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1.
BMC Pulm Med ; 21(1): 52, 2021 Feb 05.
Artículo en Inglés | MEDLINE | ID: mdl-33546651

RESUMEN

OBJECTIVE: To develop and validate a clinical risk prediction score for noninvasive ventilation (NIV) failure defined as intubation after a trial of NIV in non-surgical patients. DESIGN: Retrospective cohort study of a multihospital electronic health record database. PATIENTS: Non-surgical adult patients receiving NIV as the first method of ventilation within two days of hospitalization. MEASUREMENT: Primary outcome was intubation after a trial of NIV. We used a non-random split of the cohort based on year of admission for model development and validation. We included subjects admitted in years 2010-2014 to develop a risk prediction model and built a parsimonious risk scoring model using multivariable logistic regression. We validated the model in the cohort of subjects hospitalized in 2015 and 2016. MAIN RESULTS: Of all the 47,749 patients started on NIV, 11.7% were intubated. Compared with NIV success, those who were intubated had worse mortality (25.2% vs. 8.9%). Strongest independent predictors for intubation were organ failure, principal diagnosis group (substance abuse/psychosis, neurological conditions, pneumonia, and sepsis), use of invasive ventilation in the prior year, low body mass index, and tachypnea. The c-statistic was 0.81, 0.80 and 0.81 respectively, in the derivation, validation and full cohorts. We constructed three risk categories of the scoring system built on the full cohort; the median and interquartile range of risk of intubation was: 2.3% [1.9%-2.8%] for low risk group; 9.3% [6.3%-13.5%] for intermediate risk category; and 35.7% [31.0%-45.8%] for high risk category. CONCLUSIONS: In patients started on NIV, we found that in addition to factors known to be associated with intubation, neurological, substance abuse, or psychiatric diagnoses were highly predictive for intubation. The prognostic score that we have developed may provide quantitative guidance for decision-making in patients who are started on NIV.


Asunto(s)
Reglas de Decisión Clínica , Intubación Intratraqueal/estadística & datos numéricos , Ventilación no Invasiva , Insuficiencia Respiratoria/terapia , Afroamericanos/estadística & datos numéricos , Anciano , Asma/epidemiología , Estudios de Cohortes , Registros Electrónicos de Salud , Grupo de Ascendencia Continental Europea/estadística & datos numéricos , Femenino , Insuficiencia Cardíaca/epidemiología , Mortalidad Hospitalaria , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Enfermedades del Sistema Nervioso/epidemiología , Neumonía/epidemiología , Trastornos Psicóticos/epidemiología , Enfermedad Pulmonar Obstructiva Crónica/epidemiología , Respiración Artificial/estadística & datos numéricos , Insuficiencia Respiratoria/epidemiología , Estudios Retrospectivos , Medición de Riesgo , Sepsis/epidemiología , Accidente Cerebrovascular/epidemiología , Trastornos Relacionados con Sustancias/epidemiología , Insuficiencia del Tratamiento
3.
BMJ Case Rep ; 14(2)2021 Feb 04.
Artículo en Inglés | MEDLINE | ID: mdl-33541967

RESUMEN

A 29-year-old pregnant woman presented at 26 weeks of gestation with fever and cough for 4 days. On admission, her nasopharyngeal swab confirmed COVID-19. As her respiratory distress worsened, she was shifted to the intensive care unit (ICU). Since the patient was unable to maintain saturation even on high settings of mechanical ventilation, she underwent venovenous extracorporeal membrane oxygenation (VV-ECMO) and was monitored in surgical ICU by a multidisciplinary team. The obstetrical team was on standby to perform urgent delivery if needed. Her condition improved, and she was weaned off after 5 days on extracorporeal membrane oxygenation. She was observed in the antenatal ward for another week and discharged home with the mother and fetus in good condition. VV-ECMO can be considered as rescue therapy for pregnant women with refractory hypoxaemia of severe respiratory failure due to COVID-19. It can save two lives, the mother and fetus.


Asunto(s)
/terapia , Oxigenación por Membrana Extracorpórea/métodos , Complicaciones Infecciosas del Embarazo/terapia , /terapia , Adulto , Femenino , Humanos , Unidades de Cuidados Intensivos , Embarazo , Complicaciones Infecciosas del Embarazo/virología , Segundo Trimestre del Embarazo , Respiración Artificial , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/terapia , Resultado del Tratamiento
4.
BMJ Case Rep ; 14(1)2021 Jan 25.
Artículo en Inglés | MEDLINE | ID: mdl-33495169

RESUMEN

Infective endocarditis is associated with a variety of clinical signs, but its association with multisystem vasculitis is rarely reported. A high index of suspicion is necessary to differentiate a primary autoimmune vasculitis from an infectious cause as the wrong treatment can lead to significant morbidity and mortality. We present a 71-year-old female patient with negative blood cultures, on antibiotics for recent bacteraemia, who presented with cutaneous and renal leucocytoclastic vasculitis. Workup revealed a vegetation adjacent to her right atrial pacemaker lead consistent with infective endocarditis and her vasculitis completely resolved with appropriate antibiotics.


