Effectiveness and safety of non-invasive ventilation in the management of cardiogenic shock.

INTRODUCTION AND OBJECTIVES: Cardiogenic shock (CS) has long been considered a contraindication for the use of non-invasive ventilation (NIV). The main objective of this study was to analyze the effectiveness, measured as NIV success, in patients with respiratory failure due to CS. As secondary objective, we studied risk factors for NIV failure and compared the outcome of patients treated with NIV versus invasive mechanical ventilation (IMV). METHODS: Retrospective study on a prospective database, over a period of 25 years, of all consecutively patients admitted to an intensive care unit, with a diagnosis of CS and treated with NIV. A comparison was made between patients on NIV and patients on IMV using propensity score matching analysis. RESULTS: Three hundred patients were included, mean age 73.8 years, mean SAPS II 49. The main cause of CS was acute myocardial infarction (AMI): 164 (54.7%). NIV failure occurred in 153 (51%) cases. Independent factors for NIV failure included D/E stages of CS, AMI, NIV related complications, and being transferred from the ward. In the propensity analysis, hospital mortality (OR 1.69, 95% CI 1.09-2.63) and 1 year mortality (OR 1.61, 95% CI 1.04-2.51) was higher in IMV. Mortality was lower with NIV (vs. EIT-IMV) in C stage (10.1% vs. 32.9%; p<0.001) but did not differ in D stage or E stage. CONCLUSIONS: NIV seems to be relatively effective and safe in the treatment of early-stage CS.

Analysis of combined non-invasive respiratory support in the first six waves of the COVID-19 pandemic. Outcome according to the first respiratory support.

Introduction: COVID-19 can lead to acute respiratory failure (ARF) requiring admission to intensive care unit (ICU). This study analyzes COVID-19 patients admitted to the ICU, according to the initial respiratory support. Its main aim is to determine if the use of combination therapy: high-flow oxygen system with nasal cannula (HFNC) and non-invasive ventilation (NIV), is effective and safe in the treatment of these patients. Methods: Retrospective observational study with a prospective database. All COVID-19 patients, admitted to the ICU, between March 11, 2020, and February 12, 2022, and who required HFNC, NIV, or endotracheal intubation with invasive mechanical ventilation (ETI-IMV) were analyzed. HFNC failure was defined as therapeutic escalation to NIV, and NIV failure as the need for ETI-IMV or death in the ICU. The management of patients with non-invasive respiratory support included the use of combined therapy with different devices. The study period included the first six waves of the pandemic in Spain. Results: 424 patients were analyzed, of whom 12 (2.8%) received HFNC, 397 (93.7%) NIV and 15 (3.5%) ETI-IMV as first respiratory support. PaO2/FiO2 was 145 ± 30, 119 ± 26 and 117 ± 29 mmHg, respectively (p = 0.003). HFNC failed in 11 patients (91.7%), who then received NIV. Of the 408 patients treated with NIV, 353 (86.5%) received combination therapy with HFNC. In patients treated with NIV, there were 114 failures (27.9%). Only the value of SAPS II index (p = 0.001) and PaO2/FiO2 (p < 0.001) differed between the six analyzed waves, being the most altered values in the 3rd and 6th waves. Hospital mortality was 18.7%, not differing between the different waves (p = 0.713). Conclusions: Severe COVID-19 ARF can be effectively and safely treated with NIV combined with HFNC. The clinical characteristics of the patients did not change between the different waves, only showing a slight increase in severity in the 3rd and 6th waves, with no difference in the outcome.

Outcome of patients with acute heart failure secondary to acute myocardial infarction treated with noninvasive mechanical ventilation.

INTRODUCTION AND OBJECTIVES: Noninvasive ventilation (NIV) has been shown to reduce the rate of endotracheal intubation and mortality in patients with acute heart failure (AHF). However, patients with AHF secondary to acute coronary syndrome/acute myocardial infarction (ACS-AMI) have been excluded from many clinical trials. The purpose of this study was to compare the effectiveness of NIV between patients with AHF triggered by ACS-AMI and by other etiologies. METHODS: Prospective cohort study of all patients with AHF treated with NIV admitted to the intensive care unit for a period of 20 years. Patients were divided according to whether they had ACS-AMI as the cause of the AHF episode. NIV failure was defined as the need for endotracheal intubation or death. RESULTS: A total of 1009 patients were analyzed, 403 (40%) showed ACS-AMI and 606 (60%) other etiologies. NIV failure occurred in 61 (15.1%) in the ACS-AMI group and in 64 (10.6%) in the other group (P=.031), without differences in in-hospital mortality (16.6% and 14.9%, respectively; P=.478). CONCLUSIONS: The presence of ACS-AMI as the triggering cause of AHF did not influence patients with acute respiratory failure requiring noninvasive respiratory support.

