Adherence to protective mechanical ventilation in COVID-19 versus non-COVID-19-associated acute respiratory distress syndrome: Comparison between two prospective cohorts / Adhesión a la ventilación mecánica protectora en el síndrome de dificultad respiratoria aguda asociado a COVID-19 o asociado a otras etiologias: comparación entre dos cohortes prospectivas

Objective To compare adherence to protective mechanical ventilation (MV) parametersin patients with acute respiratory distress syndrome (ARDS) caused by COVID-19 with patients with ARDS from other etiologies. Design Multiple prospective cohort study. Setting: Two Brazilian cohorts of ARDS patients were evaluated. One with COVID-19 patients admitted to two Brazilian intensive care units (ICUs) in 2020 and 2021 (C-ARDS, n=282), the other with ARDS-patients from other etiologies admitted to 37 Brazilian ICUs in 2016 (NC-ARDS, n=120). Patients: ARDS patients under MV. Interventions: None. Main variables of interest: Adherence to protective MV (tidal volume ≤8mL/kg PBW; plateau pressure ≤30cmH2O; and driving pressure ≤15cmH2O), adherence to each individual component of the protective MV, and the association between protective MV and mortality. Results Adherence to protective MV was higher in C-ARDS than in NC-ARDS patients (65.8% vs. 50.0%, p=0.005), mainly due to a higher adherence to driving pressure ≤15cmH2O (75.0% vs. 62.4%, p=0.02). Multivariable logistic regression showed that the C-ARDS cohort was independently associated with adherence to protective MV. Among the components of the protective MV, only limiting driving pressure was independently associated with lower ICU mortality. Conclusions Higher adherence to protective MV in patients with C-ARDS was secondary to higher adherence to limiting driving pressure. Additionally, lower driving pressure was independently associated with lower ICU mortality, which suggests that limiting exposure to driving pressure may improve survival in these patients (AU)

Objetivo Comparar la adhesión a la ventilación mecánica (VM) protectora en pacientes con síndrome de dificultad respiratoria aguda (SDRA) causada por COVID-19 con pacientes con SDRA de otras etiologías. Diseño Estudio de cohorte prospectivo. Âmbito: Se evaluaron dos cohortes de pacientes con SDRA: 1.pacientes con COVID-19 ingresados en dos unidades de cuidados intensivos (UCI) brasileñas en 2020 y 2021 (C-ARDS, n=282); 2.pacientes con SDRA de otras etiologías ingresados en 37 UCI brasileñas en 2016 (NC-ARDS, n=120). Pacientes: Pacientes con SDRA bajo VM invasiva. Intervenciones: No. Variables de interés principals: Adhesión a la VM protectora (volumen tidal ≤8mL/kg; presión de meseta ≤30cmH2O; y presión de distensión [PD] ≤15cmH2O), adhesión a cada componente individual de la VM protectora, y la asociación entre la VM protectora y la mortalidad. Resultados La adhesión a la VM protectora fue mayor en la cohorte C-ARDS que en la NC-ARDS (65,8% vs. 50,0%, p=0,005), principalmente debido a mayor adhesión a la PD≤15cmH2O (75,0% vs. 62,4%, p=0,02). La regresión logística multivariable mostró que la cohorte C-ARDS se asoció de forma independiente con la adhesión a la VM protectora. Entre los componentes de la VM protectora, sólo la limitación de la PD se asoció de forma independiente con menor mortalidad en la UCI. Conclusión La mayor adhesión a la VM protectora en los pacientes con C-ARDS fue secundaria a la mayor adhesión a limitación da PD. Además, una menor PD se asoció de forma independiente a menor mortalidad en la UCI, lo que sugiere que limitar la exposición a altas PD puede mejorar la supervivencia en estos pacientes (AU)

Risk factors associated with mortality among elderly patients with COVID-19: Data from 55 intensive care units in Spain.

INTRODUCTION AND OBJECTIVES: Critically-ill elderly ICU patients with COVID-19 have poor outcomes. We aimed to compare the rates of in-hospital mortality between non-elderly and elderly critically-ill COVID-19 ventilated patients, as well as to analyze the characteristics, secondary outcomes and independent risk factors associated with in-hospital mortality of elderly ventilated patients. PATIENTS AND METHODS: We conducted a multicentre, observational cohort study including consecutive critically-ill patients admitted to 55 Spanish ICUs due to severe COVID-19 requiring mechanical ventilation (non-invasive respiratory support [NIRS; include non-invasive mechanical ventilation and high-flow nasal cannula] and invasive mechanical ventilation [IMV]) between February 2020 and October 2021. RESULTS: Out of 5,090 critically-ill ventilated patients, 1,525 (27%) were aged ≥70 years (554 [36%] received NIRS and 971 [64%] received IMV. In the elderly group, median age was 74 years (interquartile range 72-77) and 68% were male. Overall in-hospital mortality was 31% (23% in patients <70 years and 50% in those ≥70 years; p<0.001). In-hospital mortality in the group ≥70 years significantly varied according to the modality of ventilation (40% in NIRS vs. 55% in IMV group; p<0.001). Factors independently associated with in-hospital mortality in elderly ventilated patients were age (sHR 1.07 [95%CI 1.05-1.10], p<0.001); previous admission within the last 30 days (sHR 1.40 [95%CI 1.04-1.89], p = 0.027); chronic heart disease (sHR 1.21 [95%CI 1.01-1.44], p = 0.041); chronic renal failure (sHR 1.43 [95%CI 1.12- 1.82], p = 0.005); platelet count (sHR 0.98 [95% CI 0.98-0.99], p<0.001); IMV at ICU admission (sHR 1.41 [95% CI 1.16- 1.73], p<0.001); and systemic steroids (sHR 0.61 [95%CI 0.48- 0.77], p<0.001). CONCLUSIONS: Amongst critically-ill COVID-19 ventilated patients, those aged ≥70 years presented significantly higher rates of in-hospital mortality than younger patients. Increasing age, previous admission within the last 30 days, chronic heart disease, chronic renal failure, platelet count, IMV at ICU admission and systemic steroids (protective) all comprised independent factors for in-hospital mortality in elderly patients.

