Lesión pulmonar aguda producida por transfusión (TRALI): Reporte de caso / Transfusion-induced acute lung injury (TRALI): Case report

Introducción: La lesión pulmonar aguda (TRALI) y la sobrecarga circulatoria (TACO) son las principales causas de morbilidad y mortalidad relacionadas con la transfusión. La TRALI se presenta durante o después de las transfusiones de plasma y sus derivados, o por inmunoglobulinas en alta concentración intravenosa; se asocia a procesos sépticos, cirugías y transfusiones masivas. La TACO es la exacerbación de manifestaciones respiratorias en las primeras 6 horas postransfusión. Reporte caso: Paciente de sexo masculino de 38 días de vida, ingresó al servicio de urgencias con un cuadro clínico de 8 días de evolución, caracterizado por dificultad respiratoria dado por retracciones subcostales y aleteo nasal sin otro síntoma asociado, con antecedentes de importancia de prematuridad y bajo peso al nacer. El reporte de hemograma arrojó cifras compatibles con anemia severa, por lo que requirió transfusión de glóbulos rojos empaquetados desleucocitados. El paciente presentó un cuadro respiratorio alterado en un periodo menor a 6 horas, por lo que se descartaron causas infecciosas y finalmente se consideró cuadro compatible con TRALI. Conclusiones: Se debe considerar una lesión pulmonar aguda relacionada con una transfusión de sangre si se produce una insuficiencia respiratoria aguda durante o inmediatamente después de la infusión de hemoderivados que contienen plasma.

Introduction: Acute lung injury (TRALI) and circulatory overload (TACO) are the main causes of transfusion-related morbidity and mortality. TRALI occurs during or after transfusions of plasma or its derivatives, or by immunoglobulins in high intravenous concentration; it is associated with septic processes, surgeries, and massive transfusions. TACO is the exacerbation of respiratory manifestations in the first 6 hours post transfusion. Case report: A 38-day-old male was admitted to the emergency department with clinical symptoms experienced over the course of 8 days and characterized by respiratory distress due to subcostal retractions and nasal flaring with no other associated symptoms. Important antecedents included prematurity and low birth weight. The hemogram report showed figures compatible with anemia, which benefited from transfusion of packed red blood cells without leukocytes. In a period of less than 6 hours, the patient presented altered respiratory symptoms, practitioners ruled out infectious causes and finally considered clinical signs compatible with TRALI. Conclusion: Acute lung injury related to blood transfusion should be considered if acute respiratory failure occurs during or immediately after infusion of plasma-containing blood products.

Control de la ventilación y regulación del estado ácido-base del pez al hombre / Control of ventilation and regulation of acid-base status from fish to man

RESUMEN Este artículo analiza ciertos aspectos evolutivos en el intercambio gaseoso, el desa rrollo pulmonar, la bomba respiratoria, el estado ácido-base y el control de la ventila ción en relación con un evento trascendente: el pasaje de la vida acuática a la terres tre. Su estudio puede permitir comprender ciertos aspectos con los que lidiamos en la práctica clínica: ¿Por qué las personas con debilidad muscular respiratoria extrema respiran como ranas (respiración frog)?, ¿Por qué los recién nacidos con dificultad respiratoria tienen aleteo nasal y quejido espiratorio?, ¿cómo es posible que los mús culos abdominales, típicamente espiratorios, asistan a la inspiración en casos de la parálisis diafragmática?, ¿por qué en la insuficiencia respiratoria el patrón respiratorio tiene menos variabilidad y se torna más rígido? y, por último, ¿es posible imaginar un pH neutro que no tenga el valor de 7,0, para qué sirve este conocimiento y como se deben interpretar los gases en hipotermia? La transición del agua a la tierra es una de las más importantes e inspiradoras de las grandes transiciones en la evolución de los vertebrados. Ante la sorprendente diversi dad de organismos vivos, es tentador imaginar una cantidad enorme de adaptaciones evolutivas para resolver los diferentes desafíos que cada especie tiene para la vida en la tierra. Hay desarrollos tempranos que comparten algunos factores cruciales y algunas de las redes genéticas regulatorias cercanas y lejanas están conservadas. Somos testigos de hallazgos clínicos que son el testimonio de especies que han vivido en épocas remotas y nos han legado su historia evolutiva.

