Noninvasive mechanical ventilation with average volume assured pressure support (AVAPS) in patients with chronic obstructive pulmonary disease and hypercapnic encephalopathy.

BACKGROUND: Non-invasive mechanical ventilation (NIV) in patients with acute respiratory failure has been traditionally determined based on clinical assessment and changes in blood gases, with NIV support pressures manually adjusted by an operator. Bilevel positive airway pressure-spontaneous/timed (BiPAP S/T) with average volume assured pressure support (AVAPS) uses a fixed tidal volume that automatically adjusts to a patient's needs. Our study assessed the use of BiPAP S/T with AVAPS in patients with chronic obstructive pulmonary disease (COPD) and hypercapnic encephalopathy as compared to BiPAP S/T alone, upon immediate arrival in the Emergency-ICU. METHODS: We carried out a prospective interventional match-controlled study in Guayaquil, Ecuador. A total of 22 patients were analyzed. Eleven with COPD exacerbations and hypercapnic encephalopathy with a Glasgow Coma Scale (GCS) <10 and a pH of 7.25-7.35 were assigned to receive NIV via BiPAP S/T with AVAPS. Eleven patients were selected as paired controls for the initial group by physicians who were unfamiliar with our study, and these patients were administered BiPAP S/T. Arterial blood gases, GCS, vital signs, and ventilatory parameters were then measured and compared between the two groups. RESULTS: We observed statistically significant differences in favor of the BiPAP S/T + AVAPS group in GCS (P = .00001), pCO(2) (P = .03) and maximum inspiratory positive airway pressure (IPAP) (P = .005), among others. However, no significant differences in terms of length of stay or days on NIV were observed. CONCLUSIONS: BiPAP S/T with AVAPS facilitates rapid recovery of consciousness when compared to traditional BiPAP S/T in patients with chronic obstructive pulmonary disease and hypercapnic encephalopathy. TRIAL REGISTRATION: Current Controlled Trials application ref is ISRCTN05135218.

Use of high-flow nasal cannula and intravenous propofol sedation while performing flexible video bronchoscopy in the intensive care unit: Case reports.

Flexible video bronchoscopy is a procedure that plays an important role in diagnosing various types of pulmonary lesions and abnormalities. Case 1 is a 68-year-old male patient with a lesion in the right lung apex of approximately 4 mm × 28 mm with atelectasis bands due to a crash injury. High-flow system with 35 L/min and fraction of inspired oxygen (FiO2) 0.45 and temperature of 34 °C was installed prior to the video bronchoscopy. SpO2 was maintained at 98%-100%. The total dose of sedative was 50 mg of propofol. In Case 2, a 64-year-old male patient with bronchiectasis, cystic lesions and pulmonary fibrosis of the left lung field was placed on a high-flow system with 45 L/min and 0.35 FiO2 at a temperature of 34 °C. SpO2 was maintained at 100%. The total duration of the procedure was 25 min; SpO2 of 100% was sustained with oxygenation during maintenance time with the flexible bronchoscope within the airway. The total dose of propofol to reach the degree of desired sedation was 0.5-1 mg/kg. Both patients presented hypotension. For the patient of case 1, a vasopressor (norepinephrine at doses of 0.04 µg/kg/min) was given, and for the patient of case 2, only saline volume expansion was used. The video bronchoscopy with propofol sedation and high-flow nasal cannula allows adequate oxygenation during procedure in the intensive care unit.

Spontaneous Pneumothorax After Rupture of the Cavity as the Initial Presentation of Tuberculosis in the Emergency Department.

BACKGROUND Spontaneous pneumothorax can be secondary to a wide variety of lung diseases. Spontaneous pneumothorax secondary to pulmonary tuberculosis occurs in rare cases of residual fibrosis with retractions and bullae. CASE REPORT We present the case of a 65-year-old male patient from a rural area in the province of Los Ríos in Babahoyo, Ecuador, with no history of contact with tuberculosis. The patient arrived at the Emergency Department of the Regional Hospital of the Instituto Ecuatoriano de Seguridad Social (IESS), Babahoyo, due to acute respiratory failure, preceded by 10 days of evolution due to cough accompanied by greenish expectoration, chest pain, asthenia, and weight loss. On chest radiography, a left pneumothorax and interstitial pulmonary infiltrate were reported. A chest tube was placed, and the patient was intubated and was placed on invasive mechanical ventilation due to severe respiratory failure. Use of the GeneXpert MTB/RIF System detected Mycobacterium tuberculosis without resistance to rifampicin. Ziehl-Neelsen (ZN) staining for the identification of bacillus acid-resistant alcohol was positive in alveolar bronchial lavage. MALDI-TOF mass spectrometry and phenotypic analysis showed the presence of Pseudomonas aeruginosa and Klebsiella pneumonia with carbapenemases resistance mechanism, and the KPC type enzyme was identified. The culture for Mycobacterium tuberculosis was positive from the fourth week. CONCLUSIONS Secondary pneumothorax due to rupture of the polymicrobial cavity and especially of tuberculous origin is a very special form of acute respiratory failure in patients with previous structural pulmonary lesions in the Emergency Department.