Adherence to protective mechanical ventilation in COVID-19 versus non-COVID-19-associated acute respiratory distress syndrome: Comparison between two prospective cohorts.

OBJECTIVE: To compare adherence to protective mechanical ventilation (MV) parameters in patients with acute respiratory distress syndrome (ARDS) caused by COVID-19 with patients with ARDS from other etiologies. DESIGN: Multiple prospective cohort study. SETTING: Two Brazilian cohorts of ARDS patients were evaluated. One with COVID-19 patients admitted to two Brazilian intensive care units (ICUs) in 2020 and 2021 (C-ARDS, n=282), the other with ARDS-patients from other etiologies admitted to 37 Brazilian ICUs in 2016 (NC-ARDS, n=120). PATIENTS: ARDS patients under MV. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Adherence to protective MV (tidal volume ≤8mL/kg PBW; plateau pressure ≤30cmH2O; and driving pressure ≤15cmH2O), adherence to each individual component of the protective MV, and the association between protective MV and mortality. RESULTS: Adherence to protective MV was higher in C-ARDS than in NC-ARDS patients (65.8% vs. 50.0%, p=0.005), mainly due to a higher adherence to driving pressure ≤15cmH2O (75.0% vs. 62.4%, p=0.02). Multivariable logistic regression showed that the C-ARDS cohort was independently associated with adherence to protective MV. Among the components of the protective MV, only limiting driving pressure was independently associated with lower ICU mortality. CONCLUSIONS: Higher adherence to protective MV in patients with C-ARDS was secondary to higher adherence to limiting driving pressure. Additionally, lower driving pressure was independently associated with lower ICU mortality, which suggests that limiting exposure to driving pressure may improve survival in these patients.

Ventilación mecánica en España, 1998-2016: cambios en la desconexión de la ventilación mecánica / Mechanical ventilation in Spain, 1998-2016: changes in the disconnection of mechanical ventilation

Objetivo Evaluar los cambios en la desconexión de la ventilación mecánica en España desde 1998 hasta 2016. Diseño Análisis post-hoc de 4 estudios de cohorte. Ámbito Un total de 138 UCI. Enfermos Un total de 2.141 enfermos extubados de forma programada. Intervenciones Ninguna. Variables de interés principales Demográficas, motivo de ventilación mecánica, complicaciones, métodos para la desconexión, fracaso del primer intento de desconexión, duración de la desconexión, reintubación, traqueotomía post-reintubación, estancia y mortalidad en la UCI. Resultados Se observa un aumento significativo (p<0,001) en la presión de soporte como técnica de desconexión. Ha aumentado, a lo largo del tiempo, la probabilidad ajustada de utilizar la presión de soporte progresivamente decreciente frente a una prueba de ventilación espontánea, tanto para el primer intento de desconexión (referencia estudio de 1998: odds ratio 0,99 en 2004, 0,57 en 2010 y 2,43 en 2016) como para la desconexión difícil/prolongada (referencia estudio de 1998: odds ratio 2,29 en 2004, 1,23 en 2010 y 2,54 en 2016). La proporción de extubación tras el primer intento de desconexión ha aumentado con el tiempo. Hay una disminución del tiempo dedicado a la desconexión (desde un 45% en 1998 hasta un 36% en 2016). Sin embargo, no ha disminuido la duración en la desconexión difícil/prolongada (mediana 3 días en todos los estudios, p=0,435). Conclusiones Ha habido cambios significativos en el modo de desconexión de la ventilación mecánica, con un aumento progresivo del uso de la presión de soporte. Se han observado mínimos cambios en los desenlaces (AU)

