Epidemiología de la ventilación mecánica en Argentina. Estudio observacional multicéntrico EpVAr / Epidemiology of Mechanical Ventilation in Argentina. The EpVAr Multicenter Observational Study

Objetivo Describir las prácticas relacionadas a ventilación mecánica (VM) en Argentina y explorar los factores asociados a la mortalidad en UCI en esta población. Diseño Se realizó un estudio observacional, prospectivo, multicéntrico. Ámbito Unidad de Cuidados Intensivos. Pacientes Incluimos pacientes mayores de 18 años ingresados en las UCI participantes que requirieron VM invasiva durante al menos 12 horas desde el ingreso a la institución de salud. Intervenciones Ninguna. Variables Todas las variables se clasificaron en tres categorías: variables relacionadas con factores demográficos y clínicos antes de la VM, factores relacionados con el primer día de VM, y factores relacionados con los eventos ocurridos durante la VM (complicaciones y destete de la VM). El destete de la ventilación mecánica y la mortalidad se clasificaron según WIND (Weaning according to a New Definition). Resultados El análisis primario incluyó a 950 pacientes. La principal indicación de VM fue insuficiencia respiratoria aguda (58% de los pacientes). El modo de ventilación inicial fue ventilación mandatoria continua con control de volumen en el 75% de los casos. La mortalidad en UCI y hospitalaria fue del 44,6% y 47,9%, respectivamente. Las variables identificadas como predictoras independientes de mortalidad en UCI fueron edad (OR 3,48 IC 95%, 1,22-11,66; p=0,028), fracaso en la implementación de ventilación mecánica no invasiva (VNI) antes de VM (OR 2,76, IC 95%, 1,02-7,10; p=0,038), diagnóstico de sepsis (OR 2,46, IC 95%, 1,09-5,47; p=0,027) y fracaso de la extubación (OR 4,50, IC 95%, 2,05-9,90; p<0,001). Conclusiones El presente estudio permitió describir las características y evolución clínica de los pacientes que recibieron ventilación mecánica en Argentina, encontrando como principal resultado que la mortalidad fue mayor a la reportada en estudios internacionales (AU)

Objetive To describe mechanical ventilation (MV) practices in Argentina, and to explore factors associated with ICU mortality in this population. Design A prospective, multicenter, observational study was carried out. Setting Intensive Care. Patients We enrolled patients above 18 years old admitted to any of the participating ICUs requiring invasive MV for at least 12hours since the admission to the healthcare institution, including MV initiation in emergency department, operating room or other hospitals. Interventions None. Variables All variables were classified into three categories: variables related to demographic and clinical factors before the MV, factors related to the first day on MV, and factors related to events happening during the MV (complications and weaning from MV). Mechanical ventilation weaning and mortality were classified according to WIND. Results The primary analysis included 950 patients. The main indication for MV was acute respiratory failure (58% of patients). Initial ventilation mode was volume control-continuous mandatory ventilation in 75% of cases. ICU and hospital mortality were 44.6% and 47.9% respectively. The variables identified as independent predictors of mortality in ICU were age (OR3.48 IC95% 1.22-11.66; p=0.028), failure to implement NIV before MV (OR 2.76, IC 95%, 1.02-7.10; p=0.038), diagnosis of sepsis (OR 2.46, IC 95%, 1.09-5.47; p=0.027) and extubation failure (OR 4.50, IC 95%, 2.05-9.90; p<0.001). Conclusions The present study allowed us to describe the characteristics and clinical course of the patients who received mechanical ventilation in Argentina, finding as the main result that mortality was higher than that reported in international studies (AU)

Epidemiology of mechanical ventilation in Argentina. The EpVAr multicenter observational study.

