Failure of First Transition to Pressure Support Ventilation After Spontaneous Awakening Trials in Hypoxemic Respiratory Failure: Influence of COVID-19.

OBJECTIVES: To describe the rate of failure of the first transition to pressure support ventilation (PSV) after systematic spontaneous awakening trials (SATs) in patients with acute hypoxemic respiratory failure (AHRF) and to assess whether the failure is higher in COVID-19 compared with AHRF of other etiologies. To determine predictors and potential association of failure with outcomes. DESIGN: Retrospective cohort study. SETTING: Twenty-eight-bedded medical-surgical ICU in a private hospital (Argentina). PATIENTS: Subjects with arterial pressure of oxygen (AHRF to Fio2 [Pao2/Fio2] < 300 mm Hg) of different etiologies under controlled mechanical ventilation (MV). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We collected data during controlled ventilation within 24 hours before SAT followed by the first PSV transition. Failure was defined as the need to return to fully controlled MV within 3 calendar days of PSV start. A total of 274 patients with AHRF (189 COVID-19 and 85 non-COVID-19) were included. The failure occurred in 120 of 274 subjects (43.7%) and was higher in COVID-19 versus non-COVID-19 (49.7% and 30.5%; p = 0.003). COVID-19 diagnosis (odds ratio [OR]: 2.22; 95% CI [1.15-4.43]; p = 0.020), previous neuromuscular blockers (OR: 2.16; 95% CI [1.15-4.11]; p = 0.017) and higher fentanyl dose (OR: 1.29; 95% CI [1.05-1.60]; p = 0.018) increased the failure chances. Higher BMI (OR: 0.95; 95% CI [0.91-0.99]; p = 0.029), Pao2/Fio2 (OR: 0.87; 95% CI [0.78-0.97]; p = 0.017), and pH (OR: 0.61; 95% CI [0.38-0.96]; p = 0.035) were protective. Failure groups had higher 60-day ventilator dependence (p < 0.001), MV duration (p < 0.0001), and ICU stay (p = 0.001). Patients who failed had higher mortality in COVID-19 group (p < 0.001) but not in the non-COVID-19 (p = 0.083). CONCLUSIONS: In patients with AHRF of different etiologies, the failure of the first PSV attempt was 43.7%, and at a higher rate in COVID-19. Independent risk factors included COVID-19 diagnosis, fentanyl dose, previous neuromuscular blockers, acidosis and hypoxemia preceding SAT, whereas higher BMI was protective. Failure was associated with worse outcomes.

Airway and Transpulmonary Driving Pressure by End-Inspiratory Holds During Pressure Support Ventilation.

BACKGROUND: The precision of quasi-static airway driving pressure (ΔP) assessed in pressure support ventilation (PSV) as a surrogate of tidal lung stress is debatable because persistent muscular activity frequently alters the readability of end-inspiratory holds. In this study, we used strict criteria to discard excessive muscular activity during holds and assessed the accuracy of ΔP in predicting global lung stress in PSV. Additionally, we explored whether the physiological effects of high PEEP differed according to the response of respiratory system compliance (CRS). METHODS: Adults with ARDS undergoing PSV were enrolled. An esophageal catheter was inserted to calculate lung stress through transpulmonary driving pressure (ΔPL). ΔP and ΔPL were assessed in PSV at PEEP 5, 10, and 15 cm H2O by end-inspiratory holds. CRS was calculated as tidal volume (VT)/ΔP. We analyzed the effects of high PEEP on pressure-time product per minute (PTPmin), airway pressure at 100 ms (P0.1), and VT over PTP per breath (VT/PTPbr) in subjects with increased versus decreased CRS at high PEEP. RESULTS: Eighteen subjects and 162 end-inspiratory holds were analyzed; 51/162 (31.5%) of the holds had ΔPL ≥ 12 cm H2O. Significant association between ΔP and ΔPL was found at all PEEP levels (P < .001). ΔP had excellent precision to predict ΔPL, with 15 cm H2O being identified as the best threshold for detecting ΔPL ≥ 12 cm H2O (area under the receiver operating characteristics 0.99 [95% CI 0.98-1.00]). CRS changes from low to high PEEP corresponded well with lung compliance changes (R2 0.91, P < .001) When CRS increased, a significant improvement of PTPmin and VT/PTPbr was found, without changes in P0.1. No benefits were observed when CRS decreased. CONCLUSIONS: In subjects with ARDS undergoing PSV, high ΔP assessed by readable end-inspiratory holds accurately detected potentially dangerous thresholds of ΔPL. Using ΔP to assess changes in CRS induced by PEEP during assisted ventilation may inform whether higher PEEP could be beneficial.

Epidemiology of Weaning From Invasive Mechanical Ventilation in Subjects With COVID-19.

BACKGROUND: Patients requiring mechanical ventilation due to COVID-19 have different characteristics of evolution and outcome compared to the general ICU population. Although early weaning from mechanical ventilation is associated with improved outcomes, inadequate identification of patients unable to be weaned may lead to extubation failure and increased days on mechanical ventilation. Outcomes related to mechanical ventilation weaning in this population are scare and inconclusive. Therefore, the objective of this study was to describe the characteristics of mechanical ventilation weaning in subjects with acute respiratory failure induced by COVID-19. METHODS: This was a multi-center, prospective cohort study. We included adult subjects requiring at least 12 h of mechanical ventilation due to COVID-19 infection admitted to any participating ICUs. Characteristics of the mechanical ventilation weaning and extubation process, as well as clinical results, were the primary outcome variables. Weaning types were defined according to previously described and internationally recognized categories. RESULTS: Three hundred twenty-six subjects from 8 ICUs were included. A spontaneous breathing trial (SBT) was not performed in 52.1% of subjects. One hundred twenty-eight subjects were extubated, and 29.7% required re-intubation. All the subjects included could be classified by Weaning according to a New Definition (WIND) classification (group 0 = 52.1%, group 1 = 28.5%, group 2 = 8.0%, and group 3 = 11.3%) with statistically significant differences in duration of mechanical ventilation (P < .001) and ICU length of stay (P < .001) between groups. CONCLUSIONS: The mechanical ventilation weaning process in subjects with COVID-19 was negatively affected by the disease, with many subjects never completing an SBT. Even though temporal variables were modified, the clinical outcomes in each weaning group were similar to those previously reported.

