated, noninvasive ven tilation should be the ventilatory support strategy of first choice; otherwise, endotracheal intubation should be considered. The mechanical ventilation strategy should prioritize the reversal of dynamic hyperinflation. The transition to weaning requires judicious use of pressure support ventilation and, again, the use of noninvasive ventilation in difficult-t o-wean patients with persistent hypercapnia. In parallel, pharmacological interventions, such as the liberal use of inhaled bronchodilators, systemic corticosteroids, and broad-spectrum antibiotics, are recommended. In cases of failure-to-wean, a multifactorial approach is required in order to assess and treat the underlying disease and multiple comorbidities. The prognosis is poor, and sequential follow up by a specialist is recommended becauseof the high rate of recurrence of this condition

Improvement of cognitive function after a three-month pulmonary rehabilitation program for COPD patients.

The objective of the study was to evaluate the effect of multidisciplinary pulmonary rehabilitation program on cognitive function in COPD patients, adjusting for potential confounders (gender, age, tobacco consumption, and educational level). In this prospective study, 34 COPD patients were submitted to neuropsychological testing before and after a 3-month pulmonary rehabilitation program. A control group with 18 healthy subjects of similar age, sex, and educational status was used to compare the cognitive function of COPD patients and healthy subjects at baseline. The association between the rehabilitation and change on th scores of cognitive variables, adjusted for each covariate, was estimated by means of linear random-intercept regression models. At baseline, the COPD patients had worse cognitive function with regard to verbal learning, memory, subjective organization, and verbal processing in comparison to the healthy volunteers. The improvement in cognitive performance by the COPD patients was evidenced even after adjusting for the sociodemographic factors that could potentially interfere on cognitive function. Male gender and age less than 65 years old were associated to higher scores in verbal learning and memory at baseline and after the rehabilitation program. The clinical approach to COPD-induced cognitive dysfunction should include participation in pulmonary rehabilitation programs. There were gender- and age-related differences in cognitive scores that persisted after rehabilitation.

Fatores de risco na síndrome do desconforto respiratório agudo / Risk factors for acute respiratory distress syndrome

A síndrome do desconforto respiratório agudo (SDRA) é uma condição crítica que consiste de insuficiência respiratória hipoxêmica aguda grave, com infiltrados pulmonares bilaterais que não são atribuídos a hipertensão atrial esquerda. Trata-se de uma desordem heterogênea que pode ser desencadeada por variadas etiologias. Um melhor conhecimento de seus fatores de risco pode ajudar no seu diagnóstico precoce. Os fatores de risco para SDRA têm permanecido os mesmos por vários anos e incluem pneumonia, sepse, aspiração de conteúdo gástrico, trauma grave e múltiplas transfusões, dentre outros. Essas condições clínicas podem ser divididas entre aquelas associadas à lesão direta dos pulmões (fatores pulmonares) e àquelas que causam lesão indireta, no contexto de um processo sistêmico (fatores extrapulmonares). Enquanto alguns autores argumentam que esses fatores resultam em apresentações diferentes, as implicações clínicas dessa classificação não foram bem estabelecidas. Outras condições podem aumentar a suscetibilidade para SDRA, como abuso de álcool, obesidade e ventilação mecânica com altos volumes correntes e altas pressões de vias aéreas; por outro lado, diabetes parece reduzir o risco de desenvolvimento de SDRA. Nos últimos anos, especial interesse tem surgido em estudos sobre predisposição genética à SDRA, e, no futuro, eles poderão ajudar na compreensão do motivo pelo qual apenas alguns pacientes com estímulo patológico desenvolvem a síndrome.

