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BACKGROUND: Asthma is a common chronic respiratory disease affecting 1-29% of the population in different countries. Exacerbations represent a change in symptoms and lung function from the patient's usual condition that requires emergency department (ED) admission. Recently, the use of a High-Flow Nasal Cannula (HFNC) plus an in-line vibrating mesh nebulizer (VMN) for aerosol drug delivery has been advocated in clinical practice. Thus, this pilot observational study aims to investigate the feasibility of HFNC treatment with VMN for in-line bronchodilator delivery in patients with severe asthma. METHODS: This study was conducted from May 2022 to May 2023. Subjects ≥ 18 years old with a previous diagnosis of asthma who were admitted to the ED during severe exacerbation were included. The primary endpoint was the change in peak expiratory flow ratio (PEFR) after 2-h of treatment with bronchodilator delivered by HFNC with in-line VMN. Additional outcomes were changes in forced expiratory volume in 1 second (FEV1) and clinical variables before treatment. RESULTS: 30 patients mean age of 43 (SD ± 16) years, mostly female (67%) were studied. A significant change in PEFR (147 ± 31 L/m vs. 220 ± 38 L/m; p < 0.001) was observed after treatment with HFNC and in-line VMN with significant improvement in clinical variables. And no subjects required invasive mechanical ventilation (IMV) during the study. CONCLUSIONS: HFNC treatment with in-line VMN for bronchodilator delivery appears feasible and safe for patients with severe asthma exacerbation. These preliminary promising results should be confirmed with appropriately large-designed studies.
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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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BACKGROUND: Bronchodilator delivery via a high-flow nasal cannula (HFNC) has generated interest in recent years. The efficacy of in-line vibrating mesh nebulizers with an HFNC during COPD exacerbation is limited. The aim of this study was to evaluate the clinical response of subjects with COPD exacerbation who require bronchodilator therapy (anticholinergic and ß-agonist) by using a vibrating mesh nebulizer in line with an HFNC. METHODS: This was a prospective single-center study performed in a respiratory intermediate care unit that enrolled patients with a diagnosis of COPD exacerbation who required noninvasive ventilation on admission. All the subjects underwent noninvasive ventilation breaks with an HFNC. After clinical stability, pulmonary function tests were performed to assess changes in FEV1 and clinical parameters before and after bronchodilation by using a vibrating mesh nebulizer in line with an HFNC. RESULTS: Forty-six patients with COPD exacerbation were admitted. Five patients who did not use noninvasive ventilation and 10 patients who did not receive bronchodilator treatment with a vibrating mesh nebulizer were excluded. Thirty-one were selected, but 1 subject was secondarily excluded due to loss of data. Finally, 30 subjects were included. The primary outcome was spirometric changes in FEV1. The mean ± SD FEV1 before receiving bronchodilator treatment by using a vibrating mesh nebulizer in line with an HFNC was 0.74 ± 0.10 L, and, after receiving treatment, the mean ± SD FEV1 changed to 0.88 ± 0.12 L (P < .001). Similarly, the mean ± SD FVC increased from 1.75 ± 0.54 L to 2.13 ± 0.63 L (P < .001). Considerable differences were observed in breathing frequency and heart rate after receiving bronchodilator treatment. No relevant changes were observed in the Borg scale or Sp O2 after treatment. The mean clinical stability recorded was 4 d. CONCLUSIONS: In subjects with COPD exacerbation, bronchodilator treatment by using a vibrating mesh nebulizer in line with an HFNC showed a mild but significant improvement in FEV1 and FVC. In addition, a decrease in breathing frequency was observed, suggesting a reduction in dynamic hyperinflation.