Purpose To evaluate changes in the disconnection of mechanical ventilation in Spain from 1998 to 2016. Design Post-hoc analysis of four cohort studies. Ambit 138 Spanish ICUs. Patients 2141 patients scheduled extubated. Interventions None. Variables of interest Demographics, reason for mechanical ventilation, complications, methods for disconnection, failure on the first attempt at disconnection, duration of weaning, reintubation, post-reintubation tracheotomy, ICU stay and mortality. Results There was a significant increase (p<0.001) in the use of gradual reduction of support pressure. The adjusted probability of using the gradual reduction in pressure support versus a spontaneous breathing trial has increased over time, both for the first attempt at disconnection (taking the 1998 study as a reference: odds ratio 0.99 in 2004, 0.57 in 2010 and 2.43 in 2016) and for difficult/prolonged disconnection (taking the 1998 study as a reference: odds ratio 2.29 in 2004, 1.23 in 2010 and 2.54 in 2016). The proportion of patients extubated after the first attempt at disconnection has increased over time. There is a decrease in the ventilation time dedicated to weaning (from 45% in 1998 to 36% in 2016). However, the duration in difficult/prolonged weaning has not decreased (median 3 days in all studies, p=0.435). Conclusions There have been significant changes in the mode of disconnection of mechanical ventilation, with a progressive increase in the use of gradual reduction of pressure support. No relevant changes in outcomes have been observed (AU)

Mechanical ventilation in Spain, 1998-2016: Changes in the disconnection of mechanical ventilation.

PURPOSE: To evaluate changes in the disconnection of mechanical ventilation in Spain from 1998 to 2016. DESIGN: Post-hoc analysis of four cohort studies. AMBIT: 138 Spanish ICUs. PATIENTS: 2141 patients scheduled extubated. INTERVENTIONS: None. VARIABLES OF INTEREST: Demographics, reason for mechanical ventilation, complications, methods for disconnection, failure on the first attempt at disconnection, duration of weaning, reintubation, post-reintubation tracheotomy, ICU stay and mortality. RESULTS: There was a significant increase (p < 0.001) in the use of gradual reduction of support pressure. The adjusted probability of using the gradual reduction in pressure support versus a spontaneous breathing trial has increased over time, both for the first attempt at disconnection (taking the 1998 study as a reference: odds ratio 0.99 in 2004, 0.57 in 2010 and 2.43 in 2016) and for difficult/prolonged disconnection (taking the 1998 study as a reference: odds ratio 2.29 in 2004, 1.23 in 2010 and 2.54 in 2016). The proportion of patients extubated after the first attempt at disconnection has increased over time. There is a decrease in the ventilation time dedicated to weaning (from 45% in 1998 to 36% in 2016). However, the duration in difficult/prolonged weaning has not decreased (median 3 days in all studies, p = 0.435). CONCLUSIONS: There have been significant changes in the mode of disconnection of mechanical ventilation, with a progressive increase in the use of gradual reduction of pressure support. No relevant changes in outcomes have been observed.

Sumario de las recomendaciones y puntos clave del Consenso de las Sociedades Científicas Españolas (SEPAR, SEMICYUC, SEMES; SECIP, SENeo, SEDAR, SENP) para la utilización de la ventilación no invasiva y terapia de alto flujo con cánulas nasales en el paciente adulto, pediátrico y neonatal con insuficiencia respiratoria aguda grave / Summary of recommendations and key points of the consensus of Spanish scientific societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the use of non-invasive ventilation and high-flow oxygen therapy with nasal cannulas in adult, pediatric, and neonatal patients with severe acute respiratory failure

El soporte respiratorio no invasivo (SRNI) comprende 2 modalidades de tratamiento, la ventilación mecá-nica no invasiva (VMNI) y la terapia de alto flujo con cánulas nasales (TAFCN) que se aplican en pacientes adultos, pediátricos y neonatales con insuficiencia respiratoria aguda (IRA). Sin embargo, el grado de acuerdo entre las distintas especialidades sobre el beneficio de estas técnicas en diferentes escenarios clínicos es controvertido. El objetivo del presente consenso fue elaborar una serie de recomendaciones de buena práctica clínica para la aplicación de soporte no invasivo en pacientes con IRA, avaladas por todas las sociedades científicas involucradas en el manejo del paciente adulto y pediátrico/neonatal con IRA. Para ello se contactó con las diferentes sociedades implicadas, quienes designaron a su vez a un grupo de 26 profesionales con suficiente experiencia en su aplicación. Se realizaron 3 reuniones presenciales para consensuar las recomendaciones (hasta un total de 71) fundamentadas en la revisión de la literatura y en la actualización de la evidencia disponible en relación con 3 categorías: indicaciones, monitorización yseguimiento del SRNI. Finalmente, se procedió a votación telemática de cada una de las recomendaciones, por parte de los expertos de cada sociedad científica implicada. Para la clasificación del grado de acuerdo se optó por un sistema analógico de clasificación fácil e intuitivo de usar, y que expresara con claridad si el procedimiento relacionado con el SRNI debía hacerse, podía hacerse o no debía hacerse. (AU)

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analogue classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied. (AU)

Mechanical ventilation in Spain, 1998-2016: changes in the disconnection of mechanical ventilation. / Ventilación mecánica en España, 1998-2016: cambios en la desconexión de la ventilación mecánica.