Acute respiratory distress syndrome (ARDS) results in critical illness consisting of acute severe hypoxemic respiratory failure with bilateral pulmonary infiltrates that are not attributable to left atrial hypertension. It is a heterogeneous disorder that can be triggered by myriad etiologies. Greater knowledge of the risk factors involved could increase the rate of early ARDS diagnosis. The risk factors for ARDS, which have remained the same for several years, include pneumonia, sepsis, aspiration of gastric contents, severe trauma, and multiple transfusions. These can be divided into those associated with direct injury to the lung (pulmonary factors) and those that cause indirect lung injury in the setting of a systemic process (extrapulmonary factors). Although some authors argue that the various risk factors provoke different presentations, the clinical implications have not been clarified. Other conditions that can increase susceptibility to ARDS include alcohol abuse, obesity, and mechanical ventilation with high tidal volume and high airway pressure. However, diabetes seems to reduce the risk of developing ARDS. In recent years, there has been increased interest in the study of genetic predisposition to ARDS, which might eventually prove helpful in explaining why only some patients with pathologic stimuli develop the syndrome.

Continuous positive airway pressure effects on regional lung aeration in patients with COPD: a high-resolution CT scan study.

BACKGROUND: The effects of nasal continuous positive airway pressure (CPAP) on the lung parenchyma of patients with COPD, to our knowledge, have never been assessed by high-resolution CT (HRCT) scanning. METHODS: HRCT scans were obtained at the apex, hilum, and basis of the lungs at functional residual capacity while on spontaneous respiration and at the end of CPAP trials of 5 cm water (H(2)O), 10 cm H(2)O, and 15 cm H(2)O in 11 stable patients with COPD and eight healthy volunteers. Lung aeration was assessed by quantitative density parameters and by qualitative analysis of each CT image after processing by means of a density-based color-mask computational algorithm. The quantitative parameters were density histograms, the relative area of the lungs with attenuation values < -950 Hounsfield units (percentage of hyperaerated areas) and the 15th percentile (the density value separating the 15% voxels of least density). RESULTS: A CPAP of 5 cm H(2)O caused little increase in lung aeration in both groups, but in some patients with COPD, CPAP deflated some regions of the lungs. CPAP levels of 10 cm H(2)O and 15 cm H(2)O increased the emphysematous zones in all sectors of the lungs, including dorsal and apical regions in patients with COPD compared to little hyperaeration predominantly in the ventral areas in healthy volunteers. CONCLUSIONS: Nasal CPAP causes variable effects on regional lung aeration in relation to the applied pressure and the regional distribution of emphysema in patients with COPD. Low pressure levels may cause regional lung deflation in some patients. High levels increase the emphysematous areas wherever they are located inside the lungs.

Assessment of the burden of caregiving for patients with chronic obstructive pulmonary disease.

OBJECTIVE: To determine the effect of chronic obstructive pulmonary disease (COPD) on the quality of life of caregivers. DESIGN AND METHODS: A cross-sectional study was carried out with forty-two COPD patients and their primary caregivers. Patients were assessed with the medical outcome survey short form (SF-36), the physical and mental component summary (PCS and MCS), Saint George's respiratory questionnaire (SGRQ), 6-min walking test, and spirometric and blood gas measurements. Caregivers were assessed using the medical outcome survey short form (SF-36), the physical and mental component summary (PCS and MCS), the 5-point Likert scale for measuring caregiver/patient relationships and the caregiver burden scale (CB scale). RESULTS: The majority of caregivers were female (85.3%), married (59%) and had low levels of income and schooling. The mean age was 51.6+/-16 years. Mean caregiver PCS and MCS scores were 45.9+/-10 and 46+/-12, while the mean total burden score was 1.79+/-0.6. The regression analysis showed caregiver/patient relationship quality, caregiver MCS scores and patient PCS scores to be important predictors of burden and explained 63% of the variance. CONCLUSIONS: COPD causes a significant impact on the quality of life of caregivers. The two most important predictors of COPD burden are the relationship between caregivers and patients and caregiver MCS scores.

