Lung Ultrasound in Emergency and Critically Ill Patients: Number of Supervised Exams to Reach Basic Competence.

BACKGROUND: Lung ultrasound is increasingly used in critically ill patients as an alternative to bedside chest radiography, but the best training method remains uncertain. This study describes a training curriculum allowing trainees to acquire basic competence. METHODS: This multicenter, prospective, and educational study was conducted in 10 Intensive Care Units in Brazil, China, France and Uruguay. One hundred residents, respiratory therapists, and critical care physicians without expertise in transthoracic ultrasound (trainees) were trained by 18 experts. The main study objective was to determine the number of supervised exams required to get the basic competence, defined as the trainees' ability to adequately classify lung regions with normal aeration, interstitial-alveolar syndrome, and lung consolidation. An initial 2-h video lecture provided the rationale for image formation and described the ultrasound patterns commonly observed in critically ill and emergency patients. Each trainee performed 25 bedside ultrasound examinations supervised by an expert. The progression in competence was assessed every five supervised examinations. In a new patient, 12 pulmonary regions were independently classified by the trainee and the expert. RESULTS: Progression in competence was derived from the analysis of 7,330 lung regions in 2,562 critically ill and emergency patients. After 25 supervised examinations, 80% of lung regions were adequately classified by trainees. The ultrasound examination mean duration was 8 to 10 min in experts and decreased from 19 to 12 min in trainees (after 5 vs. 25 supervised examinations). The median training duration was 52 (42, 82) days. CONCLUSIONS: A training curriculum including 25 transthoracic ultrasound examinations supervised by an expert provides the basic skills for diagnosing normal lung aeration, interstitial-alveolar syndrome, and consolidation in emergency and critically ill patients.

Corrigendum to "Public versus Private Healthcare Systems following Discharge from the ICU: A Propensity Score-Matched Comparison of Outcomes".

[This corrects the article DOI: 10.1155/2016/6568531.].

Public versus Private Healthcare Systems following Discharge from the ICU: A Propensity Score-Matched Comparison of Outcomes.

Purpose. The long-term outcomes of patients after discharge from tertiary ICUs as they relate to the public versus private healthcare systems in Brazil have not yet been evaluated. Materials and Methods. A multicenter prospective cohort study was conducted to compare the all-cause mortality and the physical functional status (PFS) 24 months after discharge from the ICU between adult patients treated in the public and private healthcare systems. A propensity score- (PS-) matched comparison of all causes of mortality and PFS 24 months after discharge from the ICU was performed. Results. In total, 928 patients were discharged from the ICU including 172 (18.6%) patients in the public and 756 (81.4%) patients in the private healthcare system. The results of the PS-matched comparison of all-cause mortality revealed higher mortality rates among the patients of the public healthcare system compared to those of the private healthcare system (47.3% versus 27.6%, P = 0.003). The comparison of the PS-matched Karnofsky performance and Lawton activities of daily living scores between the ICU survivors of the public and private healthcare systems revealed no significant differences. Conclusions. The patients of private healthcare system exhibited significantly greater survival rates than the patients of the public healthcare system with similar PFS following ICU discharge.

Use of a homemade introducer guide (bougie) for intubation in emergency situation in patients who present with difficult airway: a case series / Emprego de guia introdutor (bougie) artesanal para intubação em situação de emergência em pacientes que se apresentam com via aérea de difícil intubação: série de casos

ABSTRACT BACKGROUND AND OBJECTIVES: The incidence of difficult airway reaches 10% of emergency intubations. Although few studies address the use of handmade introducer guides in emergency and intensive care environment, there are descriptions of handmade guides available on the Internet. We describe a case series on the use of a handmade introducer guide (bougie) for emergency intubation in patients with difficult airway. CASE REPORT: The handmade introducer guide was used in five consecutive patients with difficult airways, and clinical instability and in the absence of another immediate method to obtain an airway. This technique provided successful intubation and there were no complications. CONCLUSIONS: The use of the handmade introducer guide can be a useful option for the management of difficult airways.