Infecciones asociadas a la atención de la Salud en pacientes internados en una Unidad de Terapia Intensiva durante la pandemia por COVID-19 en el año 2020

Introducción: La pandemia por coronavirus se diseminó mundialmente con una amplia variedad de presentaciones clínicas. Se reportó que 15% de los pacientes requirió internación en una unidad de cuidados intensivos (UCI). Estudios epidemiológicos demostraron que pacientes con ventilación mecánica invasiva (VMi) por SARS-Cov-2 presentan más riesgo de infecciones asociadas a la atención de la salud (IAAS). Objetivo: Describir la incidencia IAAS en adultos internados en UCI en VMi del Sanatorio Anchorena San Martín, durante la pandemia en 2020. Pacientes y Métodos: Estudio de cohorte retrospectivo, el análisis de normalidad se efectuó mediante test Shapiro-Wilk. El análisis de regresión múltiple se realizó en forma automática, (backward selection). Para la comparación entre grupo COVID-19 y no COVID-19 se utilizó T test o Test de Wilcoxon según correspondiera; y el χ2 o el test exacto de Fisher. Todas las estimaciones de las funciones de incidencia acumuladas fueron realizadas con el paquete cmprsk. Resultados: Se incluyeron 252 pacientes, 40 desarrollaron IAAS (incidencia acumulada de 15,9%), con un total de 60 eventos de IAAS. La edad (OR 0,96), cantidad de accesos venosos centrales (AVC) (OR 2,01), COVID-19 (OR 2,96) y decúbito prono (OR 2,78) se asociaron a IAAS. Desarrollar IAAS se asoció a más días de VMi y estadía en UCI. La incidencia acumulada de IAAS en pacientes NO COVID fue menor que en COVID-19. Días de VMi y mortalidad en UCI fueron mayores en pacientes con COVID. El 29,6% de los pacientes con COVID-19 desarrolló algún tipo de IAAS vs 7,1% en NO COVID. Conclusión: Describimos la incidencia de IAAS en nuestra cohorte. La presencia de COVID-19, AVC, el decúbito prono y estadía en UCI se asociaron con mayor probabilidad de contraer una IAAS.

Background: Coronavirus disease 2019 (COVID-19) has spread fast globally comprising a great variety of clinical presentations. It was reported that 15% of patients required admission to intensive care units (ICU). Previous epidemiological studies have reported higher risk of healthcare-associated infections (HCAI) in those patients requiring invasive mechanical ventilation (iMV) due to COVID-19. Aim: To analyze the incidence of HCAI in adults under iMV admitted to ICU of Anchorena San Martín Clinic during COVID-19 pandemic. Methods: Retrospective cohort study, the analysis of normality was carried out using the Shapiro-Wilk test. The multiple regression analysis was performed automatically, based on backward elimination of the variables (backward selection). For the comparison between the COVID-19 and non-COVID-19 groups, the T test or Wilcoxon test was used, as appropriate; and the χ2 or Fisher's exact test. All cumulative incidence function estimates were made with the cmprsk package. Results: 252 patients were included, 40 patients developed HCAI (accumulated incidence was 15.9%), counting for 60 total HCAI events. Age (OR 0.96), number of central venous access devices (CVAD) (OR 2.01), COVID-19 (OR 2.96) and prone positioning (OR 2.78) were associated with HCAI. HCAI was associated with more days of iMV and ICU stay. The accumulated incidence of HCAI in non-COVID-19 patients was lower than in COVID-19 patients. iMV days and mortality were higher in COVID-19. 29.6% of COVID-19 patients developed HCAIs vs 7.1% of non-COVID-19 ones. Conclusión: We describe the incidence of HCAI. Age, COVID-19, CVAD, prone positioning and ICU stay were associated with higher probability of HCAIs.

Impact of liberal versus conservative saturation targets on gas exchange indices in COVID-19 related acute respiratory distress syndrome: a physiological study. / Impacto de alvos de saturação liberais versus conservadores sobre os índices de troca gasosa na síndrome do desconforto respiratório agudo relacionada à COVID-19: um estudo fisiológico.

OBJECTIVE: To compare gas exchange indices behavior by using liberal versus conservative oxygenation targets in patients with moderate to severe acute respiratory distress syndrome secondary to COVID-19 under invasive mechanical ventilation. We also assessed the influence of high FiO2 on respiratory system mechanics. METHODS: We prospectively included consecutive patients aged over 18 years old with a diagnosis of COVID-19 and moderate-severe acute respiratory distress syndrome. For each patient, we randomly applied two FiO2 protocols to achieve SpO2 88% - 92% or 96%. We assessed oxygenation indices and respiratory system mechanics. RESULTS: We enrolled 15 patients. All the oxygenation indices were significantly affected by the FiO2 strategy (p < 0.05) selected. The PaO2/FiO2 deteriorated, PA-aO2 increased and Pa/AO2 decreased significantly when using FiO2 to achieve SpO2 96%. Conversely, the functional shunt fraction was reduced. Respiratory mechanics were not affected by the FiO2 strategy. CONCLUSION: A strategy aimed at liberal oxygenation targets significantly deteriorated gas exchange indices, except for functional shunt, in COVID-19-related acute respiratory distress syndrome. The respiratory system mechanics were not altered by the FiO2 strategy.Clinical Trials Register: NCT04486729.