ABSTRACT This article analyzes certain evolutionary aspects of gas exchange, lung development, the respiratory pump, the acid-base status and control of ventilation in relation to a significant event: the passing from aquatic to terrestrial life. By studying this, we can understand certain aspects that are present in the clinical practice: Why do people with extreme respiratory muscle weakness breathe as frogs? (frog breathing); why do newborns with breathing difficulties have nasal flaring and expiratory grunting?; how is it possible that abdominal muscles, which are typically expiratory, assist with inspira tion in cases of diaphragmatic paralysis?; why does the breathing pattern of respiratory failure has less variability and becomes more rigid? and, finally, is it possible to imagine a neutral pH that doesn't have the 7.0 value?; what's the use of this knowledge, and how should gases in hypothermia be interpreted? Water-to-land transition is one of the most important and inspiring major transitions of vertebrate evolution. Given the amazing diversity of living organisms, it is tempting to imagine an enormous amount of evolutionary adaptation processes to solve the different challenges of living on earth faced by each species. There are certain early development processes that share some crucial factors, and some of the close and distant gene regulatory networks are conserved. We are witnesses of clinical findings that serve as testimony of the species that lived in remote times and left us their evo lutionary history.

Hiperplasia de células neuroendocrinas: reporte de caso / Neuroendocrine cell hyperplasia: case report

A clinical case of Neuroendocrine Cell Hyperplasia is presented with a bibliographic review. An infant patient with respiratory distress syndrome, characterized by nasal flaring, retractions, and tachypnea with temporary resolution with the use of bronchodilators. However, the patient requires oxygen. With complementary examinations (negative viral panel twice) and epidemiology it is classified as a viral Bronchiolitis. Without improvement, extrapulmonar pathologies were suspected, discarding hearth disease, epilepsy, pathological gastroesophageal reflux. New tests were performed to rule out other pathologies, including immunological disorders. Those results were normal, so a high-resolution chest tomography was done which allowed the diagnosis of Neuroendocrine Cell Hyperplasia. During the follow up the child had improved and required oxygen until he was two years old. Neuroendocrine Cell Hyperplasia belongs to a huge group of less common interstitial disorders, which diagnosis is clinical and radiological. It can easily be confused with common respiratory disorders. For this reason, it is important to know about this disease to make an early diagnosis. Most of the cases had a gradual (months to years) improvement.

Se presenta un caso clínico de Hiperplasia de Células Neuroendocrinas y la revisión de la literatura. Paciente lactante menor con cuadro de dificultad respiratoria, caracterizado por aleteo nasal, retracciones y taquipnea persistente acompañada de desaturación. Sin adecuada respuesta al uso de broncodilatadores. Por exámenes complementarios, panel viral negativo en dos ocasiones y epidemiología, se le diagnostica una bronquiolitis viral. Por no presentar mejoría se completan estudios, descartándose neumonía atípica, cardiopatía, epilepsia, reflujo gastroesofágico patológico y compromiso inmunológico. El diagnóstico fue determinado en base a la clínica, junto con imágenes en vidrio esmerilado característicos en lóbulo medio y língula. En su seguimiento mejora paulatinamente, requiriendo soporte de oxígeno hasta los dos años. La Hiperplasia de Células Neuroendocrinas es una patología intersticial pulmonar poco frecuente, cuyo diagnóstico es clínico y radiológico. Puede ser fácilmente confundida con desórdenes respiratorios comunes, por lo que es importante sospecharla para realizar un diagnóstico precoz. La mayor parte de los casos evolucionan con declinación de los síntomas, mejorando espontáneamente en meses o en los primeros años de vida.

