ABSTRACT
BACKGROUND: The benefits of high-flow nasal cannula (HFNC) as primary intervention in patients with acute hypoxemic respiratory failure (AHRF) are still a matter in debate. Our objective was to compare HFNC therapy versus conventional oxygen therapy (COT) in the prevention of endotracheal intubation in this group of patients. METHODS: An open-label, controlled and single-centre clinical trial was conducted in patients with severe AHRF, defined by a PaO2/FIO2 ratio ⩽200, to compare HFNC with a control group (CG) treated by COT delivered through a face mask, with the need to perform intubation as the primary outcome. The secondary outcomes included tolerance of the HFNC device and to look for the predictive factors for intubation in these patients. RESULTS: A total of 46 patients were included (22 in the COT group and 24 in the HFNC group) 48% of whom needed intubation: 63% in the COT group and 33% in the HFNC group, with significant differences both in intention to treat [χ2 = 4.2; p = 0.04, relative risk (RR) = 0.5; confidence interval (CI) 95%: 0.3-1.0] and also in treatment analysis (χ2 = 4.7; p = 0.03; RR = 0.5; IC 95%: 0.3-0.9) We obtained a number needed to treat (NNT) = 3 patients treated to avoid an intubation. Intubation occurred significantly later in the HFNC group. Estimated PaO2/FIO2, respiratory rate and dyspnea were significantly better in the HFNC group. Patients treated with HFNC who required intubation presented significant worsening after the first 8 h, as compared with non-intubated HFNC group patients. Mortality was 22% with no differences. The HFNC group patients were hospitalized for almost half of the time in the intensive care unit (ICU) and in the ward, with significantly less hospital length of stay. A total of 14 patients in the HFNC group (58%) complained of excessive heat and 17% of noise; 3 patients did not tolerate HFNC. CONCLUSION: Patients with severe acute hypoxemic respiratory failure who tolerate HFNC present a significantly lower need for endotracheal intubation compared with conventional oxygen therapy. CLINICAL TRIAL REGISTER: EUDRA CT number: 2012-001671-36The reviews of this paper are available via the supplemental material section.
Subject(s)
Intubation, Intratracheal , Lung/physiopathology , Oxygen Inhalation Therapy , Respiratory Insufficiency/therapy , Adult , Aged , Cannula , Female , Humans , Intubation, Intratracheal/adverse effects , Intubation, Intratracheal/mortality , Length of Stay , Male , Middle Aged , Oxygen Inhalation Therapy/adverse effects , Oxygen Inhalation Therapy/instrumentation , Oxygen Inhalation Therapy/mortality , Respiratory Insufficiency/diagnosis , Respiratory Insufficiency/mortality , Respiratory Insufficiency/physiopathology , Spain , Time Factors , Treatment OutcomeABSTRACT
AIM: To analyze our results with mycophenolate mofetil (MMF) in stable liver transplantation (LT) patients presenting with adverse events (AE) related to prolonged use of calcineurin inhibitors (CNI). METHODS: Conversion to MMF was performed in 56 out of 323 LT patients from 91-02: 24 (43%) were converted to MMF in monotherapy and 32 (57%) to MMF+low doses of CNI. The indication for conversion was chronic renal insufficiency (CRI) in all patients. The mean time between AE and conversion was 38.7+/-30 months (r: 2-101 m). Post-conversion follow-up was 39+/-20 months (r: 3-72 m). RESULTS: The calculated creatinine clearance (Crauckoft), improved significantly in all patients. In those converted to MMF, improvement was seen during the first 18 months for urea and during the first 6 months for creatinine. In patients converted to MMF+CNI, improvement was maintained throughout the conversion period for both urea and creatinine. Eleven (19.6%) patients underwent acute rejection (2 severe episodes in the MMF group and 1 death). Hypertension was present in 31 patients but only improved in 4 (7%). Dyslipemia was found in 12 and improved in 4 (7%). DM was present in 14 and improved in 1 (2%). CONCLUSIONS: Conversion to MMF in monotherapy is useful in stable LT patients with CRI due to CNI, although this result is offset by more severe rejections. Therefore, for AE secondary to CNI, we propose an early conversion to MMF+low doses of CNI as a first step. If liver function remains stable and AEs persist or progress, conversion to MMF in monotherapy is recommended, as a second step, with close monitoring of the patient.
Subject(s)
Graft Rejection/prevention & control , Immunosuppression Therapy/methods , Liver Transplantation/immunology , Mycophenolic Acid/analogs & derivatives , Aged , Calcineurin Inhibitors , Creatinine/blood , Drug Therapy, Combination , Female , Graft Rejection/drug therapy , Humans , Hypertension/chemically induced , Immunosuppression Therapy/adverse effects , Immunosuppressive Agents/administration & dosage , Immunosuppressive Agents/adverse effects , Immunosuppressive Agents/therapeutic use , Kidney/physiopathology , Liver/drug effects , Liver/physiopathology , Male , Middle Aged , Mycophenolic Acid/administration & dosage , Mycophenolic Acid/adverse effects , Mycophenolic Acid/therapeutic use , Postoperative Complications , Renal Insufficiency, Chronic/blood , Renal Insufficiency, Chronic/chemically induced , Retrospective Studies , Survival Analysis , Treatment Outcome , Urea/bloodABSTRACT
Presenta Foro Juventud y nuevos desafíos de la Juventud Nicaraguense, organizado en siete paneles temßticos: juventud y nuevo milenio; institucionalidad y politicas de juventud; formación e incersion laboral; violencia juvenil y politicas publicas; participacion juvenil y cultura politica; experiencia de proyectos juveniles locales; campa±as y estrategias de comunicación. En el foro participaron 18 diferentes expositores, cada uno especialista en la maestria o actor importante en el tema a tratar. En èl se promueve el intercambio sobre experiencias y proyectos innovadores