PURPOSE: To evaluate changes in the disconnection of mechanical ventilation in Spain from 1998 to 2016. DESIGN: Post-hoc analysis of four cohort studies. AMBIT: 138 Spanish ICUs. PATIENTS: 2141 patients scheduled extubated. INTERVENTIONS: None. VARIABLES OF INTEREST: Demographics, reason for mechanical ventilation, complications, methods for disconnection, failure on the first attempt at disconnection, duration of weaning, reintubation, post-reintubation tracheotomy, ICU stay and mortality. RESULTS: There was a significant increase (p<0.001) in the use of gradual reduction of support pressure. The adjusted probability of using the gradual reduction in pressure support versus a spontaneous breathing trial has increased over time, both for the first attempt at disconnection (taking the 1998 study as a reference: odds ratio 0.99 in 2004, 0.57 in 2010 and 2.43 in 2016) and for difficult/prolonged disconnection (taking the 1998 study as a reference: odds ratio 2.29 in 2004, 1.23 in 2010 and 2.54 in 2016). The proportion of patients extubated after the first attempt at disconnection has increased over time. There is a decrease in the ventilation time dedicated to weaning (from 45% in 1998 to 36% in 2016). However, the duration in difficult/prolonged weaning has not decreased (median 3 days in all studies, p=0.435). CONCLUSIONS: There have been significant changes in the mode of disconnection of mechanical ventilation, with a progressive increase in the use of gradual reduction of pressure support. No relevant changes in outcomes have been observed.

Summary of recommendations and key points of the consensus of Spanish scientific societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the use of non-invasive ventilation and high-flow oxygen therapy with nasal cannulas in adult, pediatric, and neonatal patients with severe acute respiratory failure.

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analogue classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

Ventilación mecánica en España, 1998-2016: epidemiología y desenlaces / Mechanical ventilation in Spain, 1998-2016: Epidemiology and outcomes

OBJETIVO: Evaluar cambios en la epidemiología de la ventilación mecánica en España desde 1998 hasta 2016. DISEÑO: Análisis post-hoc de 4 estudios de cohortes. ÁMBITO: Un total de 138 UCI españolas. PACIENTES: Un total de 4.293 enfermos con ventilación mecánica invasiva más de 12h o no invasiva más de 1h. INTERVENCIONES: Ninguna. VARIABLES DE INTERÉS PRINCIPALES: Demográficas, motivo de ventilación mecánica, relacionadas con el soporte ventilatorio (modo de ventilación, volumen tidal, PEEP, presiones en vía aérea), complicaciones, duración de la ventilación mecánica, estancia y mortalidad en la UCI. RESULTADOS: Se observa aumento en la gravedad (SAPSII: 43 puntos en 1998 frente a 47 puntos en 2016), cambios en el motivo de la ventilación mecánica (disminución de la enfermedad pulmonar obstructiva crónica e insuficiencia respiratoria secundaria a traumatismo y aumento de la patología neurológica y tras parada cardiaca). Aumento en la ventilación no invasiva como primer modo de soporte ventilatorio (p < 0,001). El modo más utilizado es la ventilación controlada por volumen con un aumento de la presión de soporte y de la ventilación controlada por volumen regulada por presión. Disminuyó el volumen tidal (9ml/kg de peso estimado en 1998 y 6,6ml/kg en 2016, p < 0,001) y aumentó la PEEP (3cmH2O en 1998 y 6cmH2O en 2016, p < 0,001). La mortalidad disminuye (34% en 1998 y 27% en 2016; p < 0,001) sin variabilidad geográfica (MOR 1,43; p = 0,258). CONCLUSIONES: Se observa una disminución en la mortalidad de los enfermos ventilados en UCI españolas. Esta disminución podría estar relacionada con cambios para minimizar el daño inducido por el ventilador

PURPOSE: To evaluate changes in the epidemiology of mechanical ventilation in Spain from 1998 to 2016. DESIGN: A post hoc analysis of four cohort studies was carried out. SETTING: A total of 138 Spanish ICUs. PATIENTS: A sample of 4293 patients requiring invasive mechanical ventilation for more than 12h or noninvasive ventilation for more than 1h. INTERVENTIONS: None. VARIABLES OF INTEREST: Demographic variables, reason for mechanical ventilation, variables related to ventilatory support (ventilation mode, tidal volume, PEEP, airway pressures), complications during mechanical ventilation, duration of mechanical ventilation, ICU stay and ICU mortality. RESULTS: There was an increase in severity (SAPSII: 43 points in 1998 vs. 47 points in 2016), changes in the reason for mechanical ventilation (decrease in chronic obstructive pulmonary disease and acute respiratory failure secondary to trauma, and increase in neurological disease and post-cardiac arrest). There was an increase in noninvasive mechanical ventilation as the first mode of ventilatory support (p < 0.001). Volume control ventilation was the most commonly used mode, with increased support pressure and pressure-regulated volume-controlled ventilation. A decrease in tidal volume was observed (9ml/kg actual b.w. in 1998 and 6.6ml/kg in 2016; p < 0.001) as well as an increase in PEEP (3cmH2O in 1998 and 6cmH2O in 2016; p < 0.001). In-ICU mortality decreased (34% in 1998 and 27% in 2016; p < 0.001), without geographical variability (median OR 1.43; p = 0.258). CONCLUSIONS: A significant decrease in mortality was observed in patients ventilated in Spanish ICUs. These changes in mortality could be related to modifications in ventilation strategy to minimize ventilator-induced lung injury

Mechanical ventilation in Spain, 1998-2016: Epidemiology and outcomes. / Ventilación mecánica en España, 1998-2016: epidemiología y desenlaces.

