Cuidados respiratorios en pacientes con atrofia muscular espinal para evitar el fallo ventilatorio agudo y la traqueostomía: revisión literaria y recomendaciones consensuadas / Respiratory care in patients with spinal muscular atrophy to avoid acute ventilatory failure and tracheostomy: literature review and consensus recommendations

La atrofia muscular espinal (AME) 5q es una de las enfermedades neuromusculares de mayor incidencia en la infancia. Sin embargo, la prevalencia de AME tipo 1, su forma más severa de presentación, es menor debido a muertes prematuras evitables antes de los dos años por insuficiencia ventilatoria subtratada. La irrupción de nuevos tratamientos modificadores de la enfermedad pueden cambiar dramáticamente este pronóstico y es una oportunidad para actualizar el manejo respiratorio, a través de cuidados estandarizados básicos, preferentemente no invasivos, abordando la debilidad de los músculos respiratorios, la insuficiencia tusígena y ventilatoria, con un enfoque preventivo. La siguiente revisión literaria entrega estrategias para evitar la intubación y la traqueostomía usando soporte ventilatorio no invasivo (SVN), reclutamiento de volumen pulmonar (RVP) y facilitación de la tos. Se analizan en detalle los protocolos de extubación en niños con AME tipo 1.

Spinal muscular atrophy (SMA) 5q is one of the neuromuscular diseases with the highest incidence in childhood. Nevertheless, the prevalence of its most severe form SMA1 is lower due to premature preventable deaths before two years of age related to ventilatory insufficiency undertreated. The emergence of new disease-modifying treatments can dramatically change this prognosis and is an opportunity to update respiratory management, through basic standardized care, mostly non-invasive, addressing respiratory muscles pump weakness, cough and ventilatory insufficiency with a preventive approach. This literature review provides consensus recommendations for strategies to avoid intubation and tracheostomy using noninvasive ventilatory support (NVS), lung volume recruitment (LVR), and cough facilitation. Extubation protocols in children with SMA type 1 are analyzed in detail.

Assessing the reproducibility and predictive value of objective cough measurement for successful withdrawal of invasive ventilatory support in adult patients.

BACKGROUND: Utilizing clinical tests, such as objective cough measurement, can assist in predicting the success of the weaning process in critically ill patients. METHODS: A multicenter observational analytical study was conducted within a prospective cohort of patients recruited to participate in COBRE-US. We assessed the capability of objective cough measurement to predict the success of the spontaneous breathing trial (SBT) and extubation. Intra- and inter-observer reproducibility of the cough test and was evaluated using the intraclass correlation coefficient (ICC) and Cohen's weighted kappa. We used receiver operating characteristic curves (ROC-curve) to evaluate the predictive ability of objective cough measurement. RESULTS: We recruited 367 subjects who were receiving invasive mechanical ventilation. A total of 451 objective cough measurements and 456 SBTs were conducted. A significant association was found between objective cough measurement and successful SBT (OR: 1.68; 95% CI 1.48-1.90; p = 0.001). The predictive capability of the objective cough test for SBT success had a ROC-curve of 0.58 (95% CI: 0.56-0.61). Objective cough measurement to predict successful extubation had a ROC-curve of 0.61 (95% CI: 0.56-0.66). The intraobserver reproducibility exhibited an ICC of 0.94 (95% CI: 0.89-0.96; p < 0.001), while the interobserver reproducibility demonstrated an ICC of 0.72 (95% CI: 0.51-0.85; p < 0.001). The intraobserver agreement, assessed using Cohen's weighted kappa was 0.94 (95% CI: 0.93-0.99; p < 0.001), whereas the interobserver agreement was 0.84 (95% CI: 0.67 - 0.10; p < 0.001). CONCLUSIONS: The objective measurement of cough using the method employed in our study demonstrates nearly perfect intra-observer reproducibility and agreement. However, its ability to predict success or failure in the weaning process is limited.

Chronic rhinosinusitis possibly associated with decreased lung function in chronic cough patients.

OBJECTIVES: The purpose of this study is to investigate the lung function in Chronic Rhinosinusitis (CRS) patients with Chronic Cough (CC). METHODS: A total of 1413 CC patients were retrospectively screened and 109 CRS patients with CC were enrolled. Lung function, Lund-Mackay Computed Tomography (CT) score, smoking status, peripheral blood eosinophil count, and immunoglobulin E concentration in serum samples, and Sino-Nasal Outcome Test were examined. Normal control subjects are also recruited. RESULTS: The Forced Expiratory Volume in 1 second (FEV1.0), Percent Predicted FEV1.0, and FEV1.0/Forced Vital Capacity (FVC) ratio in the patients were significantly low as compared with the control subjects. The FEV1.0/FVC ratio was negatively correlated with the Lund-Mackay CT scores of the patients with a high CT score. CONCLUSIONS: The CRS patients with CC should be investigated with lung function. In addition, the multidisciplinary evaluation including a pulmonologist is needed to manage the CRS patients with CC. LEVEL OF EVIDENCE: Level 4.

fim3-24/ptxP-3 genotype is associated to whooping cough outbreak in Brazilian Midwest: The selection of Bordetella pertussis strains driven by vaccine immunization.

