[High flow oxygen therapy with nasal cannula: use and applications in respiratory failure in internal medicine.] / Ossigenoterapia ad alti flussi con cannule nasali: razionale di utilizzo e applicazioni nell'insufficienza respiratoria in medicina interna.

High-flow nasal cannula (HFNC) are an oxygen therapy device developed in the last years for the treatment of patients with acute or acute on chronic hypoxemic respiratory failure with different etiology and severity (including covid-19 pneumonia). HFNC combine the possibility of delivering high flows of gases, actively humidified and heated, with the use of a comfortable nasal interface, resulting generally well tolerated by most patients. In light of these characteristics, together with the simplicity of use and versatility, they have spread not only in intensive and semi-intensive care units but also in general medical ward in which they can play an important role in the treatment of elderly, frail patients with comorbidity where other more aggressive and invasive methods of ventilations are not indicated or not practicable.

Comprehensive care of a patient with obesity of BMI >70 kg/m2.

A 31-year-old woman, with a body mass index of 70.31 kg/m2, presented with progressive worsening of dyspnoea for 3 days. She had multiple comorbidities, including obesity hypoventilation syndrome. The patient developed type II respiratory failure with respiratory acidosis along with multiorgan failure. She was intubated and put on a mechanical ventilator and treated with intravenous diuretics, subcutaneous low-molecular-weight heparin and other supportive measures. Later, she was on noninvasive, continuous positive airway pressure ventilation overnight. She was prescribed a very-low-calorie diet along with physiotherapy and exercise. The patient underwent bariatric surgery 2 months after resolution of acute illness. Ten months after surgery, her body weight reduced from 180 kg to 121 kg, and her general condition improved. Successful management before and after surgical intervention depends on multidisciplinary teamwork, which includes the dietician, physiotherapist, endocrinologist, pulmonologist, nursing care and other supportive care.

Predictors of NIV Treatment in Patients with COPD Exacerbation Complicated by Respiratory Acidaemia.

Non-invasive ventilation (NIV) treatment decisions are poorly understood for patients with COPD exacerbation complicated by acute hypercapnic respiratory failure and respiratory acidaemia (ECOPD-RA). We identified 420 NIV-eligible patients from the DECAF study cohorts admitted with an ECOPD-RA. Using bivariate and multivariate analyses, we examined which indices were associated with clinicians' decisions to start NIV, including whether the presence of pneumonia was a deterrent. Admitting hospital, admission from institutional care, partial pressure of oxygen, cerebrovascular disease, pH, systolic blood pressure and white cell count were all associated with the provision of NIV. Of these indices, only pH was also a predictor of inpatient death. Those not treated with NIV included those with milder acidaemia and higher (and sometimes excessive) oxygen levels, and a frailer population with higher Extended Medical Research Council Dyspnoea scores, presumably deemed not suitable for NIV. Pneumonia was not associated with NIV treatment; 34 of 111 (30.6%) NIV-untreated patients had pneumonia, whilst 107 of 309 (34.6%) NIV-treated patients had pneumonia (p = 0.483). In our study, one in four NIV-eligible patients were not treated with NIV. Clinicians' NIV treatment decisions are not based on those indices most strongly associated with mortality risk. One of the strongest predictors of whether a patient received a life-saving treatment is which hospital they attended. Further research is required to aid in the risk stratification of this patient group which may help standardise and improve care.

Study of Acid-Base Disorders and Biochemical Findings of Patients in a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

INTRODUCTION: Acid base disorder is a condition characterized by alteration in blood pH by the imbalance between the components of blood leading to a life threatening situation. The main aim of this study was to find the prevalence of acid-base disorders and biochemical findings of such disorders in patients in a tertairy care hospital. METHODS: This descriptive cross-sectional study was conducted in Nobel Medical College Teaching Hospital from 1st September, 2018 to 31st August, 2019. Ethical apporoval was taken from Institutional Review Committee. All the patients presented to emergency department, intensive care units and wards were included during the study period. Data were entered and calculations were done in Microsoft Excel, point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. RESULTS: Out of arterial blood gas analysis of 1144 patients, the prevalence of acid base disorders was 718 (62.76%) at 95% Confidence Interval (59.96-65.56%). Simple and mixed acid base disorders were observed in 332 (46.24%) and 386 (53.76%) patients respectively. Respiratory alkalosis was most common among 134 (40.36%) cases in simple acid base disorder whereas metabolic acidosis and respiratory alkalosis was most common among 204 (52.85%) in mixed acid base disorder. All types of disorders were observed more in elderly people (41-60 and >60 age group) than other age groups. CONCLUSIONS: Acid base disorder was found to be more common in very ill patients in emergency and intensive care units. Mixed acid base disorder was the most common with male and elderly patients in predominance.