Is hypocapnia a risk factor for non-invasive ventilation failure in cardiogenic acute pulmonary edema?

INTRODUCTION AND PURPOSE: The impact of hypocapnia in the prognosis of cardiogenic acute pulmonary edema (CAPE) has not been sufficiently studied. The aim of this study was to analyse whether hypocapnia is a risk factor for non-invasive ventilation (NIV) failure and hospital mortality, in CAPE patients CAPE. METHODS: Retrospective observational study of all patients with CAPE treated with NIV. Patients were classified in three groups according to PaCO2 level (hypocapnic, eucapnic and hypercapnic). NIV failure was defined as the need for endotracheal intubation and/or death. RESULTS: 1138 patients were analysed, 390 (34.3%) of which had hypocapnia, 186 (16.3%) had normocapnia and 562 (49.4%) had hypercapnia. NIV failure was more frequent in hypocapnic (60 patients, 15.4%) than in eucapnic (16 pacientes, 8.6%) and hypercapnic group (562 pacientes, 10.7%), with statistical significance (p = 0.027), as well as hospital mortality, 73 (18.7%), 19(10.2%) and 83 (14.8%) respectively (p = 0.026). The predicted factors for NIV failure were the presence of do-not-intubate order, complications related to NIV, a lower left ventricular ejection fraction, higher SAPS II and SOFA score and a higher HACOR score at one hour of NIV initiation. CONCLUSIONS: Hypocapnia in patients with CAPE is associated with NIV failure and a greater in-hospital mortality.

[Predictive factors related to success of non invasive ventilation and mortality in the treatment of acute cardiogenic pulmonary edema]. / Factores de predicción del éxito de la ventilación no invasiva en el tratamiento del edema agudo de pulmón cardiogénico.

BACKGROUND AND OBJECTIVE: Recent studies support the use of non invasive ventilation (NIV) in patients with acute cardiogenic pulmonary edema (ACPE). We aimed to evaluate the factors related to the success of the technique in patients admitted to an intensive care unit (ICU) with ACPE. PATIENTS AND METHOD: An observational prospective study was performed in ICU.199 consecutive patients were enrolled with ACPE at admission who received treatment with NIV and standardized pharmacological treatment. The success of the NIV was achieved when endotracheal intubation was avoided and patients were alive without dyspnea within and 24 hours after discharge from the ICU. Clinical, physiological and gasometric parameters were analyzed at admission and one hour after starting NIV. RESULTS: Patient's age was 74 years. 43% were male. The SAPS II was 45. 74.4% of the patients were successfully treated with NIV. 12.6% required endotracheal intubation. In a multivariate analysis, the success of the technique (values expressed as odds ratio [95% confidence interval]) was related to: SAPS II (0.95 [0.91-0.99]); the place of admission (6.78 [1.85-24.79]); value of PCO2 at admission (1.05 [1.01-1.09]); PO2/FiO2 index (1.03 [1.01-1.06]) and respiratory frequency (0.91 [0.84-0.99]) within the first hour; SOFA (acute failure organics score) (0.62 [0.49-0.78]); concomittant acute myocardial infarction (AMI) (0.05 [0.01-0.22]) and number of complications (0.17 [0.47-0.65]). The hospital mortality rate was 32.7%. The non intubation order (0.12 [0.04-0.32]) and the success of the technique (100.03 [28.71-348.47]) were related to the hospital mortality. CONCLUSIONS: The success of NIV in the treatment of ACPE is related to a lower SAPS II, admission at the emergency department, elevated PCO2 at admission, improvement of the PO2/FiO2 index and the respiratory rate within the first hour. The non intubation order and the success of the technique were related to the hospital mortality.

[Computerised tomography in the diagnosis of intestinal and mesenteric injuries in closed abdominal trauma]. / Utilidad de la tomografía computarizada para el diagnóstico de lesiones intestinales y mesentéricas en el trauma abdominal cerrado.

