Intubation timing as determinant of outcome in patients with acute respiratory distress syndrome by SARS-CoV-2 infection.

PURPOSE: To determine whether time-to-intubation was associated with higher ICU mortality in patients with COVID-19 on mechanical ventilation due to respiratory insufficiency. MATERIALS AND METHODS: We conducted an observational, prospective, single-center study of patients with confirmed SARS-CoV-2 infection hospitalized with moderate to severe ARDS, connected to mechanical ventilation in the ICU between March 17 and July 31, 2020. We examined their general and clinical characteristics. Time-to-intubation was the time from hospital admission to endotracheal intubation. RESULTS: We included 183 consecutive patients; 28% were female, and median age was 62 years old. Eighty-eight patients (48%) were intubated before 48 h (early) and ninety-five (52%) after 48 h (late). Patients intubated early had similar admission PaO2/FiO2 ratio (123 vs 99; p = 0.179) but were younger (59 vs 64; p = 0.013) and had higher body mass index (30 vs 28; p = 0.006) compared to patients intubated late. Mortality was higher in patients intubated late (18% versus 43%), with admission PaO2/FiO2 ratio < 100 mmHg (OR 5.2; p = 0.011), of older age (OR 1.1; p = 0.001), and with previous use of ACE inhibitors (OR 4.8; p = 0.026). CONCLUSIONS: In COVID-19 patients, late intubation, Pafi <100, older age, and previous ACE inhibitors use were associated with increased ICU mortality.

Near-Apneic Ventilation Decreases Lung Injury and Fibroproliferation in an Acute Respiratory Distress Syndrome Model with Extracorporeal Membrane Oxygenation.

RATIONALE: There is wide variability in mechanical ventilation settings during extracorporeal membrane oxygenation (ECMO) in patients with acute respiratory distress syndrome. Although lung rest is recommended to prevent further injury, there is no evidence to support it. OBJECTIVES: To determine whether near-apneic ventilation decreases lung injury in a pig model of acute respiratory distress syndrome supported with ECMO. METHODS: Pigs (26-36 kg; n = 24) were anesthetized and connected to mechanical ventilation. In 18 animals lung injury was induced by a double-hit consisting of repeated saline lavages followed by 2 hours of injurious ventilation. Then, animals were connected to high-flow venovenous ECMO, and randomized into three groups: 1) nonprotective (positive end-expiratory pressure [PEEP], 5 cm H2O; Vt, 10 ml/kg; respiratory rate, 20 bpm), 2) conventional-protective (PEEP, 10 cm H2O; Vt, 6 ml/kg; respiratory rate, 20 bpm), and 3) near-apneic (PEEP, 10 cm H2O; driving pressure, 10 cm H2O; respiratory rate, 5 bpm). Six other pigs were used as sham. All groups were maintained during the 24-hour study period. MEASUREMENTS AND MAIN RESULTS: Minute ventilation and mechanical power were lower in the near-apneic group, but no differences were observed in oxygenation or compliance. Lung histology revealed less injury in the near-apneic group. Extensive immunohistochemical staining for myofibroblasts and procollagen III was observed in the nonprotective group, with the near-apneic group exhibiting the least alterations. Near-apneic group showed significantly less matrix metalloproteinase-2 and -9 activity. Histologic lung injury and fibroproliferation scores were positively correlated with driving pressure and mechanical power. CONCLUSIONS: In an acute respiratory distress syndrome model supported with ECMO, near-apneic ventilation decreased histologic lung injury and matrix metalloproteinase activity, and prevented the expression of myofibroblast markers.

Extracorporeal membrane oxygenation improves survival in a novel 24-hour pig model of severe acute respiratory distress syndrome.