Asunto(s)
Lesión Renal Aguda/diagnóstico , Endocarditis Bacteriana/diagnóstico , Enfermedades Cutáneas Vasculares/diagnóstico , Infecciones Estafilocócicas/diagnóstico , Vasculitis/diagnóstico , Lesión Renal Aguda/etiología , Lesión Renal Aguda/inmunología , Lesión Renal Aguda/terapia , Anciano , Antibacterianos/uso terapéutico , Anticuerpos Anticitoplasma de Neutrófilos/inmunología , Bacteriemia/complicaciones , Bacteriemia/tratamiento farmacológico , Ceftriaxona/uso terapéutico , Endocarditis Bacteriana/complicaciones , Endocarditis Bacteriana/tratamiento farmacológico , Femenino , Humanos , Edema Pulmonar/etiología , Edema Pulmonar/terapia , Diálisis Renal , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/terapia , Rifampin/uso terapéutico , Enfermedades Cutáneas Vasculares/etiología , Enfermedades Cutáneas Vasculares/inmunología , Enfermedades Cutáneas Vasculares/patología , Infecciones Estafilocócicas/complicaciones , Infecciones Estafilocócicas/tratamiento farmacológico , Vasculitis/etiología , Vasculitis/inmunología , Vasculitis/patología
6.
Intern Med ; 60(1): 123-130, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-33390469

RESUMEN

Case 1: A 65-year-old man with novel coronavirus infection (COVID-19) complicated with acute respiratory failure. On admission, the patient was started on favipiravir and corticosteroid. However, due to a lack of significant improvement, he was introduced to mechanical ventilation and extracorporeal membrane oxygenation (ECMO). Although iliopsoas hematoma occurred as a complication, the patient recovered. Case 2: A 49-year-old man with COVID-19 had been started on favipiravir and corticosteroid. Due to progressive respiratory failure, the patient underwent mechanical ventilation and ECMO. The patient recovered without complications. We successfully treated these severe cases with a multimodal combination of pharmacological and non-pharmacological supportive therapy.


Asunto(s)
Corticoesteroides/uso terapéutico , Amidas/uso terapéutico , Antivirales/uso terapéutico , Oxigenación por Membrana Extracorpórea , Metilprednisolona/uso terapéutico , Pirazinas/uso terapéutico , Respiración Artificial , Anciano , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia Respiratoria/terapia , Insuficiencia Respiratoria/virología
7.
Medicine (Baltimore) ; 100(2): e24016, 2021 Jan 15.
Artículo en Inglés | MEDLINE | ID: mdl-33466145

RESUMEN

BACKGROUND: The purpose of this study is to determine the therapeutic efficacy of bi-level continuous positive airway pressure (BIPAP) intervention in patients with type II respiratory failure due to acute exacerbation of chronic obstructive pulmonary disease (COPD). METHODS: This review will only include randomized controlled trials (RCTs). The search strategy will be applied to 4 Chinese databases: China National Knowledge Infrastructure (CNKI), Wanfang Database, Chinese Science and Technology Journal Database (VIP), and Chinese Biomedical Literature Database (SinoMed); and 5 foreign literature databases: PubMed, Cochrane Library, Springer, EBSCO, and Web of Science. RCTs published from inception to October 2020 will be included. The 2 researchers will independently screen and extract the data and assess quality. The main results obtained through blood gas analysis and equipment observation, heterogeneity assessment, sensitivity analysis, funnel chart synthesis, data synthesis, and grouping analysis will be carried out using Review Manager 5.4 software. The trial sequential analysis will be completed using TSA v0.9 developed by the CTU at the Copenhagen Clinical Trial Center. RESULTS: In the current meta-analysis, we will provide more practical and targeted results for the therapeutic efficacy of BIPAP in patients with type II respiratory failure due to acute exacerbation of COPD. CONCLUSION: This study will provide new evidence for the therapeutic efficacy of BIPAP in patients with type II respiratory failure due to acute exacerbation of COPD. REGISTRATION NUMBER: INPLASY2020110003 (DOI:10.37766/inplasy2020.11.0003).