PURPOSE: To evaluate changes in the epidemiology of mechanical ventilation in Spain from 1998 to 2016. DESIGN: A post hoc analysis of four cohort studies was carried out. SETTING: A total of 138 Spanish ICUs. PATIENTS: A sample of 4293 patients requiring invasive mechanical ventilation for more than 12h or noninvasive ventilation for more than 1h. INTERVENTIONS: None. VARIABLES OF INTEREST: Demographic variables, reason for mechanical ventilation, variables related to ventilatory support (ventilation mode, tidal volume, PEEP, airway pressures), complications during mechanical ventilation, duration of mechanical ventilation, ICU stay and ICU mortality. RESULTS: There was an increase in severity (SAPSII: 43 points in 1998 vs. 47 points in 2016), changes in the reason for mechanical ventilation (decrease in chronic obstructive pulmonary disease and acute respiratory failure secondary to trauma, and increase in neurological disease and post-cardiac arrest). There was an increase in noninvasive mechanical ventilation as the first mode of ventilatory support (p<0.001). Volume control ventilation was the most commonly used mode, with increased support pressure and pressure-regulated volume-controlled ventilation. A decrease in tidal volume was observed (9ml/kg actual b.w. in 1998 and 6.6ml/kg in 2016; p<0.001) as well as an increase in PEEP (3cmH2O in 1998 and 6cmH2O in 2016; p<0.001). In-ICU mortality decreased (34% in 1998 and 27% in 2016; p<0.001), without geographical variability (median OR 1.43; p=0.258). CONCLUSIONS: A significant decrease in mortality was observed in patients ventilated in Spanish ICUs. These changes in mortality could be related to modifications in ventilation strategy to minimize ventilator-induced lung injury.

Summary of recommendations and key points of the consensus of Spanish scientific societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the use of non-invasive ventilation and high-flow oxygen therapy with nasal cannulas in adult, pediatric, and neonatal patients with severe acute respiratory failure. / Sumario de las recomendaciones y puntos clave del Consenso de las Sociedades Científicas Españolas (SEPAR, SEMICYUC, SEMES; SECIP, SENeo, SEDAR, SENP) para la utilización de la ventilación no invasiva y terapia de alto flujo con cánulas nasales en el paciente adulto, pediátrico y neonatal con insuficiencia respiratoria aguda grave.

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analogue classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

¿Se han producido cambios en la aplicación de la ventilación mecánica en relación con la evidencia científica? Estudio multicéntrico en México / Have there been changes in the application of mechanical ventilation in relation to scientific evidence? A multicenter observational study in Mexico

OBJETIVO: Los objetivos principales son describir la práctica de la ventilación mecánica en un periodo de 18 años en México y estimar los cambios en la mortalidad de los pacientes críticos con ventilación mecánica invasiva (VMI). DISEÑO: Subanálisis retrospectivo de un estudio prospectivo y observacional en 1998, 2004, 2010 y 2016. ÁMBITO: Unidades de Cuidados Intensivos (UCI) de México. PARTICIPANTES: Pacientes adultos que ingresaron consecutivamente en la UCI, durante un mes y que recibieron VMI durante más de 12 h o ventilación mecánica no invasiva durante más de una hora. El seguimiento se realizó hasta 28 días después de la inclusión. INTERVENCIONES: Ninguna. VARIABLES DE INTERÉS: Edad, sexo, gravedad al ingreso estimada por el SAPS II, parámetros de la gasometría arterial diaria, variables de tratamiento y complicaciones, fecha y estado al alta de la UCI y del hospital. RESULTADOS: Se incluyó a 959 pacientes en 81 UCI. El volumen corriente (VC) ha disminuido significativamente tanto en pacientes con criterios de SDRA (de 8,5 ml/kg de peso estimado en 1998 a 6 ml/kg en 2016; p < 0,001) como en enfermos sin SDRA (de 9 ml/kg de peso estimado en 1998 a 6ml/kg en 2016; p < 0,001). La estrategia ventilatoria protectora (definida como VC < 6 ml/kg o < 8 ml/kg y una presión meseta < 30 cmH2O) fue: 19% en 1998, 44% en 2004, 58% en 2010 y 75% en 2016 (p < 0,001). La mortalidad ajustada en UCI a lo largo de los 4 periodos fue: en 2004, oportunidad relativa (OR) 1,05 (IC 95%: 0,73-1,72; p = 0,764); en 2010, OR 1,68 (IC 95%: 1,13-2,48; p = 0,009); en 2016, OR 0,85 (IC 95%: 0,60-1,20; p = 0,368). CONCLUSIONES: La práctica clínica de la VMI en las UCI de México se ha modificado a lo largo de un periodo de 18 años. El cambio más significativo es la estrategia ventilatoria basada en VC bajos. Estos cambios no se han asociado a cambios significativos en la mortalidad