Conocimiento de los cuidadores de los niños con diagnóstico de bronquiolitis ingresados en el Hospital Nacional de Niños / Knowledge of caregivers of children with diagnosis of bronchiolitis hospitalized in at the National Children's Hospital

Resumen Justificación y objetivo: La bronquiolitis representa la causa más importante de infección respiratoria de vías inferiores durante el primer año de vida, y la razón más importante de hospitalizaciones más allá del periodo neonatal. Usualmente, se asocia con costos substanciales directos e indirectos, tanto para el sistema de salud como para las familias y la sociedad. El desconocimiento por partede los encargados de la enfermedad puede tener dos consecuencias: el mal uso de los servicios de salud llenando los servicios de emergencias y la atención tardía. Este estudio buscó identificar los conocimientos basales que poseen los cuidadores de los niños con bronquiolitis, con el fin de detectar las deficiencias y fortalezas de la educación brindada por nuestro sistema de salud. Métodos: Se realizó un estudio transversal, basado en encuesta brindada a 256 cuidadores de niños con bronquiolitis. Para el cálculo muestral se utilizó el programa de Win episcope, con una potencia del 80 % y un nivel alfa de 0,05, basados en un 30 % de prevalencia de bronquiolitis en la población general menor de 2 años; obtenidos los datos, se realizó su análisis descriptivo. Resultados: La edad promedio de los cuidadores fue de 27,3 años (DE 7,6 años) y la edad promedio de los niños hospitalizados fue de 5,7 meses (DE 5,4 meses). El cuidador primario en el 91,5 % de los casos era la madre. En cuanto a nivel académico, un 60 % de la población tenía estudios secundarios inconclusos y del 40 % restante, solo el 17,8 % obtuvo un título universitario. El 25 % de los cuidadores reportó que los niños tenían exposición a fumado pasivo. En cuanto al conocimiento basal sobre la bronquiolitis, el 95 % indicó que se debe a un virus; el 89,4 %, a transmisión principalmente por vía aérea. Entre los síntomas de inicio de la enfermedad, se indicó: fiebre, 88,9 %; irritabilidad, 87,5 %, y rinorrea, 61,2 %. Sobre datos de empeoramiento, el 99,6 % identificó la dificultad para respirar y el 82,1 %, problemas para alimentarse. Con respecto al tratamiento, el 45,3 % de la población afirmó que la bronquiolitis siempre amerita antibióticos. Además, se obtuvo un alto conocimiento de medidas preventivas, como lavado de manos (98,7 %), no exposición a tabaco (94,8 %) y estornudar con técnica correcta (93,7 %). Por otro lado, el conocimiento de los signos de alarma fue deficiente: el aleteo nasal y la cianosis mostraron porcentajes cercanos al 50 %, seguidos por taquipnea, retracciones y, en último lugar, la poca respuesta al medio. Sobre los métodos de información sugeridos, un 44,8 % indicó carteles y panfletos, un 22,9 %, charlas y talleres, un 18,8 % medios de comunicación y revistas, un 11,5 % redes sociales y un 2,1 % información verbal por parte del médico. Conclusión: La población del estudio presentó un alto conocimiento sobre la etiología, transmisión, síntomas de inicio, datos de empeoramiento y medidas preventivas de la bronquiolitis. Las áreas de conocimiento más deficientes fueron: tiempo promedio de duración, tratamiento, factores de riesgo del niño para complicaciones y datos de alarma para reconsultar al Servicio de Emergencias. Se debe hacer énfasis en la información más útil a la hora del egreso y además de reforzar la educación verbal, es preciso apoyarse de otros métodos sugeridos por la población.