Whopping cough (or Pertussis) is an acute infectious respiratory disease caused by Bordetella pertussis bacteria. The disease is highly transmissible and can be fatal in children under two years old. Since the introduction of vaccine immunization in 1940, Pertussis incidence decreased worldwide. In Brazil, the immunization was introduced in 1977 using the whole cell (wP) vaccine. Despite the high vaccination coverage, an unexpected increase in the number of observed Pertussis cases was observed in 2012. In this year, 2257 cases were reported exceeding the average incidence rate of <1000 cases per year until 2010. This outbreak reached a peak level in 2014 and ended in 2018 according to the Brazilian National Surveillance System (SINAN). To understand the relationship between the outbreak and the vaccination, bacterial isolates (n = 136) from the Brazilian Midwest region obtained during the outbreak were submitted to genotyping of two vaccine loci: ptxP and fim3. Most of isolates (102) were obtained from nursing children (29 days to 2 years old). Genotyping of 94 isolates revealed that fim3-24/ptxP-3 was the most prevalent genotype (68%) associated with the outbreak peak. Two additional genotypes were also observed: fim3-1/ptxP-3 (15%) and fim3-3/ptxP-3 (17%). Conversely, the fim3-1/ptxP-2 genotype, which is harbored by the strain used in the wP vaccine (Bp137), was not observed. These results showed that B. pertussis circulating strains in the outbreak analyzed were different from the strain used for Pertussis immunization in Brazil. These observations provide insights that could be used to target vaccination programs to prevent future whooping cough outbreaks in Brazil.

Novel vaccine candidates of Bordetella pertussis identified by reverse vaccinology.

Whooping cough is a disease caused by Bordetella pertussis, whose morbidity has increased, motivating the improvement of current vaccines. Reverse vaccinology is a strategy that helps identify proteins with good characteristics fast and with fewer resources. In this work, we applied reverse vaccinology to study the B. pertussis proteome and pangenome with several in-silico tools. We analyzed the B. pertussis Tohama I proteome with NERVE software and compared 234 proteins with B. parapertussis, B. bronchiseptica, and B. holmessi. VaxiJen was used to calculate an antigenicity value; our threshold was 0.6, selecting 84 proteins. The candidates were depurated and grouped in eight family proteins to select representative candidates, according to bibliographic information and their immunological response predicted with ABCpred, Bcepred, IgPred, and C-ImmSim. Additionally, a pangenome study was conducted with 603 B. pertussis strains and PanRV software, identifying 3421 core proteins that were analyzed to select the best candidates. Finally, we selected 15 proteins from the proteome study and seven proteins from the pangenome analysis as good vaccine candidates.

Metoprolol for prevention of bucking at orotracheal extubation: a double-blind, placebo-controlled randomised trial.

BACKGROUND: Respiratory responses to extubation can cause serious postoperative complications. Beta-blockers, such as metoprolol, can interfere with the cough pathway. However, whether metoprolol can effectively control respiratory reflexes during extubation remains unclear. The objective of this study is to evaluate the efficacy of intravenous metoprolol in attenuating respiratory responses to tracheal extubation. METHODS: Randomized, double-blinded, placebo-controlled trial. SETTING: Tertiary referral center located in Brasília, Brazil. Recruitment: June 2021 to December 2021. SAMPLE: 222 patients of both sexes with an American Society of Anesthesiologists (ASA) physical status I-III aged 18-80 years. Patients were randomly assigned to receive intravenous metoprolol 5 mg IV or placebo at the end of surgery. The primary outcome was the proportion of patients who developed bucking secondary to endotracheal tube stimulation of the tracheal mucosa during extubation. Secondary outcomes included coughing, bronchospasm, laryngospasm, Mean Blood Pressure (MAP), and Heart Rate (HR) levels. RESULTS: Two hundred and seven participants were included in the final analysis: 102 in the metoprolol group and 105 in the placebo group. Patients who received metoprolol had a significantly lower risk of bucking (43.1% vs. 64.8%, Relative Risk [RR = 0.66], 95% Confidence Interval [95% CI 0.51-0.87], p = 0.003). In the metoprolol group, 6 (5.9%) patients had moderate/severe coughing compared with 33 (31.4%) in the placebo group (RR = 0.19; 95% CI 0.08-0.43, p < 0.001). CONCLUSION: Metoprolol reduced the risk of bucking at extubation in patients undergoing general anesthesia compared to placebo.