BACKGROUND: The frequency of bowel and mesenteric injuries is increasing. They are difficult to diagnose and delays in their diagnosis leads to a significantly increased morbidity and mortality. The aim of this study is to evaluate the usefulness of the computed tomography (CT) in the detection of blunt bowel and mesenteric injuries. METHOD: Between January 2000 and October 2007, 79 patients with blunt abdominal trauma (60 men and 19 women) were included in our study. They underwent laparotomy after performing the abdominal CT. The CT findings were compared with the findings at laparotomy in order to determine the accuracy of the CT in the detection of bowel and mesenteric injuries. RESULTS: For the detection of bowel and mesenteric injuries we obtained for the CT: Sensitivity=84.2%, Specificity=75.6%, Positive Predictive Value =76.2%, Negative Predictive Value =83.8%, Positive Probability Value=3.45 and Negative Probability Value =0.21. Accuracy: 79.7%. CONCLUSION: The abdominal CT is suitable for detecting bowel and mesenteric injuries following blunt abdominal trauma.

Utilidad de la tomografía computarizada para el diagnóstico de lesiones intestinales y mesentéricas en el trauma abdominal cerrado / Computerised tomography in the diagnosis of intestinal and mesenteric injuries in closed abdominal trauma

Introducción Las lesiones de víscera hueca y mesentéricas en pacientes politraumatizados están en aumento. Su diagnóstico representa un reto para el radiólogo y el clínico experimentado, ya que su retraso aumenta la morbimortalidad. El desarrollo de la tomografía computarizada (TC) helicoidal lo ha mejorado, aunque los resultados publicados son contradictorios. El objetivo de este trabajo es valorar la utilidad de la TC en el diagnóstico de estas lesiones en el traumatismo abdominal cerrado (TabC).Material y métodos Entre enero de 2000 y octubre de 2007, 79 pacientes con TabC (60 varones y 19 mujeres) se incluyeron en este estudio. Se les realizó laparotomía exploradora tras la realización de TC abdominal, lo que permitió comparar los hallazgos de las pruebas de imagen preoperatorias con los de la laparotomía. Resultados Para la detección de lesiones de víscera hueca y mesentéricas se obtuvo para la TC sensibilidad del 84,2%, especificidad del 75,6%, valor predictivo positivo del 76,2%, valor predictivo negativo del 83,8%, coeficiente de probabilidad positivo de 3,45 y coeficiente de probabilidad negativo de 0,21. La precisión fue del 79,7%.ConclusiónLa TC helicoidal abdominal es una prueba útil para la detección de lesiones de víscera hueca y mesentéricas en pacientes con TabC (AU)

Background The frequency of bowel and mesenteric injuries is increasing. They are difficult to diagnose and delays in their diagnosis leads to a significantly increased morbidity and mortality. The aim of this study is to evaluate the usefulness of the computed tomography (CT) in the detection of blunt bowel and mesenteric injuries. Method Between January 2000 and October 2007, 79 patients with blunt abdominal trauma (60 men and 19 women) were included in our study. They underwent laparotomy after performing the abdominal CT. The CT findings were compared with the findings at laparotomy in order to determine the accuracy of the CT in the detection of bowel and mesenteric injuries. Results For the detection of bowel and mesenteric injuries we obtained for the CT: Sensitivity=84.2%, Specificity=75.6%, Positive Predictive Value =76.2%, Negative Predictive Value =83.8%, Positive Probability Value=3.45 and Negative Probability Value =0.21. Accuracy: 79.7%.ConclusionThe abdominal CT is suitable for detecting bowel and mesenteric injuries following blunt abdominal trauma (AU)

Factores de predicción del éxito de la ventilación no invasiva en el tratamiento del edema agudo de pulmón cardiogénico / Predictive factors related to success of non invasive ventilation and mortality in the treatment of acute cardiogenic pulmonary edema