Asunto(s)
Presión de las Vías Aéreas Positiva Contínua/métodos , Enfermedad Pulmonar Obstructiva Crónica/complicaciones , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/terapia , Análisis de los Gases de la Sangre , Humanos , Enfermedad Pulmonar Obstructiva Crónica/fisiopatología , Ensayos Clínicos Controlados Aleatorios como Asunto , Proyectos de Investigación
8.
Zhonghua Er Ke Za Zhi ; 59(1): 20-26, 2021 Jan 02.
Artículo en Chino | MEDLINE | ID: mdl-33396999

RESUMEN

Objective: To investigate the efficacy of high flow nasal cannula (HFNC) in children with acute respiratory failure. Methods: A prospective study was conducted. A total of 153 patients aged from 1 to 14 years with acute respiratory failure were enrolled, who were admitted to pediatric intensive care unit (PICU) of Shanghai Children's Hospital from January 2018 to December 2019. HFNC success was defined as no need for invasive mechanical ventilation and successfully withdrawn from HFNC, while HFNC failure was defined as need for invasive mechanical ventilation. HFNC at a flow rate of 2 L/(kg·min) (maximum ≤ 60 L/min) with inhaled oxygen concentration (FiO2) between 0.30 and 1.00 was applied to maintain percutaneous oxygen saturation (SpO2) of 0.94-0.97. Parameters including arterial partial pressure of oxygen (PaO2), partial pressure of carbon dioxide in artery (PaCO2), SpO2 and PaO2/FiO2 were collected before and during the application of HFNC at 1 h, 6 h, 12 h, 24 h and 48 h, as well as over 48 h after HFNC withdrawn. Comparison between the groups was performed by student t test, Mann-Whitney U test or chi-square test. The sensitivity and specificity of the above parameters in predicting HFNC success were evaluated by receiver operating characteristic (ROC) curve. Results: A total of 153 children (70 males and 83 females) were enrolled. Among them, 131 (85.6%) cases were successfully weaned off from HFNC and 22 (14.4%) failed. The duration of HFNC was 57 (38, 95) hours in the successful group, and the PaO2/FiO2 before HFNC application and after HFNC was withdrawn were 187 (170, 212) mmHg (1 mmHg=0.133 kPa) and 280 (262, 292) mmHg, respectively. The duration of HFNC in the failure group was 19 (9, 49) hours, and the PaO2/FiO2 before HFNC application and after HFNC withdrawn were 176 (171, 189) mmHg and 159 (156, 161) mmHg, respectively. The values of PaO2/FiO2 were significantly higher in the successful group than those in the failed group at using HFNC initially 1 h (196 (182, 211) vs. 174 (160, 178) mmHg, Z =-5.105, P<0.01), 6 h (213 (203, 220) vs. 168 (157, 170) mmHg, Z =-6.772, P<0.01), 12 h (226 (180, 261) vs. 165 (161, 170) mmHg, Z =-4.308, P<0.01), 24 h (229 (195, 259) vs. 165 (161, 170) mmHg, Z=-4.609, P<0.01) and 48 h (249 (216, 273) vs. 163 (158, 169) mmHg, Z =-4.628, P<0.01) after the HFNC application, and over 48 h after HFNC was withdrawn (277 (268, 283) vs. 157 (154, 158) mmHg, Z=-3.512, P<0.01). Moreover, the PaO2 levels were significantly higher in the successful group than those in the failed group using HFNC initially at 1 h (73.7 (71.0, 76.7) vs. 70.0 (66.2, 71.2) mmHg, Z=-4.587, P<0.01) and 6 h (79.0 (75.0, 82.0) vs. 71.0 (62.0, 72.0) mmHg, Z=-5.954, P<0.01) after HFNC application. Also, the SpO2 levels showed the same differences at 1 h (0.96 (0.95, 0.96) vs. 0.94 (0.92, 0.94), Z =-4.812, P<0.01) and 6 h (0.96 (0.95, 0.97) vs. 0.94(0.91, 0.95), Z=-5.024, P<0.01) after HFNC application. Forty eight hours after HFNC was withdrawn, the PaO2 (88.0 (81.7, 95.0) vs. 63.7 (63.3, 66.0) mmHg, Z =-3.032, P<0.01) and SpO2 (0.96 (0.94, 0.98) vs. 0.91 (0.90, 0.92), Z=-3.957, P<0.01) were also significantly higher in the successful group. Regarding the HFNC complications, there was one case with atelectasis and one with pneumothorax in the failure group. HFNC was used as sequential oxygen therapy after extubation in 79 children, successful in all. ROC curve showed that the area under curve of PaO2/FiO2 in predicting HFNC success was 0.990, and the optimal cut-off value was 232 mmHg with the 95%CI of 0.970-1.000 (P<0.01). Conclusions: HFNC could be used as a respiratory support strategy for children with mild to moderate respiratory failure and as a sequential oxygen therapy after extubation. The PaO2/FiO2 when HFNC withdrow is the optimal index to evaluate the success of HFNC application.