Metoprolol for prevention of bucking at orotracheal extubation: a double-blind, placebo-controlled randomised trial

Abstract Background: Respiratory responses to extubation can cause serious postoperative complications. Beta-blockers, such as metoprolol, can interfere with the cough pathway. However, whether metoprolol can effectively control respiratory reflexes during extubation remains unclear. The objective of this study is to evaluate the efficacy of intravenous metoprolol in attenuating respiratory responses to tracheal extubation. Methods: Randomized, double-blinded, placebo-controlled trial. Setting: Tertiary referral center located in Brasília, Brazil. Recruitment: June 2021 to December 2021. Sample: 222 patients of both sexes with an American Society of Anesthesiologists (ASA) physical status I-III aged 18-80 years. Patients were randomly assigned to receive intravenous metoprolol 5 mg IV or placebo at the end of surgery. The primary outcome was the proportion of patients who developed bucking secondary to endotracheal tube stimulation of the tracheal mucosa during extubation. Secondary outcomes included coughing, bronchospasm, laryngospasm, Mean Blood Pressure (MAP), and Heart Rate (HR) levels. Results: Two hundred and seven participants were included in the final analysis: 102 in the metoprolol group and 105 in the placebo group. Patients who received metoprolol had a significantly lower risk of bucking (43.1% vs. 64.8%, Relative Risk [RR = 0.66], 95% Confidence Interval [95% CI 0.51-0.87], p = 0.003). In the metoprolol group, 6 (5.9%) patients had moderate/severe coughing compared with 33 (31.4%) in the placebo group (RR = 0.19; 95% CI 0.08-0.43, p < 0.001). Conclusion: Metoprolol reduced the risk of bucking at extubation in patients undergoing general anesthesia compared to placebo.

Exploring the Feasibility of a Comprehensive Screening for Voice and Swallowing Function in Post-Extubation Patients: A Pilot Study

Objectives: This pilot study aimed to identify and test a battery of time-efficient and cost-effective voice and swallowing screening tools for post-extubated patients in Chile. Methods: A panel of four experts selected and rated voice and swallowing screening tools. Seven measures were selected: smoothed cepstral peak prominence (CPPS) and maximum phonation time (MPT) for voice assessment, Volume-Viscosity Swallow Test (V-VST) for swallowing, voluntary and reflex peak cough flow for cough assessment, Eating Assessment Tool-10 (EAT-10), and Vocal Symptom Scale (VoiSS) for patient-reported outcomes. These tools were applied to four post-extubation patients within 48-72 hours post-hospital discharge, alongside the assessment of 17 matched controls. Results: Post-extubation patients showed significantly shorter MPT, lower CPPS values, increased V-VST dysphagia signs, reduced voluntary peak cough flow, and more pronounced symptoms on both the VoiSS and EAT-10 compared to controls. Limitations: The study had a modest sample size and relied solely on clinical screening tools. Value: This pilot study suggests a feasible and cost-effective approach to voice and swallowing screening for post-extubation patients, valuable in resource-constrained settings. Conclusion: While these accessible tools are not gold-standard assessments, they offer valuable insights and can guide future research. This study underscores the potential of selected tools in facilitating early detection of voice and swallowing disorders in post-extubation patients.

Objetivos: Este estudio piloto tuvo como objetivo identificar y probar una batería de herramientas de detección de problemas de voz y deglución que fueran eficientes en cuanto a tiempo y costo para pacientes chilenos postextubados. Métodos: Un panel de cuatro expertos seleccionó y evaluó herramientas de detección de voz y deglución. Se seleccionaron siete medidas: prominencia de pico cepstral suavizado (CPPS) y tiempo máximo de fonación (TMF) para la evaluación de la voz, prueba de volumen-viscosidad (V-VST) para la deglución, flujo máximo voluntario y reflejo de la tos para evaluar la tos, Eating Assessment Tool-10 (EAT-10) y la Escala de Sintomas Vocales (ESV) para los resultados informados por los pacientes. Estas herramientas se aplicaron a cuatro pacientes postextubados (48-72 horas), junto con la evaluación de 17 controles pareados. Resultados: Los pacientes postextubados mostraron un TMF y CPPS significativamente más bajos, aumento de los indicios de disfagia en la V-VST, reducción del flujo máximo de la tos y síntomas más pronunciados tanto en la ESV como en la EAT-10 en comparación con los controles. Limitaciones: El estudio tuvo un tamaño de muestra reducida y se basó únicamente en herramientas de detección clínica. Valor: Este estudio piloto sugiere un enfoque factible y rentable para la detección de problemas de voz y deglución en pacientes postextubados, valioso en entornos con recursos limitados. Conclusión: Aunque ese abordaje no sustituye a las evaluaciones de referencia, ofrece información valiosa y puede guiar futuras investigaciones que busquen facilitar la detección temprana de los trastornos de la voz-deglución en pacientes postextubados.

Utilization of spontaneous breathing trial, objective cough test, and diaphragmatic ultrasound results to predict extubation success: COBRE-US trial.