OBJETIVO: Comparar o comportamento dos índices de troca gasosa conforme o uso de alvos de oxigenação liberais em comparação a conservadores em pacientes com síndrome do desconforto respiratório agudo moderada a grave secundária à COVID-19 e em uso de ventilação mecânica; avaliar a influência da FiO2 elevada na mecânica do sistema respiratório. MÉTODOS: Foram incluídos prospectivamente pacientes consecutivos com idades acima de 18 anos, diagnóstico de COVID-19 e síndrome do desconforto respiratório agudo moderada e grave. Para cada paciente, aplicou-se aleatoriamente dois protocolos de FiO2 para obter SpO2 de 88% a 92% ou 96%. Avaliaram-se os índices de oxigenação e a mecânica do sistema respiratório. RESULTADOS: Foram incluídos 15 pacientes. Todos seus índices foram significantemente afetados pela estratégia de FiO2 (p < 0,05). A proporção PaO2/FiO2 deteriorou, o PA-aO2 aumentou e o Pa/AO2 diminuiu significantemente com a utilização de FiO2 para obter SpO2 96%. Opostamente, a fração de shunt funcional foi reduzida. A mecânica respiratória não foi afetada pela estratégia de FiO2. CONCLUSÃO: Uma estratégia com alvos liberais de oxigenação deteriorou significantemente os índices de troca gasosa, com exceção do shunt funcional, em pacientes com síndrome do desconforto respiratório agudo relacionada à COVID-19. A mecânica do sistema respiratório não foi alterada pela estratégia de FiO2.Registro Clinical Trials: NCT04486729.

Impacto de alvos de saturação liberais versus conservadores sobre os índices de troca gasosa na síndrome do desconforto respiratório agudo relacionada à COVID-19: um estudo fisiológico / Impact of liberal versus conservative saturation targets on gas exchange indices in COVID-19 related acute respiratory distress syndrome: a physiological study

RESUMO Objetivo: Comparar o comportamento dos índices de troca gasosa conforme o uso de alvos de oxigenação liberais em comparação a conservadores em pacientes com síndrome do desconforto respiratório agudo moderada a grave secundária à COVID-19 e em uso de ventilação mecânica; avaliar a influência da FiO2 elevada na mecânica do sistema respiratório. Métodos: Foram incluídos prospectivamente pacientes consecutivos com idades acima de 18 anos, diagnóstico de COVID-19 e síndrome do desconforto respiratório agudo moderada e grave. Para cada paciente, aplicou-se aleatoriamente dois protocolos de FiO2 para obter SpO2 de 88% a 92% ou 96%. Avaliaram-se os índices de oxigenação e a mecânica do sistema respiratório. Resultados: Foram incluídos 15 pacientes. Todos seus índices foram significantemente afetados pela estratégia de FiO2 (p < 0,05). A proporção PaO2/FiO2 deteriorou, o PA-aO2 aumentou e o Pa/AO2 diminuiu significantemente com a utilização de FiO2 para obter SpO2 96%. Opostamente, a fração de shunt funcional foi reduzida. A mecânica respiratória não foi afetada pela estratégia de FiO2. Conclusão: Uma estratégia com alvos liberais de oxigenação deteriorou significantemente os índices de troca gasosa, com exceção do shunt funcional, em pacientes com síndrome do desconforto respiratório agudo relacionada à COVID-19. A mecânica do sistema respiratório não foi alterada pela estratégia de FiO2. Registro Clinical Trials: NCT04486729.

ABSTRACT Objective: To compare gas exchange indices behavior by using liberal versus conservative oxygenation targets in patients with moderate to severe acute respiratory distress syndrome secondary to COVID-19 under invasive mechanical ventilation. We also assessed the influence of high FiO2 on respiratory system mechanics. Methods: We prospectively included consecutive patients aged over 18 years old with a diagnosis of COVID-19 and moderate-severe acute respiratory distress syndrome. For each patient, we randomly applied two FiO2 protocols to achieve SpO2 88% - 92% or 96%. We assessed oxygenation indices and respiratory system mechanics. Results: We enrolled 15 patients. All the oxygenation indices were significantly affected by the FiO2 strategy (p < 0.05) selected. The PaO2/FiO2 deteriorated, PA-aO2 increased and Pa/AO2 decreased significantly when using FiO2 to achieve SpO2 96%. Conversely, the functional shunt fraction was reduced. Respiratory mechanics were not affected by the FiO2 strategy. Conclusion: A strategy aimed at liberal oxygenation targets significantly deteriorated gas exchange indices, except for functional shunt, in COVID-19-related acute respiratory distress syndrome. The respiratory system mechanics were not altered by the FiO2 strategy. Clinical Trials Register: NCT04486729.

Lesão pulmonar autoinflingida: é possível identificar o risco? Relato de caso / Self-inflicted lung injury: is it possible to identify the risk? A case report

RESUMO A respiração espontânea pode ser prejudicial para pacientes com pulmões previamente lesados, especialmente na vigência de síndrome do desconforto respiratório agudo. Mais ainda, a incapacidade de assumir a respiração totalmente espontânea durante a ventilação mecânica e a necessidade de voltar à ventilação mecânica controlada se associam com mortalidade mais alta. Existe uma lacuna no conhecimento em relação aos parâmetros que poderiam ser úteis para predizer o risco de lesão pulmonar autoinflingida pelo paciente e detecção da incapacidade de assumir a respiração espontânea. Relata-se o caso de um paciente com lesão pulmonar autoinflingida e as correspondentes variáveis, básicas e avançadas, de monitoramento da mecânica do sistema respiratório, além dos resultados fisiológicos e clínicos relacionados à respiração espontânea durante ventilação mecânica. O paciente era um homem caucasiano com 33 anos de idade e história clínica de AIDS, que apresentou síndrome do desconforto respiratório agudo e necessitou ser submetido à ventilação mecânica invasiva após falha do suporte ventilatório não invasivo. Durante os períodos de ventilação controlada, adotou-se estratégia de ventilação protetora, e o paciente mostrou evidente melhora, tanto do ponto de vista clínico quanto radiográfico. Contudo, durante cada período de respiração espontânea sob ventilação com pressão de suporte, apesar dos parâmetros iniciais adequados, das regulagens rigorosamente estabelecidas e do estrito monitoramento, o paciente desenvolveu hipoxemia progressiva e piora da mecânica do sistema respiratório, com deterioração radiográfica claramente correlacionada (lesão pulmonar autoinflingida pelo paciente). Após falha de três tentativas de respiração espontânea, o paciente faleceu por hipoxemia refratária no 29° dia. Neste caso, as variáveis básicas e avançadas convencionais não foram suficientes para identificar a aptidão para respirar espontaneamente ou predizer o risco de desenvolver lesão pulmonar autoinflingida pelo paciente durante a ventilação de suporte parcial.