Asunto(s)
Oxígeno , Insuficiencia Respiratoria , Adolescente , Anciano , Cánula , Niño , Preescolar , China , Femenino , Humanos , Lactante , Masculino , Terapia por Inhalación de Oxígeno , Estudios Prospectivos , Insuficiencia Respiratoria/terapia
9.
BMC Pulm Med ; 21(1): 25, 2021 Jan 12.
Artículo en Inglés | MEDLINE | ID: mdl-33435944

RESUMEN

BACKGROUND: Intermittent Prone Positioning (IPP) for Acute Respiratory Distress Syndrome (ARDS) decreases mortality. We present a program for IPP using expedient materials for settings of significant limitations in both overwhelmed established ICUs and particularly in low- and middle-income countries (LMICs) treating ARDS due to COVID-19 caused by SARS CoV-2. METHODS: The proning program evolved based on the principles of High Reliability Organizations (HROs) and Crew Resource Management (CRM). Patients with severe ARDS [PaO2:FiO2 ratio (PFr) ≤ 150 on FiO2 ≥ 0.6 and PEEP ≥ 5 cm H2O] received IPP. Patients were placed prone 16 h each day. When PFr was ≥ 200 for > 8 h supine IPP ceased. IPP used available materials without requiring additional work from the bedside team. Changes in PFr, PaCO2, and the SaO2:FiO2 ratio (SaFr) positionally were evaluated using t-statistics and ANOVA with Bonferroni correction (p < 0.017). RESULTS: Between 14APR2020 and 09MAY2020, at the peak of deaths in New York, there were 202 IPPs in 29 patients. Patients were 58.5 ± 1.7 years of age (37, 73), 76% male and had a body mass index (BMI) of 27.8 ± 0.8 (21, 38). Pressor agents were used in 76% and 17% received dialysis. The PFr prior to IPP was 107.5 ± 5.6 and 1 h after IPP was 155.7 ± 11.2 (p < 0.001 compared to pre-prone). PFr after the patients were placed supine was 131.5 ± 9.1 (p = 0.02). Pre-prone PaCO2 was 60.0 ± 2.5 and the 1-h post-prone PaCO2 was 67.2 ± 3.1 (p = 0.02). Supine PaCO2 after IPP was 60.4 ± 3.4 (p = 0.90). The SaFr prior to IPP was 121.3 ± 4.2 and the SaFr 1 h after positioning was 131.5 ± 5.1 (p = 0.03). The post-IPP supine SaFr was 139.7 ± 5.9 (p < 0.001). With ANOVA and Bonferroni correction there were statistically significant changes in PFr (p < 0.001) and SaFr (p < 0.001) and no significant changes in PaCO2 over the four time points measured. Using regression coefficients, the SaFrs predicted by PFrs of 150 and 200 at baseline are 133.2 and 147.3, respectively. CONCLUSIONS: An IPP program for patients with COVID-19 ARDS can be instituted rapidly, safely, and effectively during an overwhelming mass casualty scenario. This approach may be equally applicable in both traditionally austere environments in LMICs and in otherwise capable centers facing situational resource limitations.


Asunto(s)
/complicaciones , Hipoxia/etiología , Hipoxia/terapia , Posicionamiento del Paciente/métodos , Posicionamiento del Paciente/normas , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/terapia , Adulto , Anciano , Protocolos Clínicos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Posición Prona , Estudios Prospectivos , Índice de Severidad de la Enfermedad
10.
JAMA ; 325(3): 254-264, 2021 01 19.
Artículo en Inglés | MEDLINE | ID: mdl-33464336