OBJETIVE: To describe mechanical ventilation (MV) practices in Argentina, and to explore factors associated with ICU mortality in this population. DESIGN: A prospective, multicenter, observational study was carried out. SETTING: Intensive Care. PATIENTS: We enrolled patients above 18 years old admitted to any of the participating ICUs requiring invasive MV for at least 12 h since the admission to the healthcare institution, including MV initiation in emergency department, operating room or other hospitals. INTERVENTIONS: None. VARIABLES: All variables were classified into three categories: variables related to demographic and clinical factors before the MV, factors related to the first day on MV, and factors related to events happening during the MV (complications and weaning from MV). Mechanical ventilation weaning and mortality were classified according to WIND. RESULTS: The primary analysis included 950 patients. The main indication for MV was acute respiratory failure (58% of patients). Initial ventilation mode was volume control-continuous mandatory ventilation in 75% of cases. ICU and hospital mortality were 44.6% and 47.9% respectively. The variables identified as independent predictors of mortality in ICU were age (OR 3.48 IC 95% 1.22-11.66; p = 0.028), failure to implement NIV before MV (OR 2.76 IC 95% 1.02-7.10; p = 0.038), diagnosis of sepsis (OR 2.46 IC 95% 1.09-5.47; p = 0.027) and extubation failure (OR 4.50 IC 95% 2.05-9.90; p < 0.001). CONCLUSIONS: The present study allowed us to describe the characteristics and clinical course of the patients who received mechanical ventilation in Argentina, finding as the main result that mortality was higher than that reported in international studies.

High-flow nasal cannula oxygen for reverting severe acute exacerbation of chronic obstructive pulmonary disease: A case report / Oxigenoterapia de alto flujo con cánula nasal en el tratamiento de la exacerbación de la enfermedad pulmonar obstructiva crónica: informe de un caso

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Decúbito prono: revisión narrativa / Prone position: revision narrative

Los pacientes con síndrome de distrés respiratorio agudo demandan gran atención en la Unidad de Cuidados Intensivos. La utilización del decúbito prono en esta población tiene un sustento bibliográfico sumamente sólido y, en varios ensayos clínicos aleatorizados, se ha comprobado su efecto sobre la oxigenación medida a través de la relación PaO2/FiO2 e incluso su impacto en prolongar la supervivencia. Esta estrategia ha demostrado ser una maniobra útil y accesible para la mayor parte de las Unidades de Cuidados Intensivos y su implementación, realizada de manera protocolizada y por personal entrenado, debería ser considerada en un grupo selecto de pacientes quienes se beneficiarían en términos de mortalidad. En la Argentina, pareciera que muchos profesionales han decidido implementar la maniobra en sus lugares de trabajo, con un bajo porcentaje de complicaciones.(AU)

Patients with acute respiratory distress syndrome demand great attention in the Intensive Care Unit. The use of prone position in this population has a very robust literary support, and several randomized clinical trials have shown the effect on oxygenation (represented by an increase in PaO2/FiO2) and even its impact on increasing survival. The prone position has proved to be a useful and accessible maneuver for most of Intensive Care Units and its implementation, following a protocol and done for trained personnel, should be considered in a select group of patients who would benefit in terms of mortality. In Argentina, many professionals have decided to implement the prone position in their workplace, with a low percentage of complications.(AU)

Risk factors for worsened quality of life in patients on mechanical ventilation. A prospective multicenter study / Factores de riesgo relacionados al empeoramiento de la calidad de vida (QOL) en pacientes que recibieron ventilación mecánica. Estudio prospectivo multicêntrico