Abstract Background and aim: Bronchiolitis represents the most important cause of lower respiratory tract infection during the first year of life and the most important reason for hospitalizations beyond the neonatal period. It is usually associated with substantial direct and indirect costs, both for the health system and for families and society. The lack of knowledge on the part of those in charge of the disease can have two consequences: the misuse of health services, filling emergency services or late consultation. This study sought to identify the baseline knowledge that the caregivers of children with bronchiolitis possess, in order to detect the deficiencies and strengths of the education provided by our health system. Methods: A cross-sectional study was conducted, based on a survey of 256 caregivers of children with bronchiolitis. For the sample calculation, the Win episcope program was used, with a power of 80% and an alpha level of 0.05 and based on a 30% prevalence of bronchiolitis in the general population younger than 2 years; once the data was obtained, a descriptive analysis of these was performed. Results: The average age of caregivers was 27.3 years (SD 7.6 years) and the average age of hospitalized children was 5.7 months (SD 5.4 months). The primary caregiver in 91.5% of the cases was the mother. With regard to the academic level, 60% of the population had unfinished secondary education and of the remaining 40% only 17.8% obtained a university degree. 25% of caregivers reported that children had exposure to passive smoking. Regarding baseline knowledge about bronchiolitis, 95% indicated that it is due to a virus; 89.4% transmission mainly by air. Of the symptoms of disease onset, fever 88.9%, irritability 87.5% and rhinorrhea 61.2% were indicated. On data of worsening, 99.6% identified the difficulty in breathing and 82.1% problems in feeding. With respect to treatment, 45.3% of the population stated that bronchiolitis always merits antibiotics. In addition, we obtained a high knowledge of preventive measures: hand washing 98.7%, no exposure to tobacco 94.8%, sneeze with correct technique 93.7%. On the other hand, knowledge of the warning signs was poor: nasal flutter and cyanosis showed percentages close to 50%, followed by tachypnea, retractions and ultimately the poor response to the environment. Regarding the suggested information methods, 4.8% indicated posters and pamphlets, 22.9% talks and workshops, 18.8% media and magazines, 11.5% social networks and 2.1% verbal information from the doctor. Conclusion: The study population presented a high level of knowledge about the etiology, transmission, symptoms of onset, worsening data and preventive measures of bronchiolitis. The most deficient areas of knowledge were average duration, treatment, risk factors for complications and alarm signs to consult the emergency service. Emphasis should be placed on the most useful information at the time of discharge, in addition to strengthening verbal education, it is important to rely on other methods suggested by the population to better transmit the information.

Community-acquired pneumonia among children: the latest evidence for an updated management / Pneumonia adquirida na comunidade em crianc¸as: as evidências mais recentes para um manejo atualizado

Abstract Objective To provide cutting-edge information for the management of community-acquired pneumonia in children under 5 years, based on the latest evidence published in the literature. Data source A comprehensive search was conducted in PubMed, by using the expressions: "community-acquired pneumonia" AND "child" AND "etiology" OR "diagnosis" OR "severity" OR "antibiotic". All articles retrieved had the title and the abstract read, when the papers reporting the latest evidence on each subject were identified and downloaded for complete reading. Data synthesis In the era of largely implemented bacterial conjugate vaccines and widespread use of amplification nucleic acid techniques, respiratory viruses have been identified as the most frequent causative agents of community-acquired pneumonia in patients under 5 years. Hypoxemia (oxygen saturation ≤96%) and increased work of breathing are signs most associated with community-acquired pneumonia. Wheezing detected on physical examination independently predicts viral infection and the negative predictive value (95% confidence interval) of normal chest X-ray and serum procalcitonin <0.25 ng/dL was 92% (77-98%) and 93% (90-99%), respectively. Inability to drink/feed, vomiting everything, convulsions, lower chest indrawing, central cyanosis, lethargy, nasal flaring, grunting, head nodding, and oxygen saturation <90% are predictors of death and can be used as indicators for hospitalization. Moderate/large pleural effusions and multilobar infiltrates are predictors of severe disease. Orally administered amoxicillin is the first line outpatient treatment, while ampicillin, aqueous penicillin G, or amoxicillin (initiated initially by intravenous route) are the first line options to treat inpatients. Conclusions Distinct aspects of childhood community-acquired pneumonia have changed during the last three decades.