ABSTRACT Spontaneous breathing can be deleterious in patients with previously injured lungs, especially in acute respiratory distress syndrome. Moreover, the failure to assume spontaneous breathing during mechanical ventilation and the need to switch back to controlled mechanical ventilation are associated with higher mortality. There is a gap of knowledge regarding which parameters might be useful to predict the risk of patient self-inflicted lung injury and to detect the inability to assume spontaneous breathing. We report a case of patient self-inflicted lung injury, the corresponding basic and advanced monitoring of the respiratory system mechanics and physiological and clinical results related to spontaneous breathing. The patient was a 33-year-old Caucasian man with a medical history of AIDS who developed acute respiratory distress syndrome and needed invasive mechanical ventilation after noninvasive ventilatory support failure. During the controlled ventilation periods, a protective ventilation strategy was adopted, and the patient showed clear clinical and radiographic improvement. However, during each spontaneous breathing period under pressure support ventilation, despite adequate initial parameters and a strictly adjusted ventilatory setting and monitoring, the patient developed progressive hypoxemia and worsening of respiratory system mechanics with a clearly correlated radiographic deterioration (patient self-inflicted lung injury). After failing three spontaneous breathing assumption trials, he died on day 29 due to refractory hypoxemia. Conventional basic and advanced monitoring variables in this case were not sufficient to identify the aptitude to breathe spontaneously or to predict the risk and development of patient self-inflicted lung injury during partial support ventilation.

Description of physical rehabilitation in intensive care units in Argentina: usual practice and during the COVID-19 pandemic. Online survey. / Descripción de la rehabilitación física en terapias intensivas de Argentina, práctica habitual y durante la pandemia COVID-19. Encuesta tipo online.

OBJECTIVE: To describe the usual practice of mobility therapy in the adult intensive care unit for patients with and without COVID-19. METHODS: Online survey in which physical therapists working in an adult intensive care unit in Argentina participated. Sixteen multiple-choice or single-response questions grouped into three sections were asked. The first section addressed personal, professional and work environment data. The second section presented questions regarding usual care, and the third focused on practices under COVID-19 pandemic conditions. RESULTS: Of 351 physical therapists, 76.1% answer that they were exclusively responsible for patient mobility. The highest motor-based goal varied according to four patient scenarios: Mechanically ventilated patients, patients weaned from mechanical ventilation, patients who had never required mechanical ventilation, and patients with COVID-19 under mechanical ventilation. In the first and last scenarios, the highest goal was to optimize muscle strength, while for the other two, it was to perform activities of daily living. Finally, the greatest limitation in working with patients with COVID-19 was respiratory and/or contact isolation. CONCLUSION: Physical therapists in Argentina reported being responsible for the mobility of patients in the intensive care unit. The highest motor-based therapeutic goals for four classic scenarios in the closed area were limited by the need for mechanical ventilation. The greatest limitation when mobilizing patients with COVID-19 was respiratory and contact isolation.

OBJETIVO: Describir la práctica habitual de asistencia kinésica motora en la unidad de cuidados intensivos de adultos, tanto en pacientes con y sin COVID-19. MÉTODOS: Estudio observacional transversal de tipo encuesta online. Se incluyeron kinesiólogos que trabajan en unidades de cuidados intensivos de adultos en Argentina. Se realizaron 16 preguntas de respuesta múltiple o simple agrupadas en 3 apartados. El primero caracterizado por datos personales, profesionales o del ámbito laboral. El segundo, destinado a conocer el accionar habitual y un tercero enfocado en las prácticas bajo la pandemia COVID-19. RESULTADOS: Sobre 351 kinesiólogos, el 76.1% reportó que la movilización de los pacientes estaba a cargo exclusivamente de ellos. El objetivo máximo a alcanzar desde el aspecto motor fue variable según cuatro escenarios: Pacientes en ventilación mecánica, desvinculados de la ventilación mecánica, los que nunca estuvieron asociados a la ventilación mecánica y con COVID-19 en ventilación mecánica. En el primer y último escenario el objetivo máximo fue optimizar valores de fuerza muscular. En los restantes fue realizar actividades de la vida diaria. Por último, la mayor limitante en el abordaje de pacientes con COVID-19 fue el aislamiento respiratorio y/o de contacto. CONCLUSIÓN: Los kinesiólogos en Argentina reportaron encargarse de la movilización de los pacientes en la unidad de cuidados intensivos. Los objetivos máximos desde el aspecto motor para cuatro escenarios clásicos en el área cerrada podrían estar determinado por la asociación con la ventilación mecánica. La mayor limitación a la hora de movilizar a pacientes con COVID-19 fue el aislamiento respiratorio y de contacto.