Assuntos
Ventilação não Invasiva , Doença Pulmonar Obstrutiva Crônica , Humanos , Broncodilatadores , Cânula , Estudos Prospectivos , Aerossóis e Gotículas Respiratórios , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Nebulizadores e VaporizadoresRESUMO
BACKGROUND: The roles of high-flow nasal cannula (HFNC) and CPAP in coronavirus disease 2019 (COVID-19) are controversial. The objective of the study was to evaluate the impact of the application of a noninvasive respiratory support algorithm on clinical outcomes in subjects with COVID-19 and with acute respiratory failure. METHODS: We performed a single-center prospective observational study of subjects with respiratory failure from COVID-19 managed with HFNC and with CPAP plus HFNC (combined therapy). The main outcome was the intubation rate, which defined failure of therapy. We also analyzed the role of the ROX index ([[Formula: see text]/[Formula: see text]]/breathing frequency) to predict the need for intubation. RESULTS: From June to December 2020, 113 subjects with COVID-19 respiratory failure were admitted to our respiratory intermediate care unit. HFNC was applied in 65 subjects (57.52%) and combined therapy in 48 subjects (42.47%). A total of 83 subjects (73.45%) were successfully treated with noninvasive respiratory support. The intubation rate was 26.54%, and the overall mortality rate was 14.15%. The mortality rate in subjects who were intubated was 55.2%. An ROX index of 6.28 at 12 h predicted noninvasive respiratory support failure, with 97.6% sensitivity and 51.8% specificity. CONCLUSIONS: Data from our cohort managed in a respiratory intermediate care unit showed that combined noninvasive respiratory support was feasible, with favorable outcomes. Further prospective studies are required.
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COVID-19 , Ventilação não Invasiva , Insuficiência Respiratória , Cânula , Humanos , Oxigenoterapia , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/terapia , SARS-CoV-2RESUMO
Según muy bien expuso el Dr Barimboim en su artículo "Apnea del sueño como factor de riesgo en intervenciones quirúrgicas" las anestesias se pueden complicar más en pacientes con síndrome de apnea-hipopnea de sueño (SAHS) no tratados. Las estadísticas así lo demuestran. Es importante que recordemos que un paciente que requiere entrar al quirófano lo hace para mejorar cierto padecimiento y no para adquirir un nuevo problema de salud como podría ser una complicación post-quirúrgica. La teoría ya describe todas las complicaciones posibles que un paciente con SAHS no tratado puede padecer durante un acto anestésico, falta llevar a la práctica toda la información que ya tenemos. Es decir, si la anestesia la realizan los anestesistas y los pacientes con SAHS se complican al no tener diagnostico, deberíamos involucrar a estos especialistas con el diagnostico de este grupo de riesgo
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Síndromes da Apneia do Sono , Procedimentos Cirúrgicos OperatóriosRESUMO
El compromiso severo de los músculos respiratorios en el Guillain Barré se observa en alrededor del 25 por ciento de los pacientes. Para evaluar las características y la evolución de este grupo se revisaron las historias clínicas de los pacientes que ingresaron a nuestro Hospital entre enero del '87 y diciembre del '96. De los 44 pacientes con compromiso respiratorio, el 70.5 por ciento requiró ARM (asistencia respiratoria mecánica). La edad fue de 34.0 + 14.1 años. El 70.5 por ciento era de sexo masculino. El tiempo entre el inicio de síntomas y el comienzo de la ARM fue de 9.4 + 8.0 días. El tiempo de ARM fue mayor en los pacientes con menos de 48 hs de evolución de la enfermedad (2 100 + 2 076 vs 934 + 735 hs p < 0.05). Todos los pacientes presentaron, el 43 tenía disautonomía y el 55 por ciento compromiso de pares craneanos. El 24 por ciento presentó serología positiva para citomegalovirus. La capacidad vital pre'via a la ARM fue de 1 050 + 378 ml. El tiempo de ventilación mecánica fue de 1 224 + 1 208 hs. Dos de las pacientes que sobreviveron superaron los 6 meses de ARM. La mortalidad fue del 18 por ciento. La edad fue mayor en los fallecidos (44.9 + 17.5 vs 31.9 + 12.5, p < 0.02). La capacidad vital de egreso fue de 2 837 + 1 080 ml. En nuestro grupo se evidenció alto porcentaje de ARM, predominancia del sexo masculino, mayor tiempo de ARM en pacientes con evolución más rápida y tiempo de ARM prolongado. La mortalidad se relacionó con mayor edad, sepsi, barotrauma y disautonomía severa.