OBJECTIVE: To identify risk factors for worsened quality of life (QoL) and activities of daily living (ADL) at 3 and 12 months after discharge from the Intensive Care Unit (ICU) in patients on mechanical ventilation (MV). DESIGN: A prospective, multicentric observational study was made. SETTING: Three ICUs in Argentina. PATIENTS: The study included a total of 84 out of 129 mainly clinical patients admitted between 2011-2012 and requiring over 24hours of MV. INTERVENTIONS: No interventions were carried out. Variables: Quality of life was assessed with the EQ-5D (version for Argentina), and ADL with the Barthel index. RESULTS: The EQ-5D and Barthel scores were assessed upon admission to the ICU (baseline) and after three months and one year of follow-up.comorbidities, delirium, ICU acquired weakness (ICUAW), and medication received were daily assessed during ICU stay. The baseline QoL of the global sample showed a median index of [0.831 (IQR25-75% 0.527-0.931)], versus [0.513 (IQR0.245-0.838)] after three months and [0.850 (IQR0.573-1.00)] after one year. Significant differences were observed compared with QoL in the Argentinean general population [mean 0.880 (CI 0.872-0.888), p < 0.001; p < 0.001; p0.002]. Individual analysis showed that 67% of the patients had worsened their QoL at three months, while 33% had recovered their QoL. In the multivariate analysis, the variables found to be independent predictors of worsened QoL were a hospital stay ≥21 days [OR 12.57 (2.75-57.47)], age ≥50 years [OR 5.61 (1.27-24.83)], previous poor QoL [OR 0.11 (0.02-0.54)] and persistent ICUAW [OR 8.32 (1.22-56.74)]. Similar results were found for the worsening of ADL. CONCLUSIONS: Quality of life is altered after critical illness, and its recovery is gradual over time. Age, length of hospital stay, previous QoL and persistent ICUAW seem to be risk factors for worsened QoL

OBJETIVO: Identificar los factores de riesgo relacionados con el empeoramiento de la QOL y actividades de la vida diaria (AVD) a los 3 meses y al año del alta de la unidad de cuidados intensivos (ICU) en pacientes que recibieron ventilación mecánica (VM). DISEÑO: Prospectivo, observacional. Ámbito: Tres UCI en Argentina. PACIENTES: Se incluyó a 84 de 129 pacientes, predominantemente clínicos, que habían sido ingresados en las UCI entre 2011 y 2012 con>24h de VM. INTERVENCIONES: Ninguna. VARIABLES: La QOL fue evaluada a través del EQ-5D (versión argentina) y las AVD con el índice de Barthel. RESULTADOS: El EQ-5D y el índice de Barthel se evaluaron al ingreso a ICU, a los 3 meses y al año de seguimiento. Las comorbilidades, el delirio, la debilidad adquirida en UCI y los fármacos recibidos fueron evaluados diariamente. La QOL basal de toda la muestra exhibió una mediana del índice (0,831 [IQR: 0,527-0,931]), a los 3 meses (0,513 [IQR: 0,245-0,838]) y al año (0,850 [IQR: 0,573-1]) y mostró una diferencia significativa con la QOL de la población general argentina (0,880 (0,872-0,888) p < 0,001; p < 0,001; p = 0,002]. El análisis individual evidenció que el 67% de los pacientes había empeorado su QOL a los 3 meses mientras que el 33% la había recuperado. En al análisis multivariado, las variables que probaron ser predictores independientes de empeoramiento de QOL fueron estadía hospitalaria≥21 días (OR: 12,57 [2,75-57,47]), edad≥50 años (OR: 5,61 [1,27-24,83]), baja QOL previa (OR: 0,11 [0,02-0,54]), y debilidad adquirida en UCI persistente (OR: 8,32 [1,22-56,74]). Resultados similares se observaron en el empeoramiento de AVD. CONCLUSIONES: La QOL está alterada tras la enfermedad crítica y su recuperación es gradual en el tiempo. La edad, estadía hospitalaria, QOL previa y debilidad adquirida en UCI persistente parecen ser factores de riesgo que tienden a empeorar la QOL

Risk factors for worsened quality of life in patients on mechanical ventilation. A prospective multicenter study.