RESUMO JUSTIFICATIVA E OBJETIVOS: A incidência de via aérea difícil chega a 10% das intubações de emergência. Ainda que poucos estudos abordem o emprego de guia introdutor artesanal no ambiente de emergência e terapia intensiva, há descrições de guias produzidas de forma artesanal disponíveis na internet. Nosso objetivo é descrever uma série de casos sobre o uso de um guia introdutor (Bougie) artesanal para intubação de emergência em pacientes com Via Aérea Difícil. RELATO DE CASO: O guia introdutor artesanal foi utilizado em cinco pacientes consecutivos com via aérea difícil, instabilidade clínica e falta de outro método imediato para a obtenção de uma via aérea. Essa técnica proporcionou sucesso na intubação e não houve complicações. CONCLUSÕES: A utilização do guia introdutor artesanal pode ser uma opção útil para o manejo de via aérea difícil.

Use of a homemade introducer guide (bougie) for intubation in emergency situation in patients who present with difficult airway: a case series.

BACKGROUND AND OBJECTIVES: The incidence of difficult airway reaches 10% of emergency intubations. Although few studies address the use of handmade introducer guides in emergency and intensive care environment, there are descriptions of handmade guides available on the Internet. We describe a case series on the use of a handmade introducer guide (bougie) for emergency intubation in patients with difficult airway. CASE REPORT: The handmade introducer guide was used in five consecutive patients with difficult airways, and clinical instability and in the absence of another immediate method to obtain an airway. This technique provided successful intubation and there were no complications. CONCLUSIONS: The use of the handmade introducer guide can be a useful option for the management of difficult airways.

[Use of a homemade introducer guide (bougie) for intubation in emergency situation in patients who present with difficult airway: a case series]. / Emprego de guia introdutor (bougie) artesanal para intubação em situação de emergência em pacientes que se apresentam com via aérea de difícil intubação: série de casos.

BACKGROUND AND OBJECTIVES: The incidence of difficult airway reaches 10% of emergency intubations. Although few studies address the use of handmade introducer guides in emergency and intensive care environment, there are descriptions of handmade guides available on the Internet. We describe a case series on the use of a handmade introducer guide (bougie) for emergency intubation in patients with difficult airway. CASE REPORT: The handmade introducer guide was used in five consecutive patients with difficult airways, and clinical instability and in the absence of another immediate method to obtain an airway. This technique provided successful intubation and there were no complications. CONCLUSIONS: The use of the handmade introducer guide can be a useful option for the management of difficult airways.

Uso da tomografia por impedância elétrica torácica como ferramenta de auxílio às manobras de recrutamento alveolar na síndrome do desconforto respiratório agudo: relato de caso e breve revisão da literatura / Use of thoracic electrical impedance tomography as an auxiliary tool for alveolar recruitment maneuvers in acute respiratory distress syndrome: case report and brief literature review

RESUMO A tomografia por impedância elétrica torácica constitui ferramenta de monitorização não invasiva, em tempo real, da distribuição regional da ventilação pulmonar. Sua utilização à beira do leito em pacientes com síndrome do desconforto respiratório agudo tem o potencial de auxiliar na condução de manobras de recrutamento alveolar, frequentemente necessárias em casos de hipoxemia refratária. Neste relato de caso, apresentamos os resultados e a interpretação da monitorização da tomografia por impedância elétrica torácica em um paciente com síndrome do desconforto respiratório agudo, durante manobras de recrutamento alveolar, com aplicação transitória de altas pressões alveolares e titulação da pressão positiva ao final da expiração ideal. Adicionalmente, apresentamos uma breve revisão da literatura a respeito do uso de manobras de recrutamento alveolar e monitorização com tomografia por impedância elétrica torácica em pacientes com síndrome do desconforto respiratório agudo.

ABSTRACT Thoracic electrical impedance tomography is a real-time, noninvasive monitoring tool of the regional pulmonary ventilation distribution. Its bedside use in patients with acute respiratory distress syndrome has the potential to aid in alveolar recruitment maneuvers, which are often necessary in cases of refractory hypoxemia. In this case report, we describe the monitoring results and interpretation of thoracic electrical impedance tomography used during alveolar recruitment maneuvers in a patient with acute respiratory distress syndrome, with transient application of high alveolar pressures and optimal positive end-expiratory pressure titration. Furthermore, we provide a brief literature review regarding the use of alveolar recruitment maneuvers and monitoring using thoracic electrical impedance tomography in patients with acute respiratory distress syndrome.

Inhalation therapy in mechanical ventilation.