Resumo Objetivo Fornecer informações de ponta para o manejo de crianças menores de cinco anos com pneumonia adquirida na comunidade, com base nas evidências mais recentes publicadas na literatura. Fonte de dados Uma pesquisa abrangente foi feita no PubMed, com as expressões: "community-acquired pneumonia" + "child" + "etiology" ou "diagnosis" ou "severity" ou "antibiotic". Todos os artigos encontrados tiveram o título e o resumo lidos e os artigos que relatavam as evidências mais recentes sobre cada assunto foram identificados e recuperados para leitura completa. Síntese dos dados Na era das vacinas bacterianas conjugadas amplamente usadas e do uso difundido de técnicas de amplificação de ácidos nucléicos, os vírus respiratórios foram identificados como os agentes causadores mais frequentes de pneumonia adquirida na comunidade em pacientes com menos de cinco anos. A hipoxemia (saturação de oxigênio ≤ 96%) e o aumento do esforço respiratório são os sinais mais associados à pneumonia adquirida na comunidade. A sibilância detectada ao exame físico prediz de forma independente a infecção viral e o valor preditivo negativo (intervalo de confiança de 95%) da radiografia de tórax normal e a procalcitonina sérica < 0,25 ng/dL foi de 92% (77-98%) e 93% (90-99%), respectivamente. Incapacidade de beber e se alimentar, vomitar todo o alimento, convulsões, retração torácica subcostal, cianose central, letargia, aleteo nasal, estridor e saturação de oxigênio < 90% são preditores de óbito e podem ser usados como indicadores de hospitalização. Derrames pleurais moderados/grandes e infiltrados multilobulares são preditores de doença grave. A amoxicilina administrada por via oral é a opção de primeira linha para tratar pacientes ambulatoriais e a ampicilina ou penicilina cristalina G ou amoxicilina (administrada inicialmente por via intravenosa) são as opções de primeira linha para tratar pacientes hospitalizados. Conclusões Aspectos distintos da pneumonia adquirida na comunidade durante a infância mudaram durante as últimas três décadas.

The Effect of Positive Airway Pressure Treatment of Obstructive and Central Sleep Apnea on the Recurrence of Atrial Fibrillation/Flutter Postintervention.

STUDY OBJECTIVES: A strong association between sleep-disordered breathing (SDB) and atrial fibrillation and/or atrial flutter (AF) has consistently been observed in epidemiologic and interventional studies. The effect of positive airway pressure (PAP) on AF recurrence is inconclusive. This study sought to evaluate the effectiveness of PAP therapy for SDB on AF recurrence. METHODS: This was a single-center, retrospective study conducted at a tertiary referral center. All adult patients who had SDB on polysomnography and underwent AF intervention (ablation or cardioversion) following polysomnography from January 1992-December 2014 were analyzed. Primary outcome was time to first-documented recurrence of AF after AF intervention by Kaplan-Meier estimates. RESULTS: Among 30,188 patients with obstructive and central SDB, 429 had this diagnosis before AF intervention; 269 were "PAP-adherent users," the remaining 160 were "PAP-nonusers." Patients in both groups had similar age, sex, body mass index (BMI), ejection fraction, left atrial volume index (LAVI), antiarrhythmic medications, diabetes mellitus, systemic hypertension, and heart failure diagnoses. Time to recurrence of AF postintervention was no different in PAP-adherent users and nonusers (4.8 and 4.1 months respectively, P = .7). Cardioversion (compared to catheter ablation) was the strongest independent predictor of recurrent AF (hazard ratio [HR] 2.02, 95% confidence interval [CI] 1.39-2.94, P < .001). BMI and LAVI were also significant predictors of recurrence in adjusted analyses (HR 1.01, 95% CI 1.003-1.023, P = .10 and HR 1.01, 95% CI 1.001-1.019, P = .024 respectively). CONCLUSIONS: Our study found no effect of PAP treatment of SDB on time to recurrence of AF post-AF intervention. Increased risk of recurrent AF was associated with high BMI and LAVI. These findings may affect the clinical management of AF.

Aleteo nasal como factor pronóstico de mortalidad en el paciente con disnea grave / Nasal flaring as a predictor of mortality in patients with severe dyspnea

Objetivos: Determinar si la presencia de aleteo nasal es un factor de gravedad clínica y pronóstico de mortalidad hospitalaria en el paciente que consulta en urgencias por disnea. Método: Estudio prospectivo observacional un céntrico. Se incluyeron pacientes mayores de 15 años, que demandaron atención urgente por disnea, catalogados como niveles II y III por el Modelo Andorrano de Triaje (MAT). Se evaluó la presencia de aleteo nasal por dos observadores. Se recogieron variables demográficas, clínicas, signos de dificultad respiratoria, signos vitales, gasometría arterial y evolución clínica (ingreso hospitalario y mortalidad). Se realizaron análisis bivariantes y multivariantes con modelos de regresión logística. Resultados: Se incluyeron 246 pacientes, de edad media ± DE 77 (13) años (DE: 13,2) y un 52% de mujeres. Un19,5% presentaron aleteo nasal. Los pacientes con aleteo nasal tuvieron mayor gravedad en el triaje, más taquipnea, peor oxigenación, más acidosis y más hipercapnia. En el análisis bivariante los factores pronósticos de mortalidad hospitalaria fueron la edad (OR 1,05; IC95%: 1,01-1,10), la atención prehospitalaria por el servicio emergencias médicas (OR 3,97; IC95%: 1,39-11,39), el nivel de triaje II (OR 4,19; IC95%: 1,63-10,78), la presencia de signos de dificultad respiratoria como el aleteo nasal (OR 3,79; IC 95%: 1,65-8,69), la presencia de acidosis (OR 7,09; IC95%: 2,97-16,94) y la hipercapnia (OR 2,67; IC95%: 1,11-6,45). En el análisis multivariante, la edad, el nivel de triaje y el aleteonasal se mantuvieron como factores pronósticos independientes de mortalidad (AU)