Las técnicas ecoguiadas, una herramienta muy útil también para enfermería / Ultrasound-guided techniques, also a very useful tool for nursing

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Primer caso descrito de coma desencadenado por embolismo aéreo venoso retrógrado: una situación excepcional pero potencialmente letal / First described case of coma triggered by retrograde venous air embolism: an exceptional but potentially life-threatening situation

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Impaired Gas Exchange at Birth and Risk of Intellectual Disability and Autism: A Meta-analysis.

We conducted meta-analyses of 67 studies on the association between neonatal proxies of impaired gas exchange and intellectual disability (ID) or autism spectrum disorders (ASD). Neonatal acidosis was associated with an odds ratio (OR) of 3.55 [95 % confidence interval (95 % CI) 2.23-5.49] for ID and an OR of 1.10 (95 % CI 0.91-1.31) for ASD. Children with a 5-min Apgar score of <7 had an OR of 5.39 (95 % CI 3.84-7.55) for ID and an OR of 1.67 (95 % CI 1.34-2.09) for ASD. O2 treatment was associated with an OR of 4.32 (95 % CI 3.23-5.78) for ID and an OR of 2.02 (95 % CI 1.45 to 2.83) for ASD. Our meta-analysis demonstrates an increased risk of ID and (to a lesser extent) ASD in children with neonatal hypoxia. Moreover, our findings raise the possibility that concomitant ID might account for the observed association between the gas exchange proxies and ASD.

NT-PROBNP como marcador pronóstico en pacientes con enfermedad pulmonar obstructiva crónica agudizada y acidosis respiratoria / No disponible

Objetivo: El fragmento N-terminal del péptido natriurético cerebral (NT-proBNP) es una prohormona producida en el ventrículo y liberada en situaciones de estrés por los cardiomiocitos. El objetivo de nuestro estudio fue evaluar la utilidad del NT-proBNP en identificar a pacientes de alto riesgo con agudización de enfermedad pulmonar obstructiva crónica (EPOC) y necesidad de ventilación mecánica no invasiva (VMNI). Metodología: Estudio prospectivo observacional realizado en la Unidad de Monitorización Respiratoria (UMR) del Hospital Universitario La Princesa (Madrid). Se incluyeron un total de 40 pacientes con agudización de EPOC y en acidosis respiratoria con necesidad de VMNI. Se realizó una determinación de NT-proBNP en las primeras 24 horas del ingreso dividiéndose a los pacientes en 2 grupos según el resultado de éste: resultado normal (<500 pg/ml) o resultado elevado (>500 pg/ml). Resultados: Del total de la muestra, 23 pacientes eran hombres (55%), con una edad media de 75,65 años (±10,9) siendo los pacientes con valores de NT-proBNP>500 pg/ml significativamente más mayores (67,0 vs 79,3 años; p=0,001). Estos pacientes presentaron mayor número de complicaciones durante el ingreso y mayor tiempo de estancia hospitalaria (13,3 vs 8,1 días; p=0,012). En el seguimiento a un año, los pacientes que fallecieron, habían presentado niveles más elevados de NT-proBNP durante el ingreso en comparación con los que seguían vivos (6.250 pg/ml vs 2.177 pg/ml; p=0,04). Conclusiones: Los pacientes con niveles más elevados de NT-proBNP presentaron mayor número de complicaciones clínicas durante el ingreso y una mayor estancia hospitalaria, así como mayor mortalidad al año de seguimiento