RESUMEN

Importance: It is unknown whether angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) have a positive, neutral, or negative effect on clinical outcomes in patients with coronavirus disease 2019 (COVID-19). Objective: To determine whether discontinuation compared with continuation of ACEIs or ARBs changed the number of days alive and out of the hospital through 30 days. Design, Setting, and Participants: A randomized clinical trial of 659 patients hospitalized in Brazil with mild to moderate COVID-19 who were taking ACEIs or ARBs prior to hospitalization (enrolled: April 9-June 26, 2020; final follow-up: July 26, 2020). Interventions: Discontinuation (n = 334) or continuation (n = 325) of ACEIs or ARBs. Main Outcomes and Measures: The primary outcome was the number of days alive and out of the hospital through 30 days. Secondary outcomes included death, cardiovascular death, and COVID-19 progression. Results: Among 659 patients, the median age was 55.1 years (interquartile range [IQR], 46.1-65.0 years), 14.7% were aged 70 years or older, 40.4% were women, and 100% completed the trial. The median time from symptom onset to hospital admission was 6 days (IQR, 4-9 days) and 27.2% of patients had an oxygen saturation of less than 94% of room air at baseline. In terms of clinical severity, 57.1% of patients were considered mild at hospital admission and 42.9% were considered moderate. There was no significant difference in the number of days alive and out of the hospital in patients in the discontinuation group (mean, 21.9 days [SD, 8 days]) vs patients in the continuation group (mean, 22.9 days [SD, 7.1 days]) and the mean ratio was 0.95 (95% CI, 0.90-1.01). There also was no statistically significant difference in death (2.7% for the discontinuation group vs 2.8% for the continuation group; odds ratio [OR], 0.97 [95% CI, 0.38-2.52]), cardiovascular death (0.6% vs 0.3%, respectively; OR, 1.95 [95% CI, 0.19-42.12]), or COVID-19 progression (38.3% vs 32.3%; OR, 1.30 [95% CI, 0.95-1.80]). The most common adverse events were respiratory failure requiring invasive mechanical ventilation (9.6% in the discontinuation group vs 7.7% in the continuation group), shock requiring vasopressors (8.4% vs 7.1%, respectively), acute myocardial infarction (7.5% vs 4.6%), new or worsening heart failure (4.2% vs 4.9%), and acute kidney failure requiring hemodialysis (3.3% vs 2.8%). Conclusions and Relevance: Among patients hospitalized with mild to moderate COVID-19 and who were taking ACEIs or ARBs before hospital admission, there was no significant difference in the mean number of days alive and out of the hospital for those assigned to discontinue vs continue these medications. These findings do not support routinely discontinuing ACEIs or ARBs among patients hospitalized with mild to moderate COVID-19 if there is an indication for treatment. Trial Registration: ClinicalTrials.gov Identifier: NCT04364893.


Asunto(s)
Antagonistas de Receptores de Angiotensina/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Alta del Paciente , Privación de Tratamiento , Anciano , /diagnóstico , Progresión de la Enfermedad , Femenino , Insuficiencia Cardíaca/epidemiología , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Oportunidad Relativa , Respiración Artificial/estadística & datos numéricos , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/terapia , Tamaño de la Muestra , Choque/tratamiento farmacológico , Factores de Tiempo , Resultado del Tratamiento
11.
BMJ Case Rep ; 14(1)2021 Jan 18.
Artículo en Inglés | MEDLINE | ID: mdl-33462059

RESUMEN

The ongoing SARS-CoV-2 (COVID-19) pandemic has presented many difficult and unique challenges to the medical community. We describe a case of a middle-aged COVID-19-positive man who presented with pulmonary oedema and acute respiratory failure. He was initially diagnosed with acute respiratory distress syndrome. Later in the hospital course, his pulmonary oedema and respiratory failure worsened as result of severe acute mitral valve regurgitation secondary to direct valvular damage from COVID-19 infection. The patient underwent emergent surgical mitral valve replacement. Pathological evaluation of the damaged valve was confirmed to be secondary to COVID-19 infection. The histopathological findings were consistent with prior cardiopulmonary autopsy sections of patients with COVID-19 described in the literature as well as proposed theories regarding ACE2 receptor activity. This case highlights the potential of SARS-CoV-2 causing direct mitral valve damage resulting in severe mitral valve insufficiency with subsequent pulmonary oedema and respiratory failure.


Asunto(s)
/complicaciones , Insuficiencia de la Válvula Mitral/etiología , Enfermedad Aguda , Fibrilación Atrial/complicaciones , Fibrilación Atrial/fisiopatología , Cuerdas Tendinosas/diagnóstico por imagen , Ecocardiografía , Electrocardiografía , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/cirugía , Edema Pulmonar/etiología , Edema Pulmonar/fisiopatología , Edema Pulmonar/terapia , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/fisiopatología , Insuficiencia Respiratoria/terapia , Índice de Severidad de la Enfermedad , Choque Cardiogénico/etiología , Choque Cardiogénico/fisiopatología
12.
J Stroke Cerebrovasc Dis ; 30(3): 105609, 2021 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-33429238

RESUMEN

The case of a 70-year-old male presenting an ischemic stroke related to COVID-19 infection is described. He was initially admitted to the hospital with respiratory insufficiency syndrome secondary to pneumonia caused by SARS Co2. In the next days, he developed rapid neurological deterioration characterized by drowsiness which progressed to deep coma. D-dimer was elevated. Brain CT scan showed bilateral massive ischemic stroke located in the anterior circulation, CT angiogram showed occlusion in the left internal carotid artery and the right middle cerebral artery. The deterioration of the patient continued and he subsequently died. Large vessel occlusion has been reported in COVID-19 patients, but this clinical presentation is usually unilateral. Cases of bilateral occlusion of large vessels have not been previously reported in COVID-19 patients. This report shows that bilateral massive stroke may occur in COVID-19 cases and it should be suspected in patients who show rapid neurological deterioration without focal deficits.