Objective: To determine whether the presence of nasal flaring is a clinical sign of severity and a predictor of hospital mortality in emergency patients with dyspnea. Methods: Prospective, observational, single-center study. We enrolled patients older than 15 years of age who required attention for dyspnea categorized as level II or III emergencies according to the Andorran Medical Triage system. Two observers evaluated the presence of nasal flaring. We recorded demographic and clinical variables, including respiratory effort, vital signs, arterial blood gases, and clinical course (hospital admission and mortality). Bivariable analysis was performed and multivariable logistic regression models were constructed. Results: We enrolled 246 patients with a mean (SD) age of 77 (13) years; 52% were female. Nasal flaring was present in 19.5%. Patients with nasal flaring had triage levels indicating greater severity and they had more severe tachypnea, worse oxygenation, and greater acidosis and hypercapnia. Bivariable analysis detected that the following variables were associated with mortality: age (odds ratio [OR], 1.05; 95% CI, 1.01–1.10), prehospital care from the emergency medical service (OR, 3.97; 95% CI, 1.39–11.39), triage level II (OR, 4.19; 95% CI, 1.63–10.78), signs of respiratory effort such as nasal flaring (OR, 3.79; 95% CI, 1.65–8.69), presence of acidosis (OR, 7.09; 95% CI, 2.97–16.94), and hypercapnia (OR, 2.67; 95% CI, 1,11–6,45). The factors that remained independent predictors of mortality in the multivariable analysis were age, severity (triage level), and nasal flaring. Conclusions: In patients requiring emergency care for dyspnea, nasal flaring is a clinical sign of severity and a predictor of mortality (AU)

[Nasal flaring as a predictor of mortality in patients with severe dyspnea]. / Aleteo nasal como factor pronóstico de mortalidad en el paciente con disnea grave.

OBJECTIVES: To determine whether the presence of nasal flaring is a clinical sign of severity and a predictor of hospital mortality in emergency patients with dyspnea. MATERIAL AND METHODS: Prospective, observational, single-center study. We enrolled patients older than 15 years of age who required attention for dyspnea categorized as level II or III emergencies according to the Andorran Medical Triage system. Two observers evaluated the presence of nasal flaring. We recorded demographic and clinical variables, including respiratory effort, vital signs, arterial blood gases, and clinical course (hospital admission and mortality). Bivariable analysis was performed and multivariable logistic regression models were constructed. RESULTS: We enrolled 246 patients with a mean (SD) age of 77 (13) years; 52% were female. Nasal flaring was present in 19.5%. Patients with nasal flaring had triage levels indicating greater severity and they had more severe tachypnea, worse oxygenation, and greater acidosis and hypercapnia. Bivariable analysis detected that the following variables were associated with mortality: age (odds ratio [OR], 1.05; 95% CI, 1.01-1.10), prehospital care from the emergency medical service (OR, 3.97; 95% CI, 1.39-11.39), triage level II (OR, 4.19; 95% CI, 1.63-10.78), signs of respiratory effort such as nasal flaring (OR, 3.79; 95% CI, 1.65-8.69), presence of acidosis (OR, 7.09; 95% CI, 2.97-16.94), and hypercapnia (OR, 2.67; 95% CI, 1,11-6,45). The factors that remained independent predictors of mortality in the multivariable analysis were age, severity (triage level), and nasal flaring. CONCLUSION: In patients requiring emergency care for dyspnea, nasal flaring is a clinical sign of severity and a predictor of mortality.