Purpose: N terminal pro B type natriuretic peptide (NT-proBNP) is a prohormone released by the ventricles in response to cardiomyocyte stretching. The aim of our study was to evaluate the usefulness of NT-proBNP to identify high risk patients admitted with acute exacerbations of chronic obstructive pulmonary disease (COPD). Methods: We conducted an observational prospective study at the Hospital Universitario La Princesa. We included 40 patientes with acute exacerbation of COPD, respiratory acidosis and need of non-invasive mechanical ventilation at our Non-invasive Ventilation Unit. We determinated a blood determination of NT- proBNP in the first 24 hours after admission. We divided the patients in two groups according to the initial values of NT-proBNP: normal levels (<500 pg/ml), or high levels (>500 pg/ml). Results: 23 patients were male (55%) with mean age of 76.02 (±9.5) years. Patients with higher levels of NT-proBNP were elderly people (67.0 vs 79.3 años; p=0.001). Also, patients with NT-proBNP>500 pg/ml had more overall clinical complications during the admission and longer average length of stay (13.3 vs. 8.1 days; p=0.012).Mean levels of NT-proBNP at admission were higher in patients who died after 1 year of follow-up (6,250 pg/ml) compared to those alive at 1 year (2,177 pg/ml), p=0.04. Conclusions: The high NT-proBNP group had more clinical complications during admission, and had a trend towards higher mortality at admission and 1 year follow-up

Resolución de atelectasia obstructiva con ventilación mecánica no invasiva / Resolution of Obstructive Atelectasis With Non-Invasive Mechanical Ventilation

La broncoscopia es la técnica habitualmente empleada en pacientes con atelectasias secundarias a tapones mucosos. Presentamos el caso de una paciente de 82 años de edad con antecedentes de síndrome de Meige, que desarrolló un cuadro de insuficiencia respiratoria aguda al sufrir una atelectasia del lóbulo superior derecho en el contexto de una neumonía intrahospitalaria. La paciente presentaba importante disminución del nivel de conciencia, gran trabajo respiratorio y acidosis hipercápnica grave, condiciones que contraindicaban la realización de una broncoscopia. Se instauró ventilación mecánica no invasiva (VMNI) con doble nivel de presión a través de una mascarilla facial. La evolución fue favorable, con franca mejoría clínica y gasométrica. En la radiografía de tórax realizada a las 12 h se apreció resolución completa de la atelectasia. Estos datos sugieren que la VMNI podría ser útil en el tratamiento de las atelectasias de algunos pacientes críticos

Bronchoscopy is a commonly used technique in patients with atelectasis due to mucus plugs. We present here the case of an 82-year-old patient with a history of Meige's syndrome that developed acute respiratory failure due to atelectasis of the right upper lobe associated with hospital-acquired pneumonia. The patient had a severely reduced level of consciousness, significant work-of-breathing and severe hypercapnic acidosis, all of which contraindicated bronchoscopy. Bi-level non-invasive mechanical ventilation (NIMV) was initiated by way of a face mask. Progress was favorable, with clear clinical and gasometric improvement. The chest X-ray performed 12 h later showed complete resolution of the atelectasis. These data suggest that NIMV may be useful in the treatment of atelectasis is some critical patients

Life-threatening hypokalemia following rapid correction of respiratory acidosis.

A 56-year-old woman with a history of paraplegia and chronic pain due to neuromyelitis optica (Devic's syndrome) was admitted to a spinal cord injury unit for management of a sacral decubitus ulcer. During the hospitalization, she required emergency transfer to the intensive care unit (ICU) because of progressive deterioration of respiratory muscle function, severe respiratory acidosis, obtundation and hypotension. Upon transfer to the ICU, arterial blood gas revealed severe acute-on-chronic respiratory acidosis (pH 7.00, PCO2 120 mm Hg, PO2 211 mm Hg). The patient was immediately intubated and mechanically ventilated. Intravenous fluid boluses of normal saline (10.5 L in about 24 h) and vasopressors were started with rapid correction of hypotension. In addition, she was given hydrocortisone. Within 40 min of initiation of mechanical ventilation, there was improvement in acute respiratory acidosis. Sixteen hours later, however, the patient developed life-threatening hypokalemia (K(+) of 2.1 mEq/L) and hypomagnesemia (Mg of 1.4 mg/dL). Despite aggressive potassium supplementation, hypokalemia continued to worsen over the next several hours (K(+) of 1.7 mEq/L). Urine studies revealed renal potassium wasting. We reason that the recalcitrant life-threatening hypokalemia was caused by several mechanisms including total body potassium depletion (chronic respiratory acidosis), a shift of potassium from the extracellular to intracellular space (rapid correction of respiratory acidosis with mechanical ventilation), increased sodium delivery to the distal nephron (normal saline resuscitation), hyperaldosteronism (secondary to hypotension plus administration of hydrocortisone) and hypomagnesemia. We conclude that rapid correction of respiratory acidosis, especially in the setting of hypotension, can lead to life-threatening hypokalemia. Serum potassium levels must be monitored closely in these patients, as failure to do so can lead to potentially lethal consequences.