Ventilação mecânica na doença pulmonar obstrutiva crônica / Mechanical ventilation in chronic obstructive pulmonary disease

JUSTIFICATIVA E OBJETIVOS: Em 2000, foi publicado o II Consenso Brasileiro de Ventilação Mecânica. Desde então, o conhecimento na área da ventilação mecânica avançou rapidamente, com a publicação de numerosos estudos clínicos que acrescentaram informações importantes para o manejo de pacientes críticos em ventilação artificial. Além disso, a expansão do conceito de Medicina Baseada em Evidências determinou a hierarquização das recomendações clínicas, segundo o rigor metodológico dos estudos que as embasaram. Essa abordagem explícita vem ampliando a compreensão e a aplicação das recomendações clínicas. Por esses motivos, a AMIB - Associação de Medicina Intensiva Brasileira - e a SBPT - Sociedade Brasileira de Pneumologia e Tisiologia - julgaram conveniente a atualização das recomendações descritas no Consenso anterior. Dentre os tópicos selecionados a Ventilação Mecânica na Agudização da DPOC foi um dos temas propostos. O objetivo deste estudo foi descrever os pontos mais importantes relacionados à ventilação mecânica durante a agudização da doença pulmonar obstrutiva crônica (DPOC) e sugerir as principais abordagens terapêuticas. MÉTODO: Objetivou-se chegar a um documento suficientemente sintético, que refletisse a melhor evidência disponível na literatura. A revisão bibliográfica baseou-se na busca de estudos através de palavras-chave e em sua gradação conforme níveis de evidência. As palavras-chave utilizadas para a busca foram: ventilação mecânica na DPOC: COPD and mechanical ventilation. RESULTADOS: São apresentadas recomendações quanto aos modos ventilatórios e aos parâmetros a serem aplicados quando do ajuste do ventilador, além da monitoração recomendada. Apresentam-se ainda, técnicas alternativas que possam ser utilizadas. CONCLUSÕES: Estratégias protetoras de ventilação mecânica são recomendadas durante a ventilação mecânica de um paciente DPOC agudizado.

BACKGROUND AND OBJECTIVES: The II Brazilian Consensus Conference on Mechanical Ventilation was published in 2000. Knowledge on the field of mechanical ventilation evolved rapidly since then, with the publication of numerous clinical studies with potential impact on the ventilatory management of critically ill patients. Moreover, the evolving concept of evidence - based medicine determined the grading of clinical recommendations according to the methodological value of the studies on which they are based. This explicit approach has broadened the understanding and adoption of clinical recommendations. For these reasons, AMIB - Associação de Medicina Intensiva Brasileira and SBPT - Sociedade Brasileira de Pneumologia e Tisiologia - decided to update the recommendations of the II Brazilian Consensus. Mechanical ventilation in COPD exacerbation has been one of the updated topics. Describe the most important topics on the mechanical ventilation during the COPD exacerbation and suggest the main therapeutic approaches. METHODS: Systematic review of the published literature and gradation of the studies in levels of evidence, using the keywords "mechanical ventilation" and "COPD". RESULTS: We present recommendations on the ventilatory modes and settings to be adopted when ventilating a patient during an asthma attack, as well as the recommended monitoring. Alternative ventilation techniques are also presented. CONCLUSIONS: Protective ventilatory strategies are recommended when ventilating a patient during a.

[Mechanical ventilation in chronic obstructive pulmonary disease]. / Ventilação mecânica na doença pulmonar obstrutiva crônica.

BACKGROUND AND OBJECTIVES: The II Brazilian Consensus Conference on Mechanical Ventilation was published in 2000. Knowledge on the field of mechanical ventilation evolved rapidly since then, with the publication of numerous clinical studies with potential impact on the ventilatory management of critically ill patients. Moreover, the evolving concept of evidence - based medicine determined the grading of clinical recommendations according to the methodological value of the studies on which they are based. This explicit approach has broadened the understanding and adoption of clinical recommendations. For these reasons, AMIB - Associação de Medicina Intensiva Brasileira and SBPT - Sociedade Brasileira de Pneumologia e Tisiologia - decided to update the recommendations of the II Brazilian Consensus. Mechanical ventilation in COPD exacerbation has been one of the updated topics. Describe the most important topics on the mechanical ventilation during the COPD exacerbation and suggest the main therapeutic approaches. METHODS: Systematic review of the published literature and gradation of the studies in levels of evidence, using the keywords "mechanical ventilation" and "COPD". RESULTS: We present recommendations on the ventilatory modes and settings to be adopted when ventilating a patient during an asthma attack, as well as the recommended monitoring. Alternative ventilation techniques are also presented. CONCLUSIONS: Protective ventilatory strategies are recommended when ventilating a patient during a.