BACKGROUND: The results of clinical and weaning readiness tests and the spontaneous breathing trial (SBT) are used to predict the success of the weaning process and extubation. METHODS: We evaluated the capacity of the cuff leak test, rate of rapid and shallow breathing, cough intensity, and diaphragmatic contraction velocity (DCV) to predict the success of the SBT and extubation in a prospective, multicenter observational study with consecutive adult patients admitted to four intensive care units. We used receiver operating characteristic (ROC) curves to assess the tests' predictive capacity and built predictive models using logistic regression. RESULTS: We recruited 367 subjects who were receiving invasive mechanical ventilation and on whom 456 SBTs were performed, with a success rate of 76.5%. To predict the success of the SBT, we derived the following equation: (0.56 × Cough) - (0.13 × DCV) + 0.25. When the cutoff point was ≥ 0.83, the sensitivity was 91.5%, the specificity was 22.1%, and the overall accuracy was 76.2%. The area under the ROC curve (AUC-ROC) was 0.63. To predict extubation success, we derived the following equation: (5.7 × SBT) + (0.75 × Cough) - (0.25 × DCV) - 4.5. When the cutoff point was ≥ 1.25, the sensitivity was 96.8%, the specificity was 78.4%, and the overall accuracy was 91.5%. The AUC-ROC of this model was 0.91. CONCLUSION: Objective measurement of cough and diaphragmatic contraction velocity could be used to predict SBT success. The equation for predicting successful extubation, which includes SBT, cough, and diaphragmatic contraction velocity values, showed excellent discriminative capacity.

Maximal expiratory pressure compared with maximal expiratory pressure during induced cough as a predictor of extubation failure.

OBJECTIVE: To compare the diagnostic performance of maximal expiratory pressure with maximal expiratory pressure during induced cough for predicting extubation failure within 72 hours in patients who completed a spontaneous breathing trial (SBT). METHODS: The study was conducted between October 2018 and September 2019. All patients aged over 18 years admitted to the intensive care unit who required invasive mechanical ventilation for over 48 hours and successfully completed a spontaneous breathing trial were included. The maximal expiratory pressure was assessed with a unidirectional valve for 40 seconds, and verbal encouragement was given. The maximal expiratory pressure during induced cough was measured with slow instillation of 2mL of a 0.9% saline solution. The primary outcome variable was extubation failure. RESULTS: Eighty patients were included, of which 43 (54%) were male. Twenty-two patients [27.5% (95%CI 18.9 - 38.1)] failed extubation within 72 hours. Differences were observed in the maximal expiratory pressure during induced cough between the group who failed extubation, with a median of 0cmH2O (P25-75: 0 - 90), and the group without extubation failure, with a median of 120cmH2O (P25-75: 73 - 120); p < 0.001. CONCLUSION: In patients who completed a spontaneous breathing trial, the maximal expiratory pressure during induced cough had a higher diagnostic performance for predicting extubation failure within 72 hours.Clinicaltrials.gov Registry: NCT04356625.

Mecánica Tusígena / Cough Mechanics

El control neurológico de la tos o la neurofisiología de la tos, implica una serie de eventos complejos en el sistema nervioso que coordinan y desencadenan este reflejo protector pulmonar. Esta intrincada red de señales nerviosas y coordinación muscular se origina en los receptores de la tos, pasa por el centro de la tos en el bulbo raquídeo y finalmente activa los músculos necesarios para la adecuada eliminación del agente irritante. Este mecanismo involucra, la detección del estímulo por receptores especializados, transducción de señales que viajan a lo largo de fibras nerviosas aferentes hacia el sistema nervioso central, centro integrador a nivel del bulbo raquídeo, en el centro de la tos es donde se procesa las señales de los receptores y se coordina la respuesta. La integración de las señales y la respuesta radica en este centro de la tos y en la corteza cerebral quien regula y modula la tos. El control neuronal cortical de la tos implica la participación consciente y voluntaria de la corteza cerebral en la percepción, regulación y adaptación de la tos. La coordinación muscular requiere que la señal viaje por vías nerviosas eferentes motoras hacia los músculos involucrados, la contracción muscular se integra en una secuencia específica que desencadena las fases de la tos, inspiración máxima, compresión y expulsiva.

The neurological control of cough, or the neurophysiology of cough, involves a series of complex events in the nervous system that coordinate and trigger this lung protective reflex. This intricate network of nerve signals and muscle coordination originates from the cough receptors, passes through the cough center in the medulla oblongata, and finally activates the muscles necessary for proper elimination of the irritant. This mechanism involves the detection of the stimulus by specialized receptors, transduction of signals that travel along afferent nerve fibers towards the central nervous system, integrating center at the level of the medulla oblongata, in the cough center is where the signals are processed. receptors and the response is coordinated. The integration of signals and response resides in this cough center and in the cerebral cortex, which regulates and modulates coughing. Cortical neural control of cough involves the conscious and voluntary participation of the cerebral cortex in the perception, regulation, and adaptation of cough. Muscle coordination requires that the signal travel through efferent motor nerve pathways to the muscles involved; muscle contraction is integrated into a specific sequence that triggers the cough, maximum inspiration, compression, and expulsive phases.