Mixed acid-base disorders, hydroelectrolyte imbalance and lactate production in hypercapnic respiratory failure: the role of noninvasive ventilation.

BACKGROUND: Hypercapnic Chronic Obstructive Pulmonary Disease (COPD) exacerbation in patients with comorbidities and multidrug therapy is complicated by mixed acid-base, hydro-electrolyte and lactate disorders. Aim of this study was to determine the relationships of these disorders with the requirement for and duration of noninvasive ventilation (NIV) when treating hypercapnic respiratory failure. METHODS: Sixty-seven consecutive patients who were hospitalized for hypercapnic COPD exacerbation had their clinical condition, respiratory function, blood chemistry, arterial blood gases, blood lactate and volemic state assessed. Heart and respiratory rates, pH, PaO(2) and PaCO(2) and blood lactate were checked at the 1st, 2nd, 6th and 24th hours after starting NIV. RESULTS: Nine patients were transferred to the intensive care unit. NIV was performed in 11/17 (64.7%) mixed respiratory acidosis-metabolic alkalosis, 10/36 (27.8%) respiratory acidosis and 3/5 (60%) mixed respiratory-metabolic acidosis patients (p = 0.026), with durations of 45.1 ± 9.8, 36.2 ± 8.9 and 53.3 ± 4.1 hours, respectively (p = 0.016). The duration of ventilation was associated with higher blood lactate (p<0.001), lower pH (p = 0.016), lower serum sodium (p = 0.014) and lower chloride (p = 0.038). Hyponatremia without hypervolemic hypochloremia occurred in 11 respiratory acidosis patients. Hypovolemic hyponatremia with hypochloremia and hypokalemia occurred in 10 mixed respiratory acidosis-metabolic alkalosis patients, and euvolemic hypochloremia occurred in the other 7 patients with this mixed acid-base disorder. CONCLUSIONS: Mixed acid-base and lactate disorders during hypercapnic COPD exacerbations predict the need for and longer duration of NIV. The combination of mixed acid-base disorders and hydro-electrolyte disturbances should be further investigated.

Early respiratory acidosis is a new risk factor for pneumonia after lung resection.

Postoperative pneumonia (POP) is a life-threatening complication of lung resection (LR). Its risk factors, bacteriological profile and outcome are not well known. The aims of this study were to describe the outcome and causal bacteria and to identify risk factors for POP. We reviewed all cases admitted to intensive care after LR. Clinical parameters, operative and postoperative data were recorded. POP was suspected on the basis of fever, radiographic infiltrate, and either leucocytosis or purulent sputum. The diagnosis was confirmed by culture of a respiratory sample. Risk factors for POP were identified by univariate and multivariate analysis. We included 159 patients in this study. POP was diagnosed in 23 patients (14.4%) and was associated with a higher hospital mortality rate (30% versus 5%, P = 0.0007) and a longer hospital stay. Members of the Enterobacteriaceae and Pseudomonas species were the most frequently identified pathogens. Early respiratory acidosis (ERA; OR, 2.94; 95% CI, 1.1-8.1), blood transfusion (OR, 3.8; 95% CI, 1.1-13.1), bilobectomy (OR, 7.26; 95% CI, 1.2-43.1) and smoking history (OR, 1.84; 95% CI, 1.1-3) were identified as independent risk factors. ERA may be a risk factor for POP and could serve as a target for therapeutic interventions.