Descripción de la rehabilitación física en terapias intensivas de Argentina, práctica habitual y durante la pandemia COVID-19. Encuesta tipo online / Description of physical rehabilitation in intensive care units in Argentina: usual practice and during the COVID-19 pandemic. Online survey

RESUMEN Objetivo: Describir la práctica habitual de asistencia kinésica motora en la unidad de cuidados intensivos de adultos, tanto en pacientes con y sin COVID-19. Métodos: Estudio observacional transversal de tipo encuesta online. Se incluyeron kinesiólogos que trabajan en unidades de cuidados intensivos de adultos en Argentina. Se realizaron 16 preguntas de respuesta múltiple o simple agrupadas en 3 apartados. El primero caracterizado por datos personales, profesionales o del ámbito laboral. El segundo, destinado a conocer el accionar habitual y un tercero enfocado en las prácticas bajo la pandemia COVID-19. Resultados: Sobre 351 kinesiólogos, el 76.1% reportó que la movilización de los pacientes estaba a cargo exclusivamente de ellos. El objetivo máximo a alcanzar desde el aspecto motor fue variable según cuatro escenarios: Pacientes en ventilación mecánica, desvinculados de la ventilación mecánica, los que nunca estuvieron asociados a la ventilación mecánica y con COVID-19 en ventilación mecánica. En el primer y último escenario el objetivo máximo fue optimizar valores de fuerza muscular. En los restantes fue realizar actividades de la vida diaria. Por último, la mayor limitante en el abordaje de pacientes con COVID-19 fue el aislamiento respiratorio y/o de contacto. Conclusión: Los kinesiólogos en Argentina reportaron encargarse de la movilización de los pacientes en la unidad de cuidados intensivos. Los objetivos máximos desde el aspecto motor para cuatro escenarios clásicos en el área cerrada podrían estar determinado por la asociación con la ventilación mecánica. La mayor limitación a la hora de movilizar a pacientes con COVID-19 fue el aislamiento respiratorio y de contacto.

Abstract Objective: To describe the usual practice of mobility therapy in the adult intensive care unit for patients with and without COVID-19. Methods: Online survey in which physical therapists working in an adult intensive care unit in Argentina participated. Sixteen multiple-choice or single-response questions grouped into three sections were asked. The first section addressed personal, professional and work environment data. The second section presented questions regarding usual care, and the third focused on practices under COVID-19 pandemic conditions. Results: Of 351 physical therapists, 76.1% answer that they were exclusively responsible for patient mobility. The highest motor-based goal varied according to four patient scenarios: Mechanically ventilated patients, patients weaned from mechanical ventilation, patients who had never required mechanical ventilation, and patients with COVID-19 under mechanical ventilation. In the first and last scenarios, the highest goal was to optimize muscle strength, while for the other two, it was to perform activities of daily living. Finally, the greatest limitation in working with patients with COVID-19 was respiratory and/or contact isolation. Conclusion: Physical therapists in Argentina reported being responsible for the mobility of patients in the intensive care unit. The highest motor-based therapeutic goals for four classic scenarios in the closed area were limited by the need for mechanical ventilation. The greatest limitation when mobilizing patients with COVID-19 was respiratory and contact isolation.

High-Flow Oxygen Therapy Application in Chronic Obstructive Pulmonary Disease Patients With Acute Hypercapnic Respiratory Failure: A Multicenter Study.

OBJECTIVES: To evaluate the effect of high-flow oxygen implementation on the respiratory rate as a first-line ventilation support in chronic obstructive pulmonary disease patients with acute hypercapnic respiratory failure. DESIGN: Multicenter, prospective, analytic observational case series study. SETTING: Five ICUs in Argentina, between August 2018 and September 2019. PATIENTS: Patients greater than or equal to 18 years old with moderate to very severe chronic obstructive pulmonary disease, who had been admitted to the ICU with a diagnosis of hypercapnic acute respiratory failure, were entered in the study. INTERVENTIONS: High-flow oxygen therapy through nasal cannula delivered using high-velocity nasal insufflation. MEASUREMENTS AND MAIN RESULTS: Forty patients were studied, 62.5% severe chronic obstructive pulmonary disease. After the first hour of high-flow nasal cannula implementation, there was a significant decrease of respiratory rate compared with baseline values, with a 27% decline (29 vs 21 breaths/min; p < 0.001). Furthermore, a significant reduction of Paco2 (57 vs 52 mm Hg [7.6 vs 6.9 kPa]; p < 0.001) was observed. The high-flow nasal cannula application failed in 18% patients. In this group, the respiratory rate, pH, and Paco2 showed no significant change during the first hour in these patients. CONCLUSIONS: High-flow oxygen therapy through nasal cannula delivered using high-velocity nasal insufflation was an effective tool for reducing respiratory rate in these chronic obstructive pulmonary disease patients with acute hypercapnic respiratory failure. Early determination and subsequent monitoring of clinical and blood gas parameters may help predict the outcome.

Self-inflicted lung injury: is it possible to identify the risk? A case report. / Lesão pulmonar autoinflingida: é possível identificar o risco? Relato de caso.

Spontaneous breathing can be deleterious in patients with previously injured lungs, especially in acute respiratory distress syndrome. Moreover, the failure to assume spontaneous breathing during mechanical ventilation and the need to switch back to controlled mechanical ventilation are associated with higher mortality. There is a gap of knowledge regarding which parameters might be useful to predict the risk of patient self-inflicted lung injury and to detect the inability to assume spontaneous breathing. We report a case of patient self-inflicted lung injury, the corresponding basic and advanced monitoring of the respiratory system mechanics and physiological and clinical results related to spontaneous breathing. The patient was a 33-year-old Caucasian man with a medical history of AIDS who developed acute respiratory distress syndrome and needed invasive mechanical ventilation after noninvasive ventilatory support failure. During the controlled ventilation periods, a protective ventilation strategy was adopted, and the patient showed clear clinical and radiographic improvement. However, during each spontaneous breathing period under pressure support ventilation, despite adequate initial parameters and a strictly adjusted ventilatory setting and monitoring, the patient developed progressive hypoxemia and worsening of respiratory system mechanics with a clearly correlated radiographic deterioration (patient self-inflicted lung injury). After failing three spontaneous breathing assumption trials, he died on day 29 due to refractory hypoxemia. Conventional basic and advanced monitoring variables in this case were not sufficient to identify the aptitude to breathe spontaneously or to predict the risk and development of patient self-inflicted lung injury during partial support ventilation.