Conocimiento y manejo de cuidados respiratorios especializados en pacientes con enfermedades neuromusculares en unidades de cuidado intensivo: aproximación por encuesta a profesionales de la salud

Introducción: En las enfermedades neuromusculares la disminución de la capacidad vital se relaciona con dismunición de la capacidad tusígena y luego ventilatoria, la combinación de ambas genera complicaciones graves por falla ventilatoria. En los pacientes que son intubados, limita la extubación, sino se realizan cuidados respiratorios especializados. El conocimiento y aplicación de los profesionales que atienden a estos pacientes en cuidados intensivos resulta esencial. Objetivos: Reportar el conocimiento y aplicación especializada de cuidados respiratorios en enfermedades neuromusculares en las Unidades de Cuidados Intensivos. Materiales y métodos: Estudio cualitativo, descriptivo de corte transversal, no probabilístico, a criterio. La población accesible fueron profesionales de la Salud de las Unidades de Cuidados Intensivos, y el análisis de las respuestas de una encuesta estructurada, enviada a distintos profesionales a nivel mundial. Resultados: Se incluyeron los cuestionarios de 41 profesionales, el 34% de los profesionales reportaron la utilización regular de Asistente Mecánico de la Tos; 22% refirieron la utilización regular de apilamiento de aire; 31% reportaron la utilización regular de Asistencia Ventilatoria No Invasiva, 56.1% de los profesionales afirmaron conocer la diferencia entre Ventilación No Invasiva y Soporte Ventilatorio No Invasivo, 34% de los profesionales refirieron tener formación especializada en el área. Conclusión: Pese a existir una alta proporción de profesionales con conocimiento especializado, un grupo importante no los aplica rutinariamente. La justificación es principalmente por la dificultad de adquisición y financiación de los equipos necesarios.

Introduction: In neuromuscular diseases, the decrease in vital capacity relates to decreased coughing and then ventilatory capacity, the combination of both generating serious complications due to ventilatory failure. In intubated patients, the extubation process is difficult unless specialized respiratory care is provided. The knowledge and treatment application of the professionals who care for these patients in intensive care is of outmost importance. Objectives: Report the knowledge and specialized application of respiratory care in neuromuscular diseases in Intensive Care Units. Materials and methods: Qualitative, descriptive, cross-sectional, non-probabilistic study, at criteria. The accessible population were Health professionals from the Intensive Care Units, and the analysis of the responses of a structured survey, sent to different professionals worldwide. Results: The questionnaires of 41 professionals were included, 34% of the professionals reported the regular use of the Mechanical Cough Assistant; 22% reported the regular use of air stacking; 31% reported the regular use of Non-Invasive Ventilatory Assistance. 56.1% of the professionals stated that they knew the difference between Non-Invasive Ventilation and Non-Invasive Ventilatory Support, 34% of the professionals reported having specialized training in the area. Conclusion: Despite the existence of a high proportion of professionals with specialized knowledge, an important group does not routinely apply them. The justification is mainly due to the difficulty of acquiring and financing the necessary equipment.

Conocimiento y manejo de cuidados respiratorios especializados en pacientes con enfermedades neuromusculares en unidades de cuidado intensivo: aproximación por encuesta a profesionales de la salud / Knowledge and management in specialized respiratory care of patients with neuromuscular diseases in intensive care units: survey to health professionals

Introducción: En las enfermedades neuromusculares la disminución de la capacidad vital se relaciona con disminución de la capacidad tusígena y luego ventilatoria, la combinación de ambas genera complicaciones graves por falla ventilatoria. En los pacientes que son intubados, limita la extubación, sino se realizan cuidados respiratorios especializados. El conocimiento y aplicación de los profesionales que atienden a estos pacientes en cuidados intensivos resulta esencial. Objetivos: Reportar el conocimiento y aplicación especializada de cuidados respiratorios en enfermedades neuromusculares en las Unidades de Cuidados Intensivos. Materiales y métodos: Estudio cualitativo, descriptivo de corte transversal, no probabilístico, a criterio. La población accesible fueron profesionales de la Salud de las Unidades de Cuidados Intensivos, y el análisis de las respuestas de una encuesta estructurada, enviada a distintos profesionales a nivel mundial. Resultados: Se incluyeron los cuestionarios de 41 profesionales, el 34% de los profesionales reportaron la utilización regular de Asistente Mecánico de la Tos; 22% refirieron la utilización regular de apilamiento de aire; 31% reportaron la utilización regular de Asistencia Ventilatoria No Invasiva, 56.1% de los profesionales afirmaron conocer la diferencia entre Ventilación No Invasiva y Soporte Ventilatorio No Invasivo, 34% de los profesionales refirieron tener formación especializada en el área. Conclusión: Pese a existir una alta proporción de profesionales con conocimiento especializado, un grupo importante no los aplica rutinariamente. La justificación es principalmente por la dificultad de adquisición y financiación de los equipos necesarios.