OBJECTIVE: To identify risk factors for worsened quality of life (QoL) and activities of daily living (ADL) at 3 and 12 months after discharge from the Intensive Care Unit (ICU) in patients on mechanical ventilation (MV). DESIGN: A prospective, multicentric observational study was made. SETTING: Three ICUs in Argentina. PATIENTS: The study included a total of 84 out of 129 mainly clinical patients admitted between 2011-2012 and requiring over 24hours of MV. INTERVENTIONS: No interventions were carried out. VARIABLES: Quality of life was assessed with the EQ-5D (version for Argentina), and ADL with the Barthel index. RESULTS: The EQ-5D and Barthel scores were assessed upon admission to the ICU (baseline) and after three months and one year of follow-up. Comorbidities, delirium, ICU acquired weakness (ICUAW), and medication received were daily assessed during ICU stay. The baseline QoL of the global sample showed a median index of [0.831 (IQR25-75% 0.527-0.931)], versus [0.513 (IQR0.245-0.838)] after three months and [0.850 (IQR0.573-1.00)] after one year. Significant differences were observed compared with QoL in the Argentinean general population [mean 0.880 (CI 0.872-0.888), p<0.001; p<0.001; p0.002]. Individual analysis showed that 67% of the patients had worsened their QoL at three months, while 33% had recovered their QoL. In the multivariate analysis, the variables found to be independent predictors of worsened QoL were a hospital stay ≥21 days [OR 12.57 (2.75-57.47)], age ≥50 years [OR 5.61 (1.27-24.83)], previous poor QoL [OR 0.11 (0.02-0.54)] and persistent ICUAW [OR 8.32 (1.22-56.74)]. Similar results were found for the worsening of ADL. CONCLUSIONS: Quality of life is altered after critical illness, and its recovery is gradual over time. Age, length of hospital stay, previous QoL and persistent ICUAW seem to be risk factors for worsened QoL.

Mechanical ventilation in critically-ill pregnant women: a case series.

BACKGROUND: Approximately 0.1-0.2% of pregnancies are complicated by respiratory failure requiring mechanical ventilatory support, but few data exist to inform clinical management. This study aimed to characterize current practice and the effect of delivery on respiratory function. METHODS: A retrospective review was performed of pregnant women who received mechanical ventilation for more than 24h, from four intensive care units in institutions with large-volume obstetric units. RESULTS: Data were collected from 29 patients with a mean gestation at intensive care unit admission of 25.3 ± 6 weeks. Tidal volumes were 7.7 ± 1.7 mL/kg predicted body weight. Estimated respiratory system compliance was reduced, but was higher in four patients ventilated for neurological conditions without lung disease. Three maternal and three neonatal deaths occurred. Ten patients delivered while on ventilatory support: one spontaneous delivery, four for obstetric indications and five for worsening maternal condition. Following delivery of these 10 patients, three demonstrated a greater than 50% decrease in oxygenation index and five a greater than 50% increase in compliance. No characteristics identified which patients may benefit from delivery. CONCLUSIONS: Review of current practice in four centers suggests that mechanical ventilation in pregnant patients follows usual guidelines applicable to non-pregnant patients. Delivery was associated with modest improvement in maternal respiratory function in some patients. Any potential benefit of delivery in improving maternal physiology must be weighed against the stress of delivery. The risks of premature birth for the fetus must be weighed against continued exposure to maternal hypoxemia and hypotension.

Retirada de la cánula de traqueostomía. Revisión bibliográfica / Removal of the cannula from tracheostomy Review bibliographic

En la Unidad de Terapia Intensiva, la traqueostomía se utiliza en pacientes que requieren ventilación mecánica prolongada o en aquellos con mal manejo de las secreciones u obstrucción de la vía aérea. Una vez superado el proceso que obligó al procedimiento, se debe intentar el retiro de la cánula de traqueostomía. La decanulación de la traqueostomía debe considerarse un proceso que implica la evaluación de competencia de múltiples variables, y si bien no existen consensos ni protocolos que hayan demostrado ser útiles en el momento de realizar el proceso, consideramos necesario que el paciente esté liberado de la ventilación mecánica (salvo casos especiales), que tenga una vía aérea permeable y que logre un correcto manejo de sus secreciones bronquiales. Cada institución debe contar con un protocolo preciso y adecuado a su ambiente de trabajo. La decisión final debe tomarse de común acuerdo entre el equipo tratante.(AU)