FUNDAMENTO Y OBJETIVO: Estudios recientes aconsejan el uso de la ventilación no invasiva (VNI) en pacientes con edema agudo de pulmón cardiogénico (EAP). El objetivo es determinar los factores relacionados con el éxito de la técnica y con la mortalidad hospitalaria en pacientes que ingresan en una Unidad de Cuidados Intensivos (UCI) con EAP y reciben tratamiento con VNI. PACIENTES Y MÉTODO: Estudio observacional y prospectivo realizado en UCI. Se incluyó a 199 pacientes consecutivos que ingresaron con EAP y recibieron VNI junto a tratamiento médico convencional. El éxito de la técnica se definió como la evitación de intubación endotraqueal en un paciente dado de alta vivo, sin disnea, que permanecía así durante las primeras 24 h. Se recogieron los parámetros clínicos, fisiológicos y gasométricos al ingreso y tras 1 h de tratamiento, así como frecuencia de intubación y mortalidad hospitalaria. Se realizó un modelo multivariante mediante regresión logística y se incluyeron las variables que en el univariante mostraron una relación significativa (p < 0,05).RESULTADOS: La edad media de los pacientes fue de 73 años. El 43% eran varones. El Simplified Acute Physiology Score (SAPS II) al ingreso fue de 45. En 148 pacientes (74,4%) la técnica fue exitosa.se intubó a 25 pacientes (12,6%). En el análisis multivariante, el éxito de la técnica se asociócon (valores expresados como odds ratio ajustada y el intervalo de confianza [IC] del 95%): el SAPSII (0,95 [0,91-0,99]); la procedencia al Servicio de Urgencias (6,78 [1,85-24,79]); el valor de presión parcial de dióxido de carbono (pCO 2 ) al ingreso (1,05 [1,01-1,09]); el índice presión parcial de oxígeno en sangre arterial/fracción inspiratoria de oxígeno (pO 2 /FiO 2 ) (1,03 [1,01-1,06]) y de la frecuencia respiratoria (FR) en la primera hora (0,91 [0,84-0,99]); el SOFA (Acute Failure OrganicsScore) (0,62 [0,49-0,78]); el infarto agudo de miocardio (IAM) (0,05 [0,01-0,22]) y el número de complicaciones (0,17 [0,47-0,65]). La mortalidad hospitalaria fue del 32,7%. La orden de no intu-bar(0,12 [0,04-0,32]) y el éxito de la técnica (100,03 [28,71-348,47]) se relacionaron con la mortalidad hospitalaria. CONCLUSIONES: El éxito de la aplicación de la VNI en el tratamiento del EAP se asoció con un SAPS II más bajo, la procedencia del paciente desde urgencias, una pCO 2 elevada al ingreso, una mejoría de la pO 2 /FiO 2 y de la FR en la primera hora, un SOFA menor, la ausencia de IAMy un menor número de complicaciones. La mortalidad hospitalaria se relacionó con el éxito dela técnica y con una orden de no intubar previa

BACKGROUND AND OBJECTIVE: Recent studies support the use of non invasive ventilation (NIV) in patients with acute cardiogenic pulmonary edema (ACPE). We aimed to evaluate the factors related to the success of the technique in patients admitted to an intensive care unit (ICU) with ACPE. PATIENTS AND METHOD: An observational prospective study was perfomed in ICU.199 consecutive patients were enrolled with ACPE at admission who received treatment with NIV and standardized pharmacological treatment. The success of the NIV was achieved when endotracheal intubation was avoided and patients were alive without dyspnea within and 24 hours after discharge from the ICU. Clinical, physiological and gasometric parameters were analyzed at admission and one hour after starting NIV.RESULTS: Patient’s age was 74 years. 43% were male. The SAPS II was 45. 74.4% of the patients were successfully treated with NIV. 12.6% required endotracheal intubation. In a multivariate analysis, the success of the technique (values expressed as odds ratio [95% confidence interval]) was related to: SAPS II (0.95 [0.91-0.99]); the place of admission (6.78 [1.85-24.79]); value of PCO2 atad mission (1.05 [1.01-1.09]); PO 2 /FiO 2 index (1.03 [1.01-1.06]) and respiratory frecuency (0.91[0.84-0.99]) within the first hour; SOFA (acute failure organics score) (0.62 [0.49-0.78]); concomit-tantacute myocardial infarction (AMI) (0.05 [0.01-0.22]) and number of complications (0.17[0.47-0.65]). The hospital mortality rate was 32.7%. The non-intubation order (0.12 [0.04-0.32])and the success of the technique (100.03 [28.71-348.47]) were related to the hospital mortality. CONCLUSIONS: The success of NIV in the treatment of ACPE is related to a lower SAPS II, admission at the emergency department, elevated PCO 2 at admission, improvement of the PO 2 /FiO 2index and the respiratory rate within the first hour. The non-intubation order and the success of the technique were related to the hospital mortality