Introduction: In neuromuscular diseases, the decrease in vital capacity relates to decreased coughing and then ventilatory capacity, the combination of both generating serious complications due to ventilatory failure. In intubated patients, the extubation process is difficult unless specialized respiratory care is provided. The knowledge and treatment application of the professionals who care for these patients in intensive care is of outmost importance. Objectives: Report the knowledge and specialized application of respiratory care in neuromuscular diseases in Intensive Care Units. Materials and methods: Qualitative, descriptive, cross-sectional, non-probabilistic study, at criteria. The accessible population were Health professionals from the Intensive Care Units, and the analysis of the responses of a structured survey, sent to different professionals worldwide. Results: The questionnaires of 41 professionals were included, 34% of the professionals reported the regular use of the Mechanical Cough Assistant; 22% reported the regular use of air stacking; 31% reported the regular use of Non-Invasive Ventilatory Assistance. 56.1% of the professionals stated that they knew the difference between Non-Invasive Ventilation and Non-Invasive Ventilatory Support, 34% of the professionals reported having specialized training in the area. Conclusion: Despite the existence of a high proportion of professionals with specialized knowledge, an important group does not routinely apply them. The justification is mainly due to the difficulty of acquiring and financing the necessary equipment.

Menor aerolización con bloqueo del nervio laríngeo superior comparado con lidocaína intravenosa a la extubación / Less aerolization with superior laryngeal nerve block compared to intravenous lidocaine at extubation

Resumen: Introducción: La tos es una respuesta fisiológica de protección de la vía aérea, produce aerosoles que se identifican por imagen y alcanza una velocidad de hasta ocho metros por segundo. La extubación produce tos, hipertensión, taquicardia, apnea y laringoespasmo, existen métodos para minimizar su aparición. Debido a la pandemia de COVID-19 se han utilizado como profilaxis del reflejo tusígeno, la lidocaína intravenosa y el bloqueo del nervio laríngeo superior. El objetivo fue compararlos en la inhibición de la tos. Material y métodos: Se seleccionaron pacientes entre 18-60 años, cirugía electiva con anestesia general balanceada, ASA 1-3, con intubación menor a tres horas. Se aleatorizó un total de 90 pacientes, 45 en cada grupo, se eliminó un total de 10 pacientes por presentar inestabilidad hemodinámica al final de la cirugía o por no administrar dosis intravenosa de lidocaína en el tiempo establecido. Resultados: No hubo diferencia estadísticamente significativa en el número de pacientes que presentaron tos en ambos grupos (13 vs 10, p = 0.4684), de éstos se obtuvo una diferencia estadísticamente significativa en el número de decibeles a favor del grupo de bloqueo (75.6 vs 67, p < 0.001). Conclusiones: El bloqueo (selectivo) presenta menos aerolización que la lidocaína intravenosa en la extubación.

Abstract: Introduction: Coughing is a physiological response to protect the airway, it produces aerosols that are identified by imaging reaching a speed of up to 8 meters per second. Extubation produces cough, hypertension, tachycardia, apnea and laryngospasm, there are methods to minimize its occurrence. Due to the COVID-19 pandemic, intravenous lidocaine and superior laryngeal nerve block have been used as cough reflex prophylaxis. The aim was to compare them in cough inhibition. Material and methods: Patients aged 18-60 years, elective surgery with balanced general anesthesia, ASA 1-3, with intubation less than 3 hours, were selected. A total of 90 patients were randomized, 45 in each group. A total of 10 patients were eliminated because they presented hemodynamic instability at the end of surgery, and because the intravenous dose of lidocaine was not administered within the established time. Results: There was no statistically significant difference in the number of patients who presented cough in both groups (13 vs 10, p = 0.4684), of these there was a statistically significant difference in the number of decibels in favor of the block group (75.6 vs 67, p < 0.001). Conclusions: Block presents less aerolization than intravenous lidocaine in extubation.

Tratamiento quirúrgico del divertículo de Zenker; un caso clínico; Hospital Militar Central de La Paz (COSSMIL) gestión 2022 / Surgical treatment of Zenker's diverticulum, a Clinical Case Central Military Hospital of La Paz (COSSMIL) gestión 2022

Se presenta un caso clínico de una paciente de 66 años de edad masculino que acude a nuestro hospital (COOSMIL), después de hacer una anamnesis donde el paciente manifiestas molestias como tos, regurgitación y mal alientos (halitosis) y se le hace exámenes complementarios y se llega a un diagnóstico de divertículo faringo-esofágico o Zenker. Esta patología no es muy frecuente, pero se presenta en ancianos por una alteración anatomo-funcional que es un debilitamiento del músculo esofágico Hay tres divertículos esofágicos de los cuales el divertículo de Zenker es el más común aunque es relativamente raro que se presente, en la mayoría de las personas en edad seniles. Después de analizar el tamaño y forma del divertículo de este paciente se toma la decisión de una intervención quirúrgica el más acertado por el tamaño que mide es la diverticulectomia este tratamiento quirúrgico actualmente se continúa realizando en esta patología y con buen pronóstico de vida del paciente. Actualmente, el paciente se encuentra en buen estado salud y su recuperación es favorable desde la operación hasta el momento.

A case of a male patient of 66 years old was referred to our hospital (COSSMIL), after making an anamnesis in which the patient manifested cough, regurgitation and bad breath (halitosis). After further examination a the diagnosis is pharyngo-esophageal diverticulum or Zenker. This condition is rare, but sometimes it happens in elders due to an anatomical and functional alteration caused by is an esophagus muscle weakening. There are three esophageal diverticula in which the Zenker diverticulum is the most common but relatively rarely to occur in elder people. Before analyzing the size and shape of the diverticulum in this patient, the decision is proceed with surgery, the most recommended solution for measuring the size of the diverticulectomy. is The surgical treatment is still being applied in this pathology, with a high probability of success. Currently, the patient is in good health and the recovery from surgery is favorable so far.