OBJECTIVE: The main study objectives were to describe the practice of mechanical ventilation over an 18-year period in Mexico, and estimate changes in mortality among critical patients subjected to invasive mechanical ventilation (IMV). DESIGN: A retrospective subanalysis of a prospective observational study conducted in 1998, 2004, 2010 and 2016 was carried out. SETTING: Intensive Care Units (ICUs) in Mexico. PARTICIPANTS: Adult patients consecutively enrolled in the ICU during one month and who underwent IMV for more than 12hours or noninvasive mechanical ventilation for more than one hour. Follow-up was performed up to a maximum of 28 days after inclusion. INTERVENTIONS: None. PRINCIPAL VARIABLES OF INTEREST: Age, sex, severity upon admission as estimated by SAPS II, parameters of daily arterial blood gases, treatment and complication variables, date and status at discharge from the ICU and from hospital. RESULTS: A total of 959 patients were included in 81 ICUs. Tidal volume (vt) decreased significantly both in patients with acute respiratory distress syndrome (ARDS) criteria (estimated 8.5 ml/kg b.w. in 1998 to 6 ml/kg in 2016; P < 0.001) and in patients without ARDS (estimated 9 ml/kg b.w. in 1998 to 6 ml/kg in 2016; P < 0.001). The ventilatory protective strategy (defined as vt < 6 ml/kg or < 8 ml/kg and a plateau pressure < 30 cmH2O) was: 19% in 1998, 44% in 2004, 58% in 2010 and 75% in 2016 (P < 0.001). The adjusted mortality rate in ICU over the 4 periods was: in 2004, odds ratio (OR) 1.05 (95% confidence interval, 95% CI: 0.73-1.72; P = 0.764); in 2010, OR 1.68 (95% CI: 1.13-2.48; P = 0.009); in 2016, OR 0.85 (95%CI: 0.60-1.20; P = 0.368). CONCLUSIONS: The clinical practice of IMV in Mexican ICUs has been modified over a period of 18 years. The most significant change is the ventilatory strategy based on low vt. These changes have not been associated with significant changes in mortality

Have there been changes in the application of mechanical ventilation in relation to scientific evidence? A multicenter observational study in Mexico. / ¿Se han producido cambios en la aplicación de la ventilación mecánica en relación con la evidencia científica? Estudio multicéntrico en México.

OBJECTIVE: The main study objectives were to describe the practice of mechanical ventilation over an 18-year period in Mexico, and estimate changes in mortality among critical patients subjected to invasive mechanical ventilation (IMV). DESIGN: A retrospective subanalysis of a prospective observational study conducted in 1998, 2004, 2010 and 2016 was carried out. SETTING: Intensive Care Units (ICUs) in Mexico. PARTICIPANTS: Adult patients consecutively enrolled in the ICU during one month and who underwent IMV for more than 12hours or noninvasive mechanical ventilation for more than one hour. Follow-up was performed up to a maximum of 28 days after inclusion. INTERVENTIONS: None. PRINCIPAL VARIABLES OF INTEREST: Age, sex, severity upon admission as estimated by SAPS II, parameters of daily arterial blood gases, treatment and complication variables, date and status at discharge from the ICU and from hospital. RESULTS: A total of 959 patients were included in 81 ICUs. Tidal volume (vt) decreased significantly both in patients with acute respiratory distress syndrome (ARDS) criteria (estimated 8.5ml/kg b.w. in 1998 to 6ml/kg in 2016; P<0.001) and in patients without ARDS (estimated 9ml/kg b.w. in 1998 to 6ml/kg in 2016; P<0.001). The ventilatory protective strategy (defined as vt < 6ml/kg or < 8ml/kg and a plateau pressure < 30cmH2O) was: 19% in 1998, 44% in 2004, 58% in 2010 and 75% in 2016 (P<0.001). The adjusted mortality rate in ICU over the 4 periods was: in 2004, odds ratio (OR) 1.05 (95% confidence interval, 95%CI: 0.73-1.72; P=0.764); in 2010, OR 1.68 (95%CI: 1.13-2.48; P=0.009); in 2016, OR 0.85 (95%CI: 0.60-1.20; P=0.368). CONCLUSIONS: The clinical practice of IMV in Mexican ICUs has been modified over a period of 18 years. The most significant change is the ventilatory strategy based on low vt. These changes have not been associated with significant changes in mortality.

Empleo de ECMO en UCI. Recomendaciones de la Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias / The use of ECMO in ICU. Recommendations of the Spanish Society of Critical Care Medicine and Coronary Units

El empleo de sistemas de oxigenación con membrana extracorpórea se ha incrementado significativamente en los últimos años; ante esta realidad, la Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias (SEMICYUC) ha decidido elaborar una serie de recomendaciones que sirvan de marco para el empleo de esta técnica en las Unidades de Cuidados intensivos. Los tres ámbitos de empleo de oxigenación con membrana extracorpórea más frecuentes en nuestro medio son: como soporte cardiocirculatorio, como soporte respiratorio y para el mantenimiento de los órganos abdominales en donantes. La SEMICYUC nombró una serie de expertos pertenecientes a los tres grupos de trabajo implicados (Cuidados Intensivos Cardiológicos y RCP, Insuficiencia Respiratoria Aguda y Grupo de trabajo de Trasplantes de SEMICYUC) que tras la revisión de la literatura existente hasta marzo de 2018, elaboraron una serie de recomendaciones. Estas recomendaciones fueron expuestas en la web de la SEMICYUC para recibir las sugerencias de los intensivistas y finalmente fueron aprobadas por el Comité Científico de la Sociedad. Las recomendaciones, en base al conocimiento actual, versan sobre qué pacientes pueden ser candidatos a la técnica, cuándo iniciarla y las condiciones de infraestructura necesarias de los centros hospitalarios o en su caso, las condiciones para el traslado a centros con experiencia. Aunque desde un punto de vista fisiopatólogico, existen claros argumentos para el empleo de oxigenación con membrana extracorpórea, la evidencia científica actual es débil por lo que es necesario estudios que definen con más precisión qué pacientes se benefician más de la técnica y en qué momento deben iniciarse