Asunto(s)
Arteriopatías Oclusivas/etiología , /etiología , Anciano , Encéfalo/diagnóstico por imagen , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/etiología , Coma/etiología , Angiografía por Tomografía Computarizada , Productos de Degradación de Fibrina-Fibrinógeno/análisis , Humanos , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Infarto de la Arteria Cerebral Media/etiología , Masculino , Enfermedades del Sistema Nervioso/etiología , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/terapia , Trombectomía
14.
Scand J Trauma Resusc Emerg Med ; 29(1): 16, 2021 Jan 12.
Artículo en Inglés | MEDLINE | ID: mdl-33436033

RESUMEN

OBJECTIVE: Despite critical hypoxemia, Covid-19 patients may present without proportional signs of respiratory distress. We report three patients with critical respiratory failure due to Covid-19, in which all presented with severe hypoxemia refractory to supplemental oxygen therapy. We discuss possible strategies for ventilatory support in the emergency pre-hospital setting, and point out some pitfalls regarding the management of these patients. Guidelines for pre-hospital care of critically ill Covid-19 patients cannot be established based on the current evidence base, and we have to apply our understanding of respiratory physiology and mechanics in order to optimize respiratory support. METHODS: Three cases with similar clinical presentation were identified within the Norwegian national helicopter emergency medical service (HEMS) system. The HEMS units are manned by a consultant anaesthesiologist. Patient's next of kin and the Regional committee for medical and health research ethics approved the publication of this report. CONCLUSION: Patients with Covid-19 and severe hypoxemia may pose a considerable challenge for the pre-hospital emergency medical services. Intubation may be associated with a high risk of complications in these patients and should be carried out with diligence when considered necessary. The following interventions are worth considering in Covid-19 patients with refractory hypoxemia before proceeding to intubation. First, administering oxygen via a tight fitting BVM with an oxygen flow rate that exceeds the patient's ventilatory minute volume. Second, applying continuous positive airway pressure, while simultaneously maintaining a high FiO2. Finally, assuming the patient is cooperative, repositioning to prone position.


Asunto(s)
/terapia , Cuidados Críticos/métodos , Enfermedad Crítica/terapia , Terapia por Inhalación de Oxígeno/métodos , Insuficiencia Respiratoria/terapia , /complicaciones , Presión de las Vías Aéreas Positiva Contínua , Femenino , Hospitales , Humanos , Masculino , Persona de Mediana Edad , Noruega , Insuficiencia Respiratoria/etiología
15.
Ann Neurol ; 89(3): 610-616, 2021 03.
Artículo en Inglés | MEDLINE | ID: mdl-33377539

RESUMEN

There is emerging evidence for multifarious neurological manifestations of coronavirus disease 2019 (COVID-19), but little is known regarding whether they reflect structural damage to the nervous system. Serum neurofilament light chain (sNfL) is a specific biomarker of neuronal injury. We measured sNfL concentrations of 29 critically ill COVID-19 patients, 10 critically ill non-COVID-19 patients, and 259 healthy controls. After adjusting for neurological comorbidities and age, sNfL concentrations were higher in patients with COVID-19 versus both comparator groups. Higher sNfL levels were associated with unfavorable short-term outcome, indicating that neuronal injury is common and pronounced in critically ill patients. ANN NEUROL 2021;89:610-616.


Asunto(s)
/sangre , Proteínas de Neurofilamentos/sangre , Adulto , Anciano , Anciano de 80 o más Años , /terapia , Estudios de Casos y Controles , Enfermedad Crítica , Femenino , Escala de Consecuencias de Glasgow , Mortalidad Hospitalaria , Humanos , Hiponatremia/sangre , Hiponatremia/terapia , Unidades de Cuidados Intensivos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Puntuaciones en la Disfunción de Órganos , Edema Pulmonar/sangre , Edema Pulmonar/terapia , Respiración Artificial/estadística & datos numéricos , Insuficiencia Respiratoria/sangre , Insuficiencia Respiratoria/terapia , Infecciones del Sistema Respiratorio/sangre , Infecciones del Sistema Respiratorio/terapia , Choque Cardiogénico/sangre , Choque Cardiogénico/terapia
16.
J Intensive Care Med ; 36(1): 9-17, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-32912049