CANVAS: una nueva etiología de la ataxia del adulto. La asociación con tos orienta al diagnóstico. Comunicación de 2 pacientes / Late-Onset Cerebellar Ataxia with Neuropathy: Uncovering the Role of RFC1 Gene Mutations

Presentamos dos pacientes no relacionados con ataxia cerebelosa de inicio tardío asociada con neuropatía y tos seca de larga data. Un paciente tenía dos hermanos afectados con neuropatía sensorial y tos. Ambos probandos tuvieron investigaciones extensas que incluyó pruebas genéticas negativas para las ataxias más comunes, así como pruebas paraneoplásicas y otras causas inmunológicas. Ambos pacientes mostraron una expansión intrónica anormal en el pentanucleótido AAGGG del gen RFC1. Esta etiología se informa como causa frecuente de ataxia de inicio en adultos; la presencia de tos puede conducir al diagnóstico correcto.

We report two unrelated patients with late-onset cerebellar ataxia associated with neuropathy and a long-standing dry cough. One patient had two siblings affected with sensory neuropathy and cough. Both probands had extensive investigations including genetics testing negative for most common ataxias as well as testing for paraneoplasic and other immunologic causes. Both patients showed an abnormal intronic expansion in the pentanucleotide AAGGG of the gene RFC1. This etiology is being reported as frequent cause of adult-onset ataxia; the presence of cough may lead to the correct diagnosis.

Comparative evaluation of the efficacy of different marbofloxacin-based products in pigs at the nursery, growth and finish phases with clinical signs of respiratory disease / Avaliação comparativa da eficácia de diferentes produtos à base de marbofloxacina em suínos nas fases de creche, crescimento e terminação com sinais clínicos de doenças respiratórias

Marbofloxacin is one of the antibiotics of choice for the treatment of pigs with clinical manifestations of respiratory disease. Some commercial products on the market contain this active ingredient, and the objective of this study was to evaluate the efficacy of 3 available marbofloxacin-based products based on the SISAAB (single injection and short-term antibiotic) concept with regard to the performance and health parameters of pigs in the nursery, growth and finish phases with clinical manifestations of respiratory disease (RD). A total of 78 animals with clinical manifestations of RD from a total of 1726 pigs were used. The animals that had RD symptoms were weighed, identified and randomly subjected to 3 treatments: T1 - Forcyl® (n = 27); T2 - Marbox® (n = 25); T3 - Resolutor® (n = 26). All treatments corresponded to a single intramuscular dose of 8 mg of marbofloxacin per kg of live weight. After treatment, clinical signs of cough and depression, water consumption, rectal temperature, performance parameters, lung lesions and the pneumonia index of the animals were evaluated. The animals that received T1 and T3 maintained a mean rectal temperature of 39.38 °C 2 days after administration. In contrast, animals in the group that received T2 had significantly higher temperatures (p = 0.068) in this period (39.53 °C). There was a greater decrease in temperature (p = 0.042) in the 24 hours after drug administration in animals that received T1 (-0.573 °C). Regarding the other performance parameters, clinical signs of cough and depression, water consumption, lung injury and the pneumonia index, no differences were observed between the marbofloxacin-based products evaluated (p > 0.05). All marbofloxacin-based products were effective in reducing the clinical signs of RD and promoting animal performance and health. However, T1 was more effective in reducing the rectal temperature of the animals.

A marbofloxacina é um dos antibióticos selecionados para o tratamento de suínos com manifestações clínicas de doenças respiratórias. Existem alguns produtos comerciais no mercado com este princípio ativo, nesse sentido, objetivou-se com esse trabalho avaliar, com base no conceito SISAAB (antibioticoterapia de curta duração e dose única), a eficiência de três marbofloxacinas disponíveis sobre os parâmetros de desempenho e saúde de suínos em fase de creche, crescimento e terminação com quadros clínicos de doenças respiratórias (DR). Foram utilizados 78 animais com manifestações clínicas de DR de um total de 1726 porcos. Os animais que apresentaram sintomas de DR foram pesados, identificados e submetidos aleatoriamente a 3 tratamentos: T1 - Forcyl® (n = 27); T2 - Marbox® (n = 25); T3 - Resolutor® (n = 26). Todos os tratamentos corresponderam a uma dose única intramuscular de 8 mg de marbofloxacina por kg de peso vivo. Após o tratamento, foram avaliados os sinais clínicos de tosse e depressão, consumo de água, temperatura retal, parâmetros de desempenho, lesões pulmonares e o índice de pneumonia dos animais. Os animais que receberam T1 e T3 mantiveram temperatura retal média de 39,38°C, 2 dias após a administração. Em contrapartida, os animais do grupo que recebeu T2 apresentaram temperaturas significativamente mais elevadas (p < 0,10) neste período (39,53 °C). Em linha, foi possível observar a maior diminuição de temperatura (p = 0,042) nas 24 horas após a aplicação da medicação nos animais do grupo T1 (-0,573 °C). Em relação aos demais parâmetros de desempenho, sinais clínicos de tosse e estado de depressão, consumo de água, lesões pulmonares e índice de pneumonia, não foram observadas diferenças entre as marboloxacinas avaliadas (p>0,05). Todas as marbofloxacinas foram eficazes na redução dos sinais clínicos de doenças respiratórias, promovendo o desempenho e saúde dos animais, entretanto foi constatada a maior eficiência de T1 na redução da temperatura retal dos animais.