The use of extracorporeal membrane oxygenation systems has increased significantly in recent years; given this reality, the Spanish Society of Critical Intensive Care Medicine and Coronary Units (SEMICYUC) has decided to draw up a series of recommendations that serve as a framework for the use of this technique in intensive care units. The three most frequent areas of extracorporeal membrane oxygenation systems use in our setting are: as a cardiocirculatory support, as a respiratory support and for the maintenance of the abdominal organs in donors. The SEMICYUC appointed a series of experts belonging to the three working groups involved (Cardiological Intensive Care and CPR, Acute Respiratory Failure and Transplant work group) that, after reviewing the existing literature until March 2018, developed a series of recommendations. These recommendations were posted on the SEMICYUC website to receive suggestions from the intensivists and finally approved by the Scientific Committee of the Society. The recommendations, based on current knowledge, are about which patients may be candidates for the technique, when to start it and the necessary infrastructure conditions of the hospital centers or, the conditions for transfer to centers with experience. Although from a physiopathological point of view, there are clear arguments for the use of extracorporeal membrane oxygenation systems, the current scientific evidence is weak, so studies are needed that define more precisely which patients benefit most from the technique and when they should start

The use of ECMO in ICU. Recommendations of the Spanish Society of Critical Care Medicine and Coronary Units. / Empleo de ECMO en UCI. Recomendaciones de la Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias.

The use of extracorporeal membrane oxygenation systems has increased significantly in recent years; given this reality, the Spanish Society of Critical Intensive Care Medicine and Coronary Units (SEMICYUC) has decided to draw up a series of recommendations that serve as a framework for the use of this technique in intensive care units. The three most frequent areas of extracorporeal membrane oxygenation systems use in our setting are: as a cardiocirculatory support, as a respiratory support and for the maintenance of the abdominal organs in donors. The SEMICYUC appointed a series of experts belonging to the three working groups involved (Cardiological Intensive Care and CPR, Acute Respiratory Failure and Transplant work group) that, after reviewing the existing literature until March 2018, developed a series of recommendations. These recommendations were posted on the SEMICYUC website to receive suggestions from the intensivists and finally approved by the Scientific Committee of the Society. The recommendations, based on current knowledge, are about which patients may be candidates for the technique, when to start it and the necessary infrastructure conditions of the hospital centers or, the conditions for transfer to centers with experience. Although from a physiopathological point of view, there are clear arguments for the use of extracorporeal membrane oxygenation systems, the current scientific evidence is weak, so studies are needed that define more precisely which patients benefit most from the technique and when they should start.

Análisis de la causalidad desde los estudios observacionales y su aplicación en la investigación clínica en Cuidados Intensivos / Analysis of causality from observational studies and its application in clinical research in Intensive Care Medicine

Una de las características fundamentales de los ensayos clínicos es la asignación aleatoria de un tratamiento o intervención sobre los pacientes. Esta asignación divide los pacientes en dos grupos que, aunque difieran por el tratamiento recibido, presentan unas características basales homogéneas haciendo que ambos grupos sean comparables y se pueda evaluar el efecto causal del tratamiento. Por otro lado, los estudios observacionales se caracterizan por la asignación no aleatoria del tratamiento y por lo tanto que los grupos de pacientes no solo difieran por el tratamiento recibido, sino también por otras características basales, a menudo relacionadas con la variable de intervención. En numerosas ocasiones, los ensayos clínicos aleatorizados no son factibles por razones éticas, logísticas, económicas o de otro tipo. Uno de los retos de la investigación clínica en Cuidados Intensivos debería ser aprovechar los datos que provienen de la práctica clínica habitual y analizarlos como si fueran ensayos clínicos. Los estudios observacionales utilizando métodos de análisis con índices de propensión (propensity score) han ido en aumento en los artículos científicos de Cuidados Intensivos. Los análisis de índices de propensión intentan controlar la confusión en estudios observacionales ajustando la probabilidad de que un determinado paciente esté expuesto. Sin embargo, los estudios con índices de propensión pueden ser confusos, y los intensivistas no están familiarizados con esta metodología y pueden no comprender plenamente la importancia de esta técnica. Los objetivos de esta revisión son: describir los fundamentos de los métodos del índice de propensión; presentar las técnicas para evaluar adecuadamente los modelos de índices de propensión, y discutir las ventajas y los inconvenientes de estas técnicas

