Prevention and treatment of skin lesions associated with non-invasive mechanical ventilation. Recommendations of experts. / Prevención y tratamiento de las lesiones cutáneas asociadas a la ventilación mecánica no invasiva. Recomendaciones de expertos.

INTRODUCTION: In the last two decades, non-invasive mechanical ventilation (NIV) has been consolidated as an initial strategy for the management of respiratory failure in critical adult and paediatric patients. OBJECTIVES: To identify risk factors and preventive strategies to reduce the incidence of skin lesions associated with clinical devices (LESADIC) related to NIV, as well as the most effective treatment for injuries that cannot be avoided. METHODOLOGY: Review in the MEDLINE, CINAHL and Cochrane databases of studies published in the last 10years to reach consensus through an expert panel. RESULTS: Knowledge about how to measure correct mask size and protection of the skin with foam or hydrocolloids dressings are factors related to the incidence of LESADIC, as it conditions the degree of pressure-friction and shear that the interface exerts on the skin. The interface that causes fewer LESADIC and is better tolerated is the face mask. When there are injuries, the first thing is to remove the interface that causes pressure on damaged skin, recommending a Helmet® hood as an alternative, treating the infection, managing the exudate and stimulating perilesional skin. CONCLUSIONS: The mask of choice is the facial, always using foam or hydrocolloid dressings on the nasal bridge. Evaluate the condition of the skin under the interface and harness every 4hours (recommended) and 11hours (maximum). Evaluate the rotation strategy of the interface at 24hours if the NIV is still needed on an ongoing basis.

Recurrent pneumothorax after cesarean delivery in the critically ill pregnant with severe COVID-19 ARDS: a case report.

OBJECTIVE: Few data are available on the ICU management and on the possible respiratory complications of invasively ventilated pregnant patients affected by COVID-19 pneumonia, especially in the early phase of pregnancy. Tension pneumothorax has been previously described as a rare cause of respiratory failure after delivery, but its occurrence in the postpartum of COVID-19 patient has not been reported yet. We hereby describe the ICU management of a 23rd gestational week pregnant woman who underwent invasive mechanical ventilation, prone positioning, and cesarean delivery during her ICU stay for COVID-19 related pneumonia. Moreover, we focused on the occurrence and management of recurrent tension pneumothorax after the cesarean delivery. CASE REPORT: A 23rd gestational week pregnant woman was admitted to the ICU for a COVID-19 bilateral pneumonia and underwent invasive mechanical ventilation and prone positioning. Cesarean delivery was planned during the ICU stay, while the patient was receiving invasive mechanical ventilation. After delivery, the patient experienced a recurrent pneumothorax that required the positioning of multiple chest drains. CONCLUSIONS: In pregnant critically ill COVID-19 patients, mechanical ventilation management is particularly challenging, especially in the postpartum period. Prone positioning is feasible and can improve oxygenation and respiratory system compliance, while tension pneumothorax must be suspected if the respiratory function suddenly deteriorates after delivery.

Prophylactic use of non-invasive mechanical ventilation in lung resection.

OBJECTIVE: To evaluate if the prophylactic application of BiPAP previous to lung resection and 17 hours postoperatively improves respiratory function. In order to do this, we studied the results of arterial blood gases and portable spirometry in the immediate postoperative period and at the first and third postoperative day. Secondary objectives included evaluating whether this same pattern decreases the incidence of postoperative pulmonary complications (PPC) and hospital stay. PATIENTS AND METHODS: This was a prospective, randomized clinical study. Between January 2012 and June 2013, 50 patients who had undergone lung resection with posterolateral thoracotomy were assigned to one of two groups by a random number generator according to whether or not they would receive prophylactic BiPAP pre- and postoperatively. RESULTS: The results of the gasometric and spirometric values were similar in both groups. There were no statistically significant differences (p > 0.05). There was not a decrease in the incidence of PPC in the group that received prophylactic BiPAP. Likewise, postoperative stay was similar in both groups. The BiPAP group was 6.60 ± 4 days and the non BiPAP group was 6.84 ± 3.94 days (p = 0.63). CONCLUSIONS: One drawback of this work was the limited number of hours that BiPAP was employed, and when compared to other studies, the application of low-pressure support. We did not find any significant differences between using prophylactic BiPAP or not, suggesting that such treatment should not be performed indiscriminately. More investigations are needed with a larger number of patients in order to better evaluate the possible benefits of using prophylactic BiPAP in thoracic surgery.

[Non-invasive mechanical ventilation in postoperative patients. A clinical review]. / Ventilación mecánica no invasiva en el postoperatorio. Revisión clínica.

Non-invasive ventilation (NIV) is a method of ventilatory support that is increasing in importance day by day in the management of postoperative respiratory failure. Its role in the prevention and treatment of atelectasis is particularly important in the in the period after thoracic and abdominal surgeries. Similarly, in the transplanted patient, NIV can shorten the time of invasive mechanical ventilation, reducing the risk of infectious complications in these high-risk patients. It has been performed A systematic review of the literature has been performed, including examining the technical, clinical experiences and recommendations concerning the application of NIV in the postoperative period.

[Non-invasive mechanical ventilation in the pre- and intraoperative period and difficult airway]. / Ventilación mecánica no invasiva en pre eintraoperatorio y vía aérea difícil.

Non-invasive mechanical ventilation is a method of ventilatory assistance aimed at increasing alveolar ventilation, thus achieving, in selected subjects, the avoidance of endotracheal intubation and invasive mechanical ventilation, with the consequent improvement in survival. There has been a systematic review and study of the technical, clinical experiences, and recommendations concerning the application of non-invasive mechanical ventilation in the pre- and intraoperative period. The use of prophylactic non-invasive mechanical ventilation before surgery that involves significant alterations in the ventilatory function may decrease the incidence of postoperative respiratory complications. Its intraoperative use will mainly depend on the type of surgery, type of anaesthetic technique, and the clinical status of the patient. Its use allows greater anaesthetic depth without deterioration of oxygenation and ventilation of patients.

A systematic technical review of the systems for the continuous positive airway pressure.

Continuous positive airway pressure (CPAP) is the application in the airways of continuous positive pressure, close to the positive end expiratory pressure. The two common available systems are by a continuous (high/low) flow system and by a mechanical ventilator. Aim of this study was to compare the mechanical performance of the CPAP systems in intubated and not intubated patients. Medical literature databases (MEDLINE and EMBASE) were searched for articles on "clinical trials" and "randomized controlled trials". The key words "continuous positive airway pressure" and "CPAP", were combined with any of these key words: adult, work of breathing, continuous flow, mechanical valve, water valve, balloon reservoir, mechanical ventilator, pressure triggering, flow triggering, lung model, demand valve, equipment. Thirty-two articles (18 human and 14 bench studies) met the inclusion criteria. The continuous flow systems are able to maintain acceptable airway pressure variations during normal breathing. The most recent mechanical ventilators equipped with flow by systems compared to the first one, presented a similar or better work of breathing compared to the continuous flow systems due to the application of a little amount of pressure support. Although the use of a continuous flow is cheaper compared to mechanical ventilators, it does not allow a continuous respiratory monitoring.