Maximal expiratory pressure compared with maximal expiratory pressure during induced cough as a predictor of extubation failure / Comparação da pressão expiratória máxima e da pressão expiratória máxima durante a tosse induzida como preditor de falha na extubação

ABSTRACT Objective: To compare the diagnostic performance of maximal expiratory pressure with maximal expiratory pressure during induced cough for predicting extubation failure within 72 hours in patients who completed a spontaneous breathing trial (SBT). Methods: The study was conducted between October 2018 and September 2019. All patients aged over 18 years admitted to the intensive care unit who required invasive mechanical ventilation for over 48 hours and successfully completed a spontaneous breathing trial were included. The maximal expiratory pressure was assessed with a unidirectional valve for 40 seconds, and verbal encouragement was given. The maximal expiratory pressure during induced cough was measured with slow instillation of 2mL of a 0.9% saline solution. The primary outcome variable was extubation failure. Results: Eighty patients were included, of which 43 (54%) were male. Twenty-two patients [27.5% (95%CI 18.9 - 38.1)] failed extubation within 72 hours. Differences were observed in the maximal expiratory pressure during induced cough between the group who failed extubation, with a median of 0cmH2O (P25-75: 0 - 90), and the group without extubation failure, with a median of 120cmH2O (P25-75: 73 - 120); p < 0.001. Conclusion: In patients who completed a spontaneous breathing trial, the maximal expiratory pressure during induced cough had a higher diagnostic performance for predicting extubation failure within 72 hours. Clinicaltrials.gov Registry:NCT04356625

RESUMO Objetivo: Comparar o desempenho diagnóstico da pressão expiratória máxima com a pressão expiratória máxima durante a tosse induzida para prever a falha na extubação em 72 horas em pacientes que completaram o teste de respiração espontânea. Métodos: O estudo foi realizado entre outubro de 2018 e setembro de 2019. Foram incluídos todos os pacientes com mais de 18 anos admitidos à unidade de terapia intensiva que necessitavam de ventilação mecânica invasiva durante mais de 48 horas e completaram com sucesso o teste de respiração espontânea. A pressão expiratória máxima foi avaliada com uma válvula unidirecional durante 40 segundos, e foi dado encorajamento verbal. A pressão expiratória máxima durante a tosse induzida foi medida com instilação lenta de 2mL de solução salina a 0,9%. A variável do desfecho primário foi a falha na extubação. Resultados: Foram incluídos 80 pacientes, dos quais 43 (54%) eram do sexo masculino. Verificou-se falha na extubação de 22 pacientes [27,5% (IC95% 18,9 - 38,1)] em 72 horas. Observou-se diferença entre a pressão expiratória máxima durante a tosse induzida do grupo com falha na extubação, com mediana de 0cmH2O (P25-75 de 0 - 90) e do grupo sem falha na extubação, com mediana de 120cmH2O (P25-75 de 73 - 120), com p < 0,001. Conclusão: Em pacientes que completaram o teste de respiração espontânea, a pressão expiratória máxima durante a tosse induzida apresentou melhor desempenho diagnóstico para prever falha na extubação em 72 horas. Registro Cliniclatrials.gov:NCT04356625

Impact of topical airway anesthesia on immediate postoperative cough/bucking: a systematic review and meta-analysis

Abstract Background Postoperative cough may occur after tracheal intubation, but it is indistinct which drug is best at diminishing these events. Additionally, airway reflexes are commonly accompanied by severe hemodynamics responses during emergence. Objectives To evaluate the role of topical airway anesthesia on immediate post-extubation cough/bucking and extubation time. Methods Randomized clinical trials from MEDLINE, EMBASE, CENTRAL, and LILACS published until December 23, 2020 were included. Our primary outcome was postoperative cough/bucking incidence which was compared between local anesthetics and controls. Extubation times were likewise considered. Predisposition appraisal and subgroup, affectability investigations were likewise performed. Results The pooled analysis found a 45% reduction in cough incidence after treatment with topical airway local anesthetic (RR = 0.55; 95% CI: 0.42 to 0.72; p< 0.001). The number needed to treat (NNT) was 4.61. The intervention showed no differences in reduction of the extubation time (mean difference = -0.07; 95% CI: -0.14 to 0.28; p= 0.49). Conclusion Topical airway anesthesia demonstrated better than placebo or no medication in reducing immediate post-extubation cough/bucking. Further studies could have this objective to combine the different ways to perform better outcomes for patients.