Patients with obstructive lung disease often require ventilatory support via invasive or noninvasive mechanical ventilation, depending on the severity of the exacerbation. The use of inhaled bronchodilators can significantly reduce airway resistance, contributing to the improvement of respiratory mechanics and patient-ventilator synchrony. Although various studies have been published on this topic, little is known about the effectiveness of the bronchodilators routinely prescribed for patients on mechanical ventilation or about the deposition of those drugs throughout the lungs. The inhaled bronchodilators most commonly used in ICUs are beta adrenergic agonists and anticholinergics. Various factors might influence the effect of bronchodilators, including ventilation mode, position of the spacer in the circuit, tube size, formulation, drug dose, severity of the disease, and patient-ventilator synchrony. Knowledge of the pharmacological properties of bronchodilators and the appropriate techniques for their administration is fundamental to optimizing the treatment of these patients.

Inhalation therapy in mechanical ventilation / Terapia inalatória em ventilação mecânica

Patients with obstructive lung disease often require ventilatory support via invasive or noninvasive mechanical ventilation, depending on the severity of the exacerbation. The use of inhaled bronchodilators can significantly reduce airway resistance, contributing to the improvement of respiratory mechanics and patient-ventilator synchrony. Although various studies have been published on this topic, little is known about the effectiveness of the bronchodilators routinely prescribed for patients on mechanical ventilation or about the deposition of those drugs throughout the lungs. The inhaled bronchodilators most commonly used in ICUs are beta adrenergic agonists and anticholinergics. Various factors might influence the effect of bronchodilators, including ventilation mode, position of the spacer in the circuit, tube size, formulation, drug dose, severity of the disease, and patient-ventilator synchrony. Knowledge of the pharmacological properties of bronchodilators and the appropriate techniques for their administration is fundamental to optimizing the treatment of these patients.

Pacientes com doenças pulmonares obstrutivas frequentemente necessitam de suporte ventilatório através de ventilação mecânica invasiva ou não invasiva, dependendo da gravidade da exacerbação. O uso de broncodilatadores inalatórios pode reduzir significativamente a resistência das vias aéreas, contribuindo para a melhora da mecânica respiratória e da sincronia do paciente com o respirador. Apesar dos diversos estudos publicados, pouco se conhece sobre a eficácia dos broncodilatadores rotineiramente prescritos para pacientes em ventilação mecânica ou sobre sua distribuição pulmonar. Os agonistas beta-adrenérgicos e as drogas anticolinérgicas são os broncodilatadores inalatórios mais usados em UTIs. Muitos fatores podem influenciar no efeito das drogas broncodilatadoras, entre eles o modo ventilatório, a posição do espaçador no circuito, o tamanho do tubo, a formulação/dose da droga, a gravidade da doença e a sincronia do paciente. O conhecimento das propriedades farmacológicas das drogas broncodilatadoras e das técnicas adequadas para sua administração são fundamentais para otimizar o tratamento desses pacientes.

Diagnostic accuracy of the Bedside Lung Ultrasound in Emergency protocol for the diagnosis of acute respiratory failure in spontaneously breathing patients.

OBJECTIVE: Bedside lung ultrasound (LUS) is a noninvasive, readily available imaging modality that can complement clinical evaluation. The Bedside Lung Ultrasound in Emergency (BLUE) protocol has demonstrated a high diagnostic accuracy in patients with acute respiratory failure (ARF). Recently, bedside LUS has been added to the medical training program of our ICU. The aim of this study was to investigate the accuracy of LUS based on the BLUE protocol, when performed by physicians who are not ultrasound experts, to guide the diagnosis of ARF. METHODS: Over a one-year period, all spontaneously breathing adult patients consecutively admitted to the ICU for ARF were prospectively included. After training, 4 non-ultrasound experts performed LUS within 20 minutes of patient admission. They were blinded to patient medical history. LUS diagnosis was compared with the final clinical diagnosis made by the ICU team before patients were discharged from the ICU (gold standard). RESULTS: Thirty-seven patients were included in the analysis (mean age, 73.2 ± 14.7 years; APACHE II, 19.2 ± 7.3). LUS diagnosis had a good agreement with the final diagnosis in 84% of patients (overall kappa, 0.81). The most common etiologies for ARF were pneumonia (n = 17) and hemodynamic lung edema (n = 15). The sensitivity and specificity of LUS as measured against the final diagnosis were, respectively, 88% and 90% for pneumonia and 86% and 87% for hemodynamic lung edema. CONCLUSIONS: LUS based on the BLUE protocol was reproducible by physicians who are not ultrasound experts and accurate for the diagnosis of pneumonia and hemodynamic lung edema.