OBJETIVO: Determinar si la presencia de aleteo nasal es un factor de gravedad clínica y pronóstico de mortalidad hospitalaria en el paciente que consulta en urgencias por disnea. METODO: Estudio prospectivo observacional unicéntrico. Se incluyeron pacientes mayores de 15 años, que demandaron atención urgente por disnea, catalogados como niveles II y III por el Modelo Andorrano de Triaje (MAT). Se evaluó la presencia de aleteo nasal por dos observadores. Se recogieron variables demográficas, clínicas, signos de dificultad respiratoria, signos vitales, gasometría arterial y evolución clínica (ingreso hospitalario y mortalidad). Se realizaron análisis bivariantes y multivariantes con modelos de regresión logística. RESULTADOS: Se incluyeron 246 pacientes, de edad media ± DE 77 (13) años (DE: 13,2) y un 52% de mujeres. Un 19,5% presentaron aleteo nasal. Los pacientes con aleteo nasal tuvieron mayor gravedad en el triaje, más taquipnea, peor oxigenación, más acidosis y más hipercapnia. En el análisis bivariante los factores pronósticos de mortalidad hospitalaria fueron la edad (OR 1,05; IC95%: 1,01-1,10), la atención prehospitalaria por el servicio emergencias médicas (OR 3,97; IC95%: 1,39-11,39), el nivel de triaje II (OR 4,19; IC95%: 1,63-10,78), la presencia de signos de dificultad respiratoria como el aleteo nasal (OR 3,79; IC 95%: 1,65-8,69), la presencia de acidosis (OR 7,09; IC95%: 2,97- 16,94) y la hipercapnia (OR 2,67; IC95%: 1,11-6,45). En el análisis multivariante, la edad, el nivel de triaje y el aleteo nasal se mantuvieron como factores pronósticos independientes de mortalidad. CONCLUSIONES: El aleteo nasal es un signo clínico de gravedad y predictor de mortalidad en los pacientes que demandan atención urgente por disnea.

Obstructive sleep apnea in patients with typical atrial flutter: prevalence and impact on arrhythmia control outcome.

BACKGROUND: The clinical yield of cavotricuspid isthmus (CTI) radiofrequency ablation of atrial flutter (AF) is limited by a high incidence of atrial fibrillation (AFib) in the long term. Among other acknowledged variables, the association of obstructive sleep apnea (OSA) could favor incomplete arrhythmia control in this setting. We assessed the impact of CPAP in reducing the occurrence of AFib after CTI ablation. METHODS: Consecutive patients with AF who were undergoing CTI ablation were screened for OSA. Relationship of the following variables with the occurrence of AFib during follow-up (12 months) was investigated: CPAP initiation, hypertension, BMI, underlying structural heart disease, left atrial diameter, and AFib documentation prior to ablation. RESULTS: We prospectively included 56 patients (mean age: 66 (± 11) years; 12 female patients), of whom 46 (82%) had OSA and 25 (45%) had severe OSA. Twenty-one patients (38%) had AFib during follow-up after CTI ablation. Both freedom from AFib prior to ablation and CPAP initiation in those patients without previously documented AFib at inclusion were associated with a reduction of AFib episodes during follow-up (P = .019 and P = .025, respectively). Inversely, CPAP was not protective from AFib recurrence when this arrhythmia was documented prior to ablation (P = .25). CONCLUSIONS: OSA is a prevalent condition in patients with AF. Treatment with CPAP is associated with a lower incidence of newly diagnosed AFib after CTI ablation. Screening for OSA in patients with AF appears to be a reasonable clinical strategy.