A respiração espontânea pode ser prejudicial para pacientes com pulmões previamente lesados, especialmente na vigência de síndrome do desconforto respiratório agudo. Mais ainda, a incapacidade de assumir a respiração totalmente espontânea durante a ventilação mecânica e a necessidade de voltar à ventilação mecânica controlada se associam com mortalidade mais alta. Existe uma lacuna no conhecimento em relação aos parâmetros que poderiam ser úteis para predizer o risco de lesão pulmonar autoinflingida pelo paciente e detecção da incapacidade de assumir a respiração espontânea. Relata-se o caso de um paciente com lesão pulmonar autoinflingida e as correspondentes variáveis, básicas e avançadas, de monitoramento da mecânica do sistema respiratório, além dos resultados fisiológicos e clínicos relacionados à respiração espontânea durante ventilação mecânica. O paciente era um homem caucasiano com 33 anos de idade e história clínica de AIDS, que apresentou síndrome do desconforto respiratório agudo e necessitou ser submetido à ventilação mecânica invasiva após falha do suporte ventilatório não invasivo. Durante os períodos de ventilação controlada, adotou-se estratégia de ventilação protetora, e o paciente mostrou evidente melhora, tanto do ponto de vista clínico quanto radiográfico. Contudo, durante cada período de respiração espontânea sob ventilação com pressão de suporte, apesar dos parâmetros iniciais adequados, das regulagens rigorosamente estabelecidas e do estrito monitoramento, o paciente desenvolveu hipoxemia progressiva e piora da mecânica do sistema respiratório, com deterioração radiográfica claramente correlacionada (lesão pulmonar autoinflingida pelo paciente). Após falha de três tentativas de respiração espontânea, o paciente faleceu por hipoxemia refratária no 29° dia. Neste caso, as variáveis básicas e avançadas convencionais não foram suficientes para identificar a aptidão para respirar espontaneamente ou predizer o risco de desenvolver lesão pulmonar autoinflingida pelo paciente durante a ventilação de suporte parcial.

Eficacia de la férula nocturna y el ultrasonido para tratar el síndrome del túnel carpiano. Estudio clínico controlado y aleatorizado / Night splinting effectiveness in carpal tunnel syndrome. A randomized controlled clinical trial

Objetivo: Comparar la eficacia de la inmovilización nocturna de la muñeca con una férula cubital en ángulo neutro junto con la aplicación de ultrasonido en pacientes con síndrome del túnel carpiano leve y moderado. Materiales y Métodos: Entre octubre de 2007 y marzo de 2010, se incluyó a pacientes >18 años con síndrome del túnel carpiano confirmado por electromiografía en un hospital de Buenos Aires. Se realizó una aleatorización estratificada, con bloques permutados aleatorios, y apareamiento por sexo y edad. Los pacientes fueron asignados al grupo experimental (GE) o al grupo de control (GC). Ambos grupos recibieron ultrasonido de 1 MHz pulsante por 15 min, 3 veces por semana, durante 6 semanas. Los pacientes del GE, además, utilizaron una férula nocturna. Se evaluaron el dolor y la parestesia con la escala analógica visual de 100 mm, la PSFS y el test de Moberg, al comenzar, a las 3 semanas y, al finalizar, a las 6 semanas, y durante el seguimiento, al mes, y a los 3 y 6 meses, con evaluador a ciego. Resultados: Se analizó a 32 pacientes del GC y a 33 del GE. Al finalizar el tratamiento, todas las variables habían mejorado en ambos grupos, con diferencia de medias estadísticamente significativa para el dolor a favor del GE a las 3 semanas de tratamiento 1,64 (IC95% 0,38-2,91; p = 0,012), pero sin diferencia clínica significativa. No se informaron efectos adversos. Conclusión: El tratamiento con una férula nocturna y ultrasonido no es superior al ultrasonido solo en pacientes con STC. Nivel de Evidencia; II

Objective: To compare the effectiveness of night wrist immobilization using an ulnar splint in neutral angle versus the use of ultrasound (US) in patients with Carpal Tunnel Syndrome (CTS). Materials and Methods: Study population included over 18 years of age that were treated for electromyography-confirmed CTS between October 2007 and March 2010 at a Buenos Aires hospital. A sex- and age-stratified randomization was performed by using randomly permuted blocks, allocating patients into the experimental group (EG) and control group (CG). Pulsed US therapy was administered for 15 minutes to all patients three times a week for six weeks at a frequency of 1 MHz. In addition, EG patients were also prescribed night splint. Pain and paresthesia were evaluated using a 100mm Visual Analogue Scale (VAS), the Patient Specific Functional Scale (PSFS), and the Moberg pickup test (MPUT) at baseline, at 3 and 6 weeks, and at 3 and 6 months after treatment institution by a blinded investigator. Results: Study population consisted of 85 cases (65 patients) that were randomly allocated to CG (n=42) or EG (n=43). Improvement of all the variables was observed at the end of treatment in both groups, with a 1.64 (95% CI: 0.38-2.91, P=0.012) statistically significant difference in means for pain in favor of the EG at 3 weeks of treatment, but without a significant clinical difference. No adverse effects were observed. Conclusion: The effectiveness of combined night splint and US therapy is not superior to the US alone treatment in CTS patients. Level of Evidence; II

Titration and characteristics of pressure-support ventilation use in Argentina: an online cross-sectional survey study. / Uso y titulación de presión soporte en Argentina: estudio transversal de tipo encuesta online.