RESUMEN

Infection with the novel 2019 coronavirus (SARS-CoV-2) is associated with the development of a viral pneumonia with severe hypoxemia and respiratory failure. In many cases these patients will require mechanical ventilation; but in others the severity of disease is significantly less and may not need invasive support. High flow nasal cannula (HFNC) is a widely used modality of delivering high concentrations of oxygen and airflow to patients with hypoxemic respiratory failure, but its use in patients with SARS-CoV-2 is poorly described. Concerns with use of HFNC have arisen including aerosolization of viral particles to healthcare workers (HCW) to delaying intubation and potentially worsening of outcomes. However, use of HFNC in other coronavirus pandemics and previous experimental evidence suggest HFNC is low risk and may be effective in select patients infected with SARS-CoV-2. With the significant increase in resource utilization in care of patients with SARS-CoV-2, identification of those that may benefit from HFNC allowing allocation of ventilators to those more critically ill is of significant importance. In this manuscript, we review pertinent literature regarding the use of HFNC in the current SARS-CoV-2 pandemic and address many concerns regarding its use.


Asunto(s)
Ventilación no Invasiva/métodos , Terapia por Inhalación de Oxígeno/métodos , Insuficiencia Respiratoria , /complicaciones , Humanos , Selección de Paciente , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/terapia
17.
Intern Med ; 60(3): 457-461, 2021 Feb 01.
Artículo en Inglés | MEDLINE | ID: mdl-33328409

RESUMEN

We herein report a case of severe coronavirus disease 2019 (COVID-19) in which high-dose intravenous immunoglobulin (IVIg) treatment achieved significant clinical improvement of deterioration of pulmonary inflammation after temporary clinical improvement. In the present case, clinical and radiological deterioration occurred despite a decrease in viral load, suggesting that deterioration was caused by reactivation of proinflammatory factors, such as tumor necrosis factor-α and interleukin-6, rather than direct viral effects. IVIg treatment may provide not only immunosuppressive effects but also inhibition of proinflammatory cytokines, indicating that treatment including IVIg may be effective by inhibiting cytokine storm in severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection.


Asunto(s)
/terapia , Inmunoglobulinas Intravenosas/administración & dosificación , Insuficiencia Respiratoria/terapia , /aislamiento & purificación , /complicaciones , Síndrome de Liberación de Citoquinas/prevención & control , Citocinas/efectos de los fármacos , Humanos , Ivermectina/uso terapéutico , Pulmón/diagnóstico por imagen , Pulmón/patología , Masculino , Persona de Mediana Edad , Radiografía Torácica , Carga Viral
18.
J Intensive Care Med ; 36(1): 18-41, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-33111601

RESUMEN

Human infection by the novel viral pathogen SARS-CoV-2 results in a clinical syndrome termed Coronavirus Disease 2019 (COVID-19). Although the majority of COVID-19 cases are self-limiting, a substantial minority of patients develop disease severe enough to require intensive care. Features of critical illness associated with COVID-19 include hypoxemic respiratory failure, acute respiratory distress syndrome (ARDS), shock, and multiple organ dysfunction syndrome (MODS). In most (but not all) respects critically ill patients with COVID-19 resemble critically ill patients with ARDS due to other causes and are optimally managed with standard, evidence-based critical care protocols. However, there is naturally an intense interest in developing specific therapies for severe COVID-19. Here we synthesize the rapidly expanding literature around the pathophysiology, clinical presentation, and management of COVID-19 with a focus on those points most relevant for intensivists tasked with caring for these patients. We specifically highlight evidence-based approaches that we believe should guide the identification, triage, respiratory support, and general ICU care of critically ill patients infected with SARS-CoV-2. In addition, in light of the pressing need and growing enthusiasm for targeted COVID-19 therapies, we review the biological basis, plausibility, and clinical evidence underlying these novel treatment approaches.


Asunto(s)
/terapia , Cuidados Críticos/métodos , Enfermedad Crítica/terapia , Adulto , /fisiopatología , Práctica Clínica Basada en la Evidencia/métodos , Humanos , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/terapia
19.
Mod Rheumatol Case Rep ; 5(1): 101-107, 2021 01.
Artículo en Inglés | MEDLINE | ID: mdl-33019894