OBJETIVO: O ultrassom pulmonar (USP) à beira do leito é uma técnica de imagem não invasiva e prontamente disponível que pode complementar a avaliação clínica. O protocolo Bedside Lung Ultrasound in Emergency (BLUE, ultrassom pulmonar à beira do leito em situações de emergência) demonstrou elevado rendimento diagnóstico em pacientes com insuficiência respiratória aguda (IRpA). Recentemente, um programa de treinamento em USP à beira do leito foi implementado na nossa UTI. O objetivo deste estudo foi avaliar a acurácia do USP baseado no protocolo BLUE, quando realizado por médicos com habilidades básicas em ultrassonografia, para orientar o diagnóstico de IRpA. MÉTODOS: Ao longo de um ano, todos os pacientes adultos consecutivos respirando espontaneamente admitidos na UTI por IRpA foram prospectivamente inclusos. Após treinamento, 4 operadores com habilidades básicas em ultrassonografia realizaram o USP em até 20 minutos após a admissão na UTI, cegados para a história do paciente. Os diagnósticos do USP foram comparados aos diagnósticos da equipe assistente ao final da internação na UTI (padrão-ouro). RESULTADOS: Foram inclusos na análise 37 pacientes (média etária: 73,2 ± 14,7 anos; APACHE II: 19,2 ± 7,3). O diagnóstico do USP demonstrou concordância com o diagnóstico final em 84% dos casos (kappa total: 0,81). As causas mais comuns de IRpA foram pneumonia (n = 17) e edema pulmonar cardiogênico (n = 15). A sensibilidade e a especificidade do USP comparado ao diagnóstico final foram de 88% e 90% para pneumonia e de 86% e 87% para edema pulmonar cardiogênico, respectivamente. CONCLUSÕES: O USP baseado no protocolo BLUE foi reproduzível por médicos com habilidades básicas em ultrassonografia e acurado para o diagnóstico de pneumonia e de edema pulmonar cardiogênico.

Diagnostic accuracy of the Bedside Lung Ultrasound in Emergency protocol for the diagnosis of acute respiratory failure in spontaneously breathing patients, / Acurácia diagnóstica do protocolo de ultrassom pulmonar à beira do leito em situações de emergência para diagnóstico de insuficiência respiratória aguda em pacientes com ventilação espontânea

Objective: Bedside lung ultrasound (LUS) is a noninvasive, readily available imaging modality that can complement clinical evaluation. The Bedside Lung Ultrasound in Emergency (BLUE) protocol has demonstrated a high diagnostic accuracy in patients with acute respiratory failure (ARF). Recently, bedside LUS has been added to the medical training program of our ICU. The aim of this study was to investigate the accuracy of LUS based on the BLUE protocol, when performed by physicians who are not ultrasound experts, to guide the diagnosis of ARF. Methods: Over a one-year period, all spontaneously breathing adult patients consecutively admitted to the ICU for ARF were prospectively included. After training, 4 non-ultrasound experts performed LUS within 20 minutes of patient admission. They were blinded to patient medical history. LUS diagnosis was compared with the final clinical diagnosis made by the ICU team before patients were discharged from the ICU (gold standard). Results: Thirty-seven patients were included in the analysis (mean age, 73.2 ± 14.7 years; APACHE II, 19.2 ± 7.3). LUS diagnosis had a good agreement with the final diagnosis in 84% of patients (overall kappa, 0.81). The most common etiologies for ARF were pneumonia (n = 17) and hemodynamic lung edema (n = 15). The sensitivity and specificity of LUS as measured against the final diagnosis were, respectively, 88% and 90% for pneumonia and 86% and 87% for hemodynamic lung edema. Conclusions: LUS based on the BLUE protocol was reproducible by physicians who are not ultrasound experts and accurate for the diagnosis of pneumonia and hemodynamic lung edema. .