OBJECTIVE: To identify common practices related to the use and titration of pressure-support ventilation (PC-CSV - pressure control-continuous spontaneous ventilation) in patients under mechanical ventilation and to analyze diagnostic criteria for over-assistance and under-assistance. The secondary objective was to compare the responses provided by physician, physiotherapists and nurses related to diagnostic criteria for over-assistance and under-assistance. METHODS: An online survey was conducted using the Survey Monkey tool. Physicians, nurses and physiotherapists from Argentina with access to PC-CSV in their usual clinical practice were included. RESULTS: A total of 509 surveys were collected from October to December 2018. Of these, 74.1% were completed by physiotherapists. A total of 77.6% reported using PC-CSV to initiate the partial ventilatory support phase, and 43.8% of respondents select inspiratory pressure support level based on tidal volume. The main objective for selecting positive end-expiratory pressure (PEEP) level was to decrease the work of breathing. High tidal volume was the primary variable for detecting over-assistance, while the use of accessory respiratory muscles was the most commonly chosen for under-assistance. Discrepancies were observed between physicians and physiotherapists in relation to the diagnostic criteria for over-assistance. CONCLUSION: The most commonly used mode to initiate the partial ventilatory support phase was PC-CSV. The most frequently selected variable to guide the titration of inspiratory pressure support level was tidal volume, and the main objective of PEEP was to decrease the work of breathing. Over-assistance was detected primarily by high tidal volume, while under-assistance by accessory respiratory muscles activation. Discrepancies were observed among professions in relation to the diagnostic criteria for over-assistance, but not for under-assistance.

Uso y titulación de presión soporte en Argentina: estudio transversal de tipo encuesta online / Titration and characteristics of pressure-support ventilation use in Argentina: an online cross-sectional survey study

RESUMEN Objetivo: Identificar las prácticas habituales de uso y titulación del modo presión soporte (PC-CSV - pressure control continuous spontaneous ventilation) en pacientes bajo ventilación mecánica y analizar las formas de reconocimiento de sobreasistencia y subasistencia. Secundariamente, comparar las respuestas según profesión en relación al diagnóstico de sobreasistencia y subasistencia. Métodos: Se realizó una encuesta online utilizando la herramienta Survey Monkey. Se incluyeron a médicos, enfermeros y kinesiólogos de Argentina que tuvieran acceso al uso de PC-CSV en su práctica habitual. Resultados: Se recolectaron 509 encuestas desde octubre a diciembre 2018. El 74,1% de ellas correspondió a kinesiólogos. Un 77,6% refirió utilizar PC-CSV para iniciar la fase de soporte parcial. Un 43,8% selecciona el valor de presión de soporte inspiratorio basándose en volumen corriente. El principal objetivo de la selección de PEEP fue disminuir el trabajo respiratorio. El volumen corriente alto fue la variable primordial de detección de sobreasistencia, mientras que el uso de músculos accesorios fue la más elegida para subasistencia. Se observaron diferencias entre médicos y kinesiólogos en relación a las formas de detección de sobreasistencia. Conclusión: El modo más utilizado para la fase de soporte parcial es PC-CSV. La variable más elegida para titular la presión de soporte inspiratorio es volumen corriente y el principal objetivo de la PEEP es disminuir el trabajo respiratorio. La sobreasistencia es detectada prioritariamente por un volumen corriente elevado, mientras que la subasistencia mediante el uso de músculos accesorios. Se halló diferencias entre profesiones en relación a los criterios de detección de sobreasistencia.

ABSTRACT Objective: To identify common practices related to the use and titration of pressure-support ventilation (PC-CSV - pressure control-continuous spontaneous ventilation) in patients under mechanical ventilation and to analyze diagnostic criteria for over-assistance and under-assistance. The secondary objective was to compare the responses provided by physician, physiotherapists and nurses related to diagnostic criteria for over-assistance and under-assistance. Methods: An online survey was conducted using the Survey Monkey tool. Physicians, nurses and physiotherapists from Argentina with access to PC-CSV in their usual clinical practice were included. Results: A total of 509 surveys were collected from October to December 2018. Of these, 74.1% were completed by physiotherapists. A total of 77.6% reported using PC-CSV to initiate the partial ventilatory support phase, and 43.8% of respondents select inspiratory pressure support level based on tidal volume. The main objective for selecting positive end-expiratory pressure (PEEP) level was to decrease the work of breathing. High tidal volume was the primary variable for detecting over-assistance, while the use of accessory respiratory muscles was the most commonly chosen for under-assistance. Discrepancies were observed between physicians and physiotherapists in relation to the diagnostic criteria for over-assistance. Conclusion: The most commonly used mode to initiate the partial ventilatory support phase was PC-CSV. The most frequently selected variable to guide the titration of inspiratory pressure support level was tidal volume, and the main objective of PEEP was to decrease the work of breathing. Over-assistance was detected primarily by high tidal volume, while under-assistance by accessory respiratory muscles activation. Discrepancies were observed among professions in relation to the diagnostic criteria for over-assistance, but not for under-assistance.

Efficacy of core exercises in patients with osteoarthritis of the knee: A randomized controlled clinical trial.

TRIAL DESIGN: Randomized, evaluator blinded, controlled, parallel group. METHODS: This trial was conducted between July 2011 and January 2015 at a public hospital in Argentina. Patients older than 40 years with a medical diagnosis of osteoarthritis (OA) were randomly assigned to the experimental group (EG) or control group (CG). Both groups performed conventional exercises 3 times a week for 12 weeks and core exercises were added to the EG intervention. The objective was to compare the efficacy of conventional treatment combined with core muscle strengthening exercises, with conventional treatment alone in terms of short- and medium-term pain reduction and physical function in patients with knee OA. The primary outcome was knee pain assessed using a visual analog scale and the secondary outcome was physical function assessed at baseline, week 8 and 12, and 2 follow-up visits held 1 month and 3 months after the end of treatment. RESULTS: 113 patients were randomized to a CG (n = 60) or EG (n = 53). 66 patients were eliminated and 25 patients in the EG and 22 in the CG were analyzed. Both pain reduction and improved physical function were observed throughout the intervention in both groups. At the end of the treatment, a statistically and clinically significant pain reduction was observed in the EG. No adverse effects were reported. CONCLUSION: The combination of core muscle activation exercises and conventional treatment was more effective in short-term pain reduction in patients with knee OA.