Random allocation of treatment or intervention is the key feature of clinical trials and divides patients into treatment groups that are approximately balanced for baseline, and therefore comparable covariates except for the variable treatment of the study. However, in observational studies, where treatment allocation is not random, patients in the treatment and control groups often differ in covariates that are related to intervention variables. These imbalances in covariates can lead to biased estimates of the treatment effect. However, randomized clinical trials are sometimes not feasible for ethical, logistical, economic or other reasons. To resolve these situations, interest in the field of clinical research has grown in designing studies that are most similar to randomized experiments using observational (i.e. non-random) data. Observational studies using propensity score analysis methods have been increasing in the scientific papers of Intensive Care. Propensity score analyses attempt to control for confounding in non-experimental studies by adjusting for the likelihood that a given patient is exposed. However, studies with propensity indexes may be confusing, and intensivists are not familiar with this methodology and may not fully understand the importance of this technique. The objectives of this review are: to describe the fundamentals of propensity index methods; to present the techniques to adequately evaluate propensity index models; to discuss the advantages and disadvantages of these techniques

Analysis of causality from observational studies and its application in clinical research in Intensive Care Medicine. / Análisis de la causalidad desde los estudios observacionales y su aplicación en la investigación clínica en Cuidados Intensivos.

Random allocation of treatment or intervention is the key feature of clinical trials and divides patients into treatment groups that are approximately balanced for baseline, and therefore comparable covariates except for the variable treatment of the study. However, in observational studies, where treatment allocation is not random, patients in the treatment and control groups often differ in covariates that are related to intervention variables. These imbalances in covariates can lead to biased estimates of the treatment effect. However, randomized clinical trials are sometimes not feasible for ethical, logistical, economic or other reasons. To resolve these situations, interest in the field of clinical research has grown in designing studies that are most similar to randomized experiments using observational (i.e. non-random) data. Observational studies using propensity score analysis methods have been increasing in the scientific papers of Intensive Care. Propensity score analyses attempt to control for confounding in non-experimental studies by adjusting for the likelihood that a given patient is exposed. However, studies with propensity indexes may be confusing, and intensivists are not familiar with this methodology and may not fully understand the importance of this technique. The objectives of this review are: to describe the fundamentals of propensity index methods; to present the techniques to adequately evaluate propensity index models; to discuss the advantages and disadvantages of these techniques.

Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients. / Recomendaciones para el tratamiento de los pacientes críticos de los Grupos de Trabajo de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC).

The standardization of the Intensive Care Medicine may improve the management of the adult critically ill patient. However, these strategies have not been widely applied in the Intensive Care Units (ICUs). The aim is to elaborate the recommendations for the standardization of the treatment of critical patients. A panel of experts from the thirteen working groups (WG) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2002 to 2016 was extracted. The clinical evidence was discussed and summarised by the experts in the course of a consensus finding of every WG and finally approved by the WGs after an extensive internal review process that was carried out between December 2015 and December 2016. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and are intended as a guide for the intensivists in the management of critical patients.

Desenlace de los enfermos traqueotomizados después de la reintubación / Outcome of tracheotomized patients following reintubation

Objetivo Evaluar el desenlace de pacientes que fueron traqueotomizados tras una reintubación. Diseño Análisis secundario de un estudio de cohorte prospectivo. Ámbito Treinta y seis unidades de cuidados intensivos de 8 países.Pacientes180 pacientes con ventilación mecánica durante más de 48 horas extubados y que requirieron reintubación en las primeras 48 horas. Intervenciones Ninguna. Variables de interés principal Mortalidad en la Unidad de Cuidados Intensivos, días de estancia en la unidad de cuidados intensivos, fracaso de órganos. Resultados Cincuenta y dos pacientes (29%) fueron traqueotomizados inicialmente después de reintubación. La mediana de tiempo desde la reintubación a la traqueotomía fue de 2,5 días (rango inter-cuartil: 1, 8). La duración de la estancia en la UCI fue significativamente mayor en el grupo de traqueotomía, en comparación con el grupo inicialmente sin traqueotomía [mediana de 25 días (rango inter-cuartil: 17, 43) versus 16,5 días (rango inter-cuartil: 11, 25); p <0,001]. En el grupo de traqueotomía no se observó una menor mortalidad (31% frente al 27%; p=0,57).Conclusiones En nuestra cohorte, la traqueotomía después de reintubación es un procedimiento común pero no ofrece ninguna ventaja significativa (AU)

Objective To evaluate the outcome of tracheotomized patients after reintubation. Method Secondary analysis from a prospective, multicenter and observational study including 36 Intensive Care Units (ICUs) from 8 countries. Patients A total of 180 patients under mechanical ventilation for more than 48hours, extubated and reintubated within 48hours.InterventionsNone.OutcomesICU mortality, length of ICU stay, organ failure. Results Fifty-two patients (29%) underwent tracheotomy after reintubation. The median time from reintubation to tracheotomy was 2.5 days (interquartile range (IQR) 1-8 days). The length of ICU stay was significantly longer in the tracheotomy group compared with the group without tracheotomy (median time 25 days, IQR 17-43 versus 16.5 days (IQR 11-25); p<0.001). ICU mortality in the tracheotomy group was not significantly different (31% versus 27%; p 0.57).Conclusions In our cohort of reintubated patients, tracheotomy is a common procedure in the ICU. Patients with tracheotomy had an outcome similar to those without tracheotomy (AU)