Objetivo: O ultrassom pulmonar (USP) à beira do leito é uma técnica de imagem não invasiva e prontamente disponível que pode complementar a avaliação clínica. O protocolo Bedside Lung Ultrasound in Emergency (BLUE, ultrassom pulmonar à beira do leito em situações de emergência) demonstrou elevado rendimento diagnóstico em pacientes com insuficiência respiratória aguda (IRpA). Recentemente, um programa de treinamento em USP à beira do leito foi implementado na nossa UTI. O objetivo deste estudo foi avaliar a acurácia do USP baseado no protocolo BLUE, quando realizado por médicos com habilidades básicas em ultrassonografia, para orientar o diagnóstico de IRpA. Métodos: Ao longo de um ano, todos os pacientes adultos consecutivos respirando espontaneamente admitidos na UTI por IRpA foram prospectivamente inclusos. Após treinamento, 4 operadores com habilidades básicas em ultrassonografia realizaram o USP em até 20 minutos após a admissão na UTI, cegados para a história do paciente. Os diagnósticos do USP foram comparados aos diagnósticos da equipe assistente ao final da internação na UTI (padrão-ouro). Resultados: Foram inclusos na análise 37 pacientes (média etária: 73,2 ± 14,7 anos; APACHE II: 19,2 ± 7,3). O diagnóstico do USP demonstrou concordância com o diagnóstico final em 84% dos casos (kappa total: 0,81). As causas mais comuns de IRpA foram pneumonia (n = 17) e edema pulmonar cardiogênico (n = 15). A sensibilidade e a especificidade do USP comparado ao diagnóstico final foram de 88% e 90% para pneumonia e de 86% e 87% para edema pulmonar cardiogênico, respectivamente. Conclusões: O USP baseado no protocolo BLUE foi reproduzível por médicos com habilidades básicas em ultrassonografia e acurado para o diagnóstico de pneumonia e de edema pulmonar cardiogênico. .

Use of thoracic electrical impedance tomography as an auxiliary tool for alveolar recruitment maneuvers in acute respiratory distress syndrome: case report and brief literature review.

Thoracic electrical impedance tomography is a real-time, noninvasive monitoring tool of the regional pulmonary ventilation distribution. Its bedside use in patients with acute respiratory distress syndrome has the potential to aid in alveolar recruitment maneuvers, which are often necessary in cases of refractory hypoxemia. In this case report, we describe the monitoring results and interpretation of thoracic electrical impedance tomography used during alveolar recruitment maneuvers in a patient with acute respiratory distress syndrome, with transient application of high alveolar pressures and optimal positive end-expiratory pressure titration. Furthermore, we provide a brief literature review regarding the use of alveolar recruitment maneuvers and monitoring using thoracic electrical impedance tomography in patients with acute respiratory distress syndrome.

Out-of-bed extubation: a feasibility study.

OBJECTIVE: In clinical intensive care practice, weaning from mechanical ventilation is accompanied by concurrent early patient mobilization. The aim of this study was to compare the success of extubation performed with patients seated in an armchair compared to extubation with patients in a supine position. METHODS: A retrospective study, observational and non-randomized was conducted in a mixed-gender, 23-bed intensive care unit. The primary study outcome was success of extubation, which was defined as the patient tolerating the removal of the endotracheal tube for at least 48 hours. The differences between the study groups were assessed using Student's t-test and chi-squared analysis. RESULTS: Ninety-one patients were included from December 2010 and June 2011. The study population had a mean age of 71 years ± 12 months, a mean APACHE II score of 21±7.6, and a mean length of mechanical ventilation of 2.6±2 days. Extubation was performed in 33 patients who were seated in an armchair (36%) and in 58 patients in a supine position (64%). There were no significant differences in age, mean APACHE II score or length of mechanical ventilation between the two groups, and a similar extubation success rate was observed (82%, seated group versus 85%, supine group, p>0.05). Furthermore, no significant differences were found between the two groups in terms of post-extubation distress, need for tracheostomy, duration of mechanical ventilation weaning, or intensive care unit stay. CONCLUSION: Our results suggest that the clinical outcomes of patients extubated in a seated position are similar to those of patients extubated in a supine position. This new practice of seated extubation was not associated with adverse events and allowed extubation to occur simultaneously with early mobilization.

Platypnea-orthodeoxia syndrome in patients presenting enlarged aortic root: case report and literature review.

We describe herein a case of a patient who, when in orthostatic positions, had severe hypoxemia and ventilatory dysfunction. Although the severity of symptoms required hospitalization in an intensive care setting, the initial tests only identified the presence of enlarged aortic root, which did not explain the condition. The association of these events with an unusual etiology, namely intracardiac shunt, characterized the diagnosis of platypnea-orthodeoxia syndrome. The literature review shows that, with advancing research methods, there was a progressive increase in the identification of this condition, and this association should be part of the differential diagnosis of dyspnea in patients with enlarged aortic root.