Chest wall effect on the monitoring of respiratory mechanics in acute respiratory distress syndrome. / Influencia de la caja torácica en el monitoreo de la mecánica respiratoria en síndrome de distrés respiratorio agudo.

The respiratory system mechanics depend on the characteristics of the lung and chest wall and their interaction. In patients with acute respiratory distress syndrome under mechanical ventilation, the monitoring of airway plateau pressure is fundamental given its prognostic value and its capacity to assess pulmonary stress. However, its validity can be affected by changes in mechanical characteristics of the chest wall, and it provides no data to correctly titrate positive end-expiratory pressure by restoring lung volume. The chest wall effect on respiratory mechanics in acute respiratory distress syndrome has not been completely described, and it has likely been overestimated, which may lead to erroneous decision making. The load imposed by the chest wall is negligible when the respiratory system is insufflated with positive end-expiratory pressure. Under dynamic conditions, moving this structure demands a pressure change whose magnitude is related to its mechanical characteristics, and this load remains constant regardless of the volume from which it is insufflated. Thus, changes in airway pressure reflect changes in the lung mechanical conditions. Advanced monitoring could be reserved for patients with increased intra-abdominal pressure in whom a protective mechanical ventilation strategy cannot be implemented. The estimates of alveolar recruitment based on respiratory system mechanics could reflect differences in chest wall response to insufflation and not actual alveolar recruitment.

La mecánica del sistema respiratorio depende de las características del pulmón, la caja torácica y su interacción. En pacientes con síndrome de distrés respiratorio agudo bajo ventilación mecánica el monitoreo de la presión meseta en la vía aérea es fundamental debido a su valor pronóstico y su capacidad de reflejar el estrés pulmonar. Sin embargo, su validez puede verse afectada por cambios en las características mecánicas de la caja torácica, y además, no otorga información para la correcta titulación de presión positiva al final de la espiración en función de restablecer el volumen pulmonar. La influencia que la caja torácica ejerce sobre la mecánica del sistema respiratorio en síndrome de distrés respiratorio agudo no ha sido completamente descripta y es probable que haya sido sobredimensionada pudiendo conducir a toma de decisiones erróneas. Ante la insuflación con presión positiva al final de la espiración, la carga impuesta por la caja torácica es despreciable. En condiciones dinámicas, desplazar esta estructura demanda un cambio de presión cuya magnitud se relaciona con sus características mecánicas, dicha carga se mantiene constante independientemente del volumen a partir del cual es insuflada. Por lo que cambios en la presión en la vía aérea reflejan modificaciones en las condiciones mecánicas del pulmón. El monitoreo avanzado podría reservarse para pacientes con incremento de la presión intra-abdominal en los que no pueda implementarse una estrategia de ventilación mecánica protectora. Las estimaciones de reclutamiento alveolar basadas en la mecánica del sistema respiratorio podrían ser reflejo del diferente comportamiento de la caja torácica a la insuflación y no verdadero reclutamiento alveolar.

Influencia de la caja torácica en el monitoreo de la mecánica respiratoria en síndrome de distrés respiratorio agudo / Chest wall effect on the monitoring of respiratory mechanics in acute respiratory distress syndrome

RESUMEN La mecánica del sistema respiratorio depende de las características del pulmón, la caja torácica y su interacción. En pacientes con síndrome de distrés respiratorio agudo bajo ventilación mecánica el monitoreo de la presión meseta en la vía aérea es fundamental debido a su valor pronóstico y su capacidad de reflejar el estrés pulmonar. Sin embargo, su validez puede verse afectada por cambios en las características mecánicas de la caja torácica, y además, no otorga información para la correcta titulación de presión positiva al final de la espiración en función de restablecer el volumen pulmonar. La influencia que la caja torácica ejerce sobre la mecánica del sistema respiratorio en síndrome de distrés respiratorio agudo no ha sido completamente descripta y es probable que haya sido sobredimensionada pudiendo conducir a toma de decisiones erróneas. Ante la insuflación con presión positiva al final de la espiración, la carga impuesta por la caja torácica es despreciable. En condiciones dinámicas, desplazar esta estructura demanda un cambio de presión cuya magnitud se relaciona con sus características mecánicas, dicha carga se mantiene constante independientemente del volumen a partir del cual es insuflada. Por lo que cambios en la presión en la vía aérea reflejan modificaciones en las condiciones mecánicas del pulmón. El monitoreo avanzado podría reservarse para pacientes con incremento de la presión intra-abdominal en los que no pueda implementarse una estrategia de ventilación mecánica protectora. Las estimaciones de reclutamiento alveolar basadas en la mecánica del sistema respiratorio podrían ser reflejo del diferente comportamiento de la caja torácica a la insuflación y no verdadero reclutamiento alveolar.

ABSTRACT The respiratory system mechanics depend on the characteristics of the lung and chest wall and their interaction. In patients with acute respiratory distress syndrome under mechanical ventilation, the monitoring of airway plateau pressure is fundamental given its prognostic value and its capacity to assess pulmonary stress. However, its validity can be affected by changes in mechanical characteristics of the chest wall, and it provides no data to correctly titrate positive end-expiratory pressure by restoring lung volume. The chest wall effect on respiratory mechanics in acute respiratory distress syndrome has not been completely described, and it has likely been overestimated, which may lead to erroneous decision making. The load imposed by the chest wall is negligible when the respiratory system is insufflated with positive end-expiratory pressure. Under dynamic conditions, moving this structure demands a pressure change whose magnitude is related to its mechanical characteristics, and this load remains constant regardless of the volume from which it is insufflated. Thus, changes in airway pressure reflect changes in the lung mechanical conditions. Advanced monitoring could be reserved for patients with increased intra-abdominal pressure in whom a protective mechanical ventilation strategy cannot be implemented. The estimates of alveolar recruitment based on respiratory system mechanics could reflect differences in chest wall response to insufflation and not actual alveolar recruitment.