Extracorporeal membrane oxygenation (ECMO) is increasingly being used to treat severe acute respiratory distress syndrome (ARDS). However, there is limited clinical evidence about how to optimize the technique. Experimental research can provide an alternative to fill the actual knowledge gap. The purpose of the present study was to develop and validate an animal model of acute lung injury (ALI) which resembled severe ARDS, and which could be successfully supported with ECMO. Eighteen pigs were randomly allocated into three groups: sham, ALI, and ALI + ECMO. ALI was induced by a double-hit consisting in repeated saline lavage followed by a 2-hour period of injurious ventilation. All animals were followed up to 24 hours while being ventilated with conventional ventilation (tidal volume 10 ml/kg). The lung injury model resulted in severe hypoxemia, increased airway pressures, pulmonary hypertension, and altered alveolar membrane barrier function, as indicated by an increased protein concentration in bronchoalveolar fluid, and increased wet/dry lung weight ratio. Histologic examination revealed severe diffuse alveolar damage, characteristic of ARDS. Veno-venous ECMO was started at the end of lung injury induction with a flow > 60 ml/kg/min resulting in rapid reversal of hypoxemia and pulmonary hypertension. Mortality was 0, 66.6 and 16.6% in the SHAM, ALI and ALI + ECMO groups, respectively (p < 0.05). This is a novel clinically relevant animal model that can be used to optimize the approach to ECMO and foster translational research in extracorporeal lung support.

Comunicación con el paciente en ventilación mecánica invasiva: revisión de la literatura / Communication with the patient in invasive mechanical ventilation: review of the literature

Introducción: La comunicación involucra la interacción recíproca de dos interlocutores, permitiendo al ser humano la expresión de necesidades y el establecimiento de relaciones con el mundo que lo rodea. Las Unidades de Cuidado Intensivo (UCI) suponen un ambiente que presenta múltiples barreras a la comunicación, siendo la Ventilación Mecánica Invasiva (VMI) una de las principales, al generar condiciones físicas especiales en el paciente que dificultan su posibilidad de comunicación. Metodología: Revisión de artículos publicados en revistas científicas en formato digital en las bases de datos Medline, EMBASE,CINHAL, PROQUEST de los últimos 10 años utilizando las palabras claves: “enfermera”, “enfermería”, “unidad de cuidados intensivos”, “críticos” y “comunicación” y la búsqueda cruzada de artículos reseñados en la bibliografía. Resultados: La ausencia de comunicación entre enfermeras y pacientes en VMI genera efectos negativos: sentimientos de ira, miedo, inquietud, pérdida de control, despersonalización, frustración y ansiedad, identificándose como barreras el tubo orotraqueal, ruido ambiental, alteración del estado de conciencia, falta de habilidades en las enfermeras, elevada carga laboral y el desinterés por comunicarse con este tipo de paciente. Así mismo, existen múltiples estrategias de comunicación utilizadas por equipos de enfermería, entre ellos: movimientos corporales, respuestas simples, uso de alfabetos y uso de lápiz y papel. Sin embargo, la disponibilidad de los diversos métodos no asegura una buena comunicación, dado que el interés por buscar instancias de comunicación convierte a las enfermeras de las UCI en agentes fundamentales, y responsables de interpretar y transmitir las necesidades de quienes se encuentran a su cuidado, en busca de mejorar la calidad del cuidado otorgado, alcanzar mejores resultados clínicos, mayor satisfacción y mayores posibilidades de recuperación del paciente...

Introduction: Communication involves reciprocal interaction two partners,enabling human beings’ expression needs and establishing relationshipswith the world what surrounds. Intensive Care Units (ICU) represent anenvironment that has multiple barriers to communication, being InvasiveMechanical Ventilation (IMV) major, generating special physicalconditions in the patient hindering the possibility of communication.Methodology: Review of articles published in journals scientific digitally onthe Medline, EMBASE, CINAHL, PROQUEST of the last 10 yearsusing the keywords: “nurse”, “nursing”, “unit intensive care”, “critical andcommunication” and search Cross-reviewed articles in the literature.Results: The lack of communication between nurses and patients inIMV, generates negative effects: feelings of anger, fear, anxiety, loss of control, depersonalization, frustration and anxiety, identified asbarriers the endotracheal tube noise environmental, altered state ofconsciousness, lack of skills nurses, high workload and lack ofinterest by contacting with this type of patient.Likewise, there are multiple strategies communication used by nursingteams, including: body movements, simple answers, use alphabets andusing pencil and paper. However, the availability of different methodsdo not ensure good communication, as interest to look for instances ofcommunication makes nurses ICUs in key actors and responsible forinterpreting and convey the needs of those who are in their care, seeksto improve the quality of care given, achieving better clinical results,greater satisfaction and greater possibilities of recovery...