Volume-assured pressure support mode plus pirfenidone as resuscitation therapy in patients with exacerbation of idiopathic pulmonary fibrosis.

INTRODUCTION: Treatment among advanced stage idiopathic pulmonary fibrosis is quite challenging, especially considering that no major evidence has been released about it. This case report demonstrates and discusses the benefit of non-invasive mechanical ventilation in volume-assured pressure support (AVAPS) mode plus pirfenidone based on the relief of apatient'ssymptoms in combination with high-resolution computed tomography (HRCT) evidence. MATERIAL AND METHODS: An 83-year-old female patient with multiple hospital admissions within a six-month period initially presented with cardiac symptoms which were later attributed to apossible exacerbation of her primary diagnosis, idiopathic pulmonary fibrosis. CONCLUSION: The addition of non-invasive mechanical ventilation in AVAPS mode plus pirfenidone can improve the survival rates even in patients with current exacerbations of acute respiratory failure due to idiopathic pulmonary fibrosis.

Ischemic Stroke and Disseminated Tuberculosis in Intensive Care: A Case Report.

BACKGROUND Tuberculosis (TB) continues to be a major public health problem worldwide. Extrapulmonary tuberculosis at the level of the central nervous system is the most devastating and deadly form of tuberculosis. CASE REPORT We present the case of a 73-year-old male Ecuadorian patient with no history of contact with tuberculosis and with a clinical picture of 4 days of evolution characterized by aphasia, deviation of the labial commissure, and deterioration of the level of consciousness with a Glasgow coma score of 7/15. A brain tomography showed evidence of indirect signs of cerebral ischemia; the patient was therefore diagnosed with non-specific cerebrovascular disease. Due to the critical nature of his clinical picture, the patient entered the Intensive Care Unit (ICU), where a chest x-ray was performed and bilateral perihilar alveolar opacities with a reticular and nodular pattern were visualized. These results, combined with the bronchoalveolar brushing, evidenced the presence of Mycobacterium tuberculosis. Adenosine of deaminase (ADA) was also detected in the cerebrospinal fluid with 30.7 µ/L and a molecular biology technique was used with high-multiplex real-time polymerase matrix MALDI-TOF mass spectrometry (Brucker Daltonics) for rapid identification of the causative agent. DNA/polymerase chain reaction (PCR) analyses were used for detection of M. tuberculosis, subsequently confirming the presence of cerebral tuberculosis. CONCLUSIONS This case illustrated an infrequent form of disseminated tuberculosis in a critically ill patient. Timely diagnosis and appropriate management are essential to reducing mortality.

Bronchial Visualization of Tetanic Contractions: A Case Report.

BACKGROUND Tetanus is a potentially fatal infectious disease which, during its evolution, creates multiple complications, usually requiring intensive management and care. CASE REPORT We present a clinical case of a 59-year-old male patient with generalized tetanus admitted to the intensive care unit. Flexible bronchoscopy revealed contraction of the bronchial demonstrating that tetany existed at the respiratory level, which rarely becomes evident. The clinical manifestations included trismus, facial paralysis, neck stiffness, and compromised respiratory function. The patient presented a state of respiratory failure that required invasive mechanical ventilation which was evaluated by bronchoscopy and that showed spasms of the bronchial musculature. The patient presented generalized tetanus in which the bronchial affectation was evaluated by bronchoscopy in the intensive care unit. In developed countries, the anti-tetanus toxoid vaccine has ostensibly decreased its incidence, while it is endemic in developing countries, and although there are measures such as vaccination that try to reduce its incidence, in Ecuador there is an increase in incidences. In this patient case, contraction of the bronchial rings was observed, demonstrating that tetany existed at the respiratory level, which rarely becomes evident. CONCLUSIONS Although muscular contractions are widespread, this clinical case evidences bronchial spams reported and visualized by bronchoscopy.

Determinants of immediate failure of noninvasive mechanical ventilation outside the intensive care unit.

BACKGROUND: This study aimed to characterize which are the early determinants of immediate failure of the use of noninvasive mechanical ventilation (NIMV) outside the ICU. METHODS: This prospective study included patients who were admitted to the Military Hospital in Guayaquil, Ecuador. Each variable was analyzed independently by using a multiple logistic regression model toward establishing an association with the event. RESULTS: A total of 249 cases of NIMV over a 10 year period of its application outside the ICU was included in the study. Fifty-five (22.10%) patients were transferred to the ICU, A multivariate analysis showed that the determinants of immediate NIMV failure outside the ICU were the following: age (OR: 1.12; P = 0.03); SBP (OR: 1.04; P = 0.001); HR (OR: 1.66; P < 0.0001); pCO2 (OR: 1.16; P = 0.007); pO2 (OR: 1.35; P = 0.003); levels of IPAP (OR: 1.35; P < 0.0001); and the number of quadrants affected, as shown in a chest X-ray (OR: 1.40; P < 0.0001). CONCLUSIONS: The number of affected quadrants in a chest X-ray, tachyarrhythmia and hypoxemia may be useful in the initial decision in the use of NIMV outside the ICU. High values of IPAP, the persistence of elevated pCO2, arterial hypotension, and age could be useful as a second screening associated with immediate NIMV failure outside the ICU.