RESUMEN

Anti-melanoma differentiation-associated gene 5 juvenile dermatomyositis (anti-MDA5 JDM) is associated with high risk of developing rapidly progressive interstitial lung disease (RP-ILD). Here we report an 11-year-old girl with anti-MDA5 JDM and RP-ILD which led to a fatal outcome, further aggravated by SARS-CoV-2 infection. She was referred to our hospital after being diagnosed with anti-MDA5 JDM and respiratory failure due to RP-ILD. On admission, fibrobronchoscopy with bronchoalveolar lavage (BAL) revealed Pneumocystis jirovecii infection so treatment with intravenous trimethoprim-sulfamethoxazole was initiated. Due to RP-ILD worsening, immunosuppressive therapy was intensified using methylprednisolone pulses, cyclophosphamide, tofacitinib and intravenous immunoglobulin without response. She developed severe hypoxemic respiratory failure, pneumomediastinum and pneumothorax, further complicated with severe RP-ILD and cervical subcutaneous emphysema. Three real-time RT-PCR for SARS-CoV-2 were made with a negative result. In addition, she was complicated with a secondary hemophagocytic lymphohistiocytosis and a fourth real-time PCR for SARS-CoV-2 performed in BAS sample was positive. Despite aggressive treatment of RP-ILD due to anti-MDA5 JDM, there was no improvement of respiratory failure in the following days and patient developed refractory septic shock and died. Anti-MDA5 JDM patients with RP-ILD have a poor prognosis with a high mortality rate. For this reason, intensive immunosuppressive therapy is essential including the use of promising drugs such as tofacitinib. COVID-19 in children with underlying health conditions like anti-MDA5 JDM may still be at risk for disease and severe complications.


Asunto(s)
/complicaciones , Dermatomiositis/complicaciones , Inmunosupresores/uso terapéutico , Enfermedades Pulmonares Intersticiales/complicaciones , Linfohistiocitosis Hemofagocítica/etiología , Neumonía por Pneumocystis/complicaciones , Adenosina Monofosfato/análogos & derivados , Adenosina Monofosfato/uso terapéutico , Alanina/análogos & derivados , Alanina/uso terapéutico , Antibacterianos/uso terapéutico , Anticuerpos Monoclonales Humanizados/uso terapéutico , Antivirales/uso terapéutico , Autoanticuerpos/inmunología , Broncoscopía , Niño , Ciclofosfamida/uso terapéutico , Dermatomiositis/tratamiento farmacológico , Dermatomiositis/inmunología , Progresión de la Enfermedad , Resultado Fatal , Femenino , Humanos , Hidroxicloroquina/uso terapéutico , Huésped Inmunocomprometido , Inmunoglobulinas Intravenosas/uso terapéutico , Factores Inmunológicos/uso terapéutico , Helicasa Inducida por Interferón IFIH1/inmunología , Pulmón/diagnóstico por imagen , Enfermedades Pulmonares Intersticiales/diagnóstico por imagen , Enfermedades Pulmonares Intersticiales/inmunología , Enfermedades Pulmonares Intersticiales/terapia , Linfohistiocitosis Hemofagocítica/inmunología , Enfisema Mediastínico/etiología , Metilprednisolona/uso terapéutico , Piperidinas/uso terapéutico , Neumonía por Pneumocystis/inmunología , Neumotórax/etiología , Pirimidinas/uso terapéutico , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/terapia , Choque Séptico/etiología , Enfisema Subcutáneo/etiología , Tomografía Computarizada por Rayos X , Combinación Trimetoprim y Sulfametoxazol/uso terapéutico
20.
PLoS One ; 15(12): e0243968, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-33326484

RESUMEN

BACKGROUND: 15% of COVID-19 patients develop severe pneumonia. Non-invasive mechanical ventilation and high-flow nasal cannula can reduce the rate of endotracheal intubation in adult respiratory distress syndrome, although failure rate is high. OBJECTIVE: To describe the rate of endotracheal intubation, the effectiveness of treatment, complications and mortality in patients with severe respiratory failure due to COVID-19. METHODS: Prospective cohort study in a first-level hospital in Madrid. Patients with a positive polymerase chain reaction for SARS-CoV-2 and admitted to the Intermediate Respiratory Care Unit with tachypnea, use of accessory musculature or SpO2 <92% despite FiO2> 0.5 were included. Intubation rate, medical complications, and 28-day mortality were recorded. Statistical analysis through association studies, logistic and Cox regression models and survival analysis was performed. RESULTS: Seventy patients were included. 37.1% required endotracheal intubation, 58.6% suffered medical complications and 24.3% died. Prone positioning was independently associated with lower need for endotracheal intubation (OR 0.05; 95% CI 0.005 to 0.54, p = 0.001). The adjusted HR for death at 28 days in the group of patients requiring endotracheal intubation was 5.4 (95% CI 1.51 to 19.5; p = 0.009). CONCLUSIONS: The rate of endotracheal intubation in patients with severe respiratory failure from COVID-19 was 37.1%. Complications and mortality were lower in patients in whom endotracheal intubation could be avoided. Prone positioning could reduce the need for endotracheal intubation.


Asunto(s)
/terapia , Resultado del Tratamiento , Anciano , /patología , Femenino , Humanos , Intubación Intratraqueal , Modelos Logísticos , Masculino , Persona de Mediana Edad , Pandemias , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Unidades de Cuidados Respiratorios , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/terapia , España/epidemiología , Tasa de Supervivencia
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