Tracheostomy is commonly used in patients with prolonged mechanical ventilation in the intensive care units, and it is also indicated in those with poor management of secretions or airway obstruction. Once the process that generated the procedure is resolved, an attempt for removal of the tracheostomy tube should be made. The tracheostomy tube decannulation should be considered a process that involves the evaluation of competence of multiple variables, for example, the patient must be without mechanical ventilation requirement (except in special cases), with airway patency and with a correct bronchial secretions management. Each institution should have a precise protocol appropriate to their work environment. The final decision should be taken in agreement with all the health care team.(AU)

El frasco humidificador como sistema de humidificación del gas inspirado no cumple con las recomendaciones. Evaluación y comparación de tres sistemas de humidificación. Estudio de laboratorio / The humidifier bottle as humidification system of the inspired gas does not meet with the recommendations. Evaluation and comparison of three humidification systems. Laboratory study

Objetivos. Demostrar que el frasco humidificador (FH), como sistema de humidificación del gas inspirado, no alcanza los valores mínimos de humedad relativa (HR), humedad absoluta (HA) y temperatura (Tº) recomendados por la literatura. Secundariamente, comparar el rendimiento del FH y dos sistemas activos de humidificación (SAH). Materiales y métodos. Las variables principales fueron T° del agua, HR, Tº y HA del gas entregado. Se realizaron mediciones a diferentes niveles de Tº, volumen de agua y flujos. Resultados. El FH no alcanzó los valores recomendados de HR 100%, HA 30 mg/l y Tº 31ºC. El SAH sin circuito calefaccionado alcanzó valores recomendados en el NIVEL III con flujos de 20-60lpm, y en el NIVEL II con flujos de 20-30lpm. El SAH con circuito calefaccionado logró valores sugeridos en los NIVELES II y III (20-60lpm). Se encontró diferencia significativa (p<0,001 Global) para flujo, Tº y tipo de humidificador. El modelo ANOVA arrojó significación estadística (p<0,001) del término interacción de flujo y tipo de humidificador en cada nivel de Tº. Conclusiones. El FH no acondiciona el gas de acuerdo a lo recomendado. El mejor rendimiento fue con 300 ml y flujo de 1 lpm: Tº 23,92(±0,69), HR 74,02%(±6,53) y HA 16,02 mg/l (±1,86), estos valores apenas superan el 50% de lo mínimo sugerido en la literatura. Los SAH acondicionaron el gas adecuadamente. El modelo ANOVA arroja que existen otros factores involucrados en mantener la HA y que la significación varía en cada tipo de humidificador a cada nivel de flujo(AU)

Objetive. To demonstrate that humidifier bottle (HB) as inspired gas humidification system does not attain the minimum values of relative humidity (RH), absolute humidity (AH) and temperature (Tº) as recommended by the literature. Furthermore, to compare the HB performance with two active humidification systems (AHS). Materials and Methods. Main variables were: water Tº, RH, Tº and AH of delivered gas. Measurements were made at different levels of Tº, water and flows volume. Results. Recommended values of RH 100%, AH 30 mg/l and Tº 31º C were not reached by the HB. AHS without heating circuit reached recommended values in LEVEL III with flows of 20-60 lpm, and in LEVEL II with flows of 20-30lpm. AHS with heating circuit obtained recommended values in LEVELS II and III (20-60lpm). A significant difference (p<0.001 Global) for flow, Tº and humidifier type was found. ANOVA model showed statistical evidence (p<0.001) of interaction between flow and type of humidifier in each Tº level. Conclusions. The HB does not condition gas in accordance with recommended values. The best performance was with 300ml and 1lpm flow: Tº 23.92 (±0.69), RH 74.02% (±6.53) and AH 16.02 mg/l (±1.86) and these values hardly exceed the 50% of minimum recommended by literature. AHS conditioned gas in a proper way. ANOVA model shows that there exist other factors involved to maintain AH and that there are important differences between each type of humidifier and each flow level.(AU)