Ventilación mecánica no invasiva y acciones de enfermería en pacientes con pulmón húmedo traumático / Non-invasive mechanical ventilation and nursing actions in patients with traumatic wet lung

Se realizó un estudio observacional, descriptivo y transversal de 12 pacientes ingresados con diagnóstico de pulmón húmedo traumático en la Unidad de Cuidados Intensivos del Hospital Provincial Clinicoquirúrgico Docente Saturnino Lora de Santiago de Cuba durante el 2007, a los cuales se aplicó ventilación mecánica no invasiva según el protocolo establecido. En la casuística predominaron los pacientes jóvenes del sexo masculino. A las 24 horas del tratamiento con la mencionada ventilación disminuyeron las manifestaciones clínicas siguientes: frecuencias respiratoria y cardíaca, tiraje, cianosis, aleteo nasal y pausas al hablar. Los valores hemogasométricos obtenidos evidenciaron cambios favorables significativos. En un solo paciente se produjo rechazo de la interfase, no se presentaron grandes complicaciones y la evolución fue satisfactoria en 83,3 por ciento de la casuística. La terapéutica aplicada mejoró la relación ventilación-perfusión, así como incrementó la difusión de gases a través de la membrana alvéolo-capilar y la oxigenación tisular; pero las acciones de enfermería intensiva fueron vitales en ello(AU)

A descriptive, observational, and cross-sectional study of 12 patients with traumatic wet lung diagnosis hospitalized at the Intensive Care Unit from Saturnino Lora Provincial Clinical Surgical Teaching Hospital in Santiago de Cuba was carried out during the year 2007. Non-invasive mechanical ventilation was applied to those patients following the established protocol. Young male patients prevailed in the case material. Clinical manifestations, such as: respiratory and cardiac frequencies, chest indrawing, nasal flaring, and gaps in speech decreased when using the aforementioned ventilation after 24 hours. The obtained hemogasometric values showed significant and favorable changes. Interface rejection was observed in just one patient. There were no major complications and clinical course was satisfactory in 83,3 percent of the case material. The applied therapy allowed the improvement of the relationship between ventilation and perfusion, as well as the increase of gas diffusion through alveolar-capillary membrane and tissular oxygenation. Intensive nursing actions were vital to achieve these results(AU)

Ventilación mecánica no invasiva y acciones de enfermería en pacientes con pulmón húmedo traumático / Non-invasive mechanical ventilation and nursing actions in patients with traumatic wet lung

Se realizó un estudio observacional, descriptivo y transversal de 12 pacientes ingresados con diagnóstico de pulmón húmedo traumático en la Unidad de Cuidados Intensivos del Hospital Provincial Clinicoquirúrgico Docente Saturnino Lora de Santiago de Cuba durante el 2007, a los cuales se aplicó ventilación mecánica no invasiva según el protocolo establecido. En la casuística predominaron los pacientes jóvenes del sexo masculino. A las 24 horas del tratamiento con la mencionada ventilación disminuyeron las manifestaciones clínicas siguientes: frecuencias respiratoria y cardíaca, tiraje, cianosis, aleteo nasal y pausas al hablar. Los valores hemogasométricos obtenidos evidenciaron cambios favorables significativos. En un solo paciente se produjo rechazo de la interfase, no se presentaron grandes complicaciones y la evolución fue satisfactoria en 83,3 por ciento de la casuística. La terapéutica aplicada mejoró la relación ventilación-perfusión, así como incrementó la difusión de gases a través de la membrana alvéolo-capilar y la oxigenación tisular; pero las acciones de enfermería intensiva fueron vitales en ello.

A descriptive, observational, and cross-sectional study of 12 patients with traumatic wet lung diagnosis hospitalized at the Intensive Care Unit from Saturnino Lora Provincial Clinical Surgical Teaching Hospital in Santiago de Cuba was carried out during the year 2007. Non-invasive mechanical ventilation was applied to those patients following the established protocol. Young male patients prevailed in the case material. Clinical manifestations, such as: respiratory and cardiac frequencies, chest indrawing, nasal flaring, and gaps in speech decreased when using the aforementioned ventilation after 24 hours. The obtained hemogasometric values showed significant and favorable changes. Interface rejection was observed in just one patient. There were no major complications and clinical course was satisfactory in 83,3 percent of the case material. The applied therapy allowed the improvement of the relationship between ventilation and perfusion, as well as the increase of gas diffusion through alveolar-capillary membrane and tissular oxygenation. Intensive nursing actions were vital to achieve these results.

Utilidad de la detección del aleteo nasal en la valoración de la gravedad de la disnea / Utility of the detection of nasal flaring in the assessment of severity of dyspnea

Objetivo: Determinar si la presencia de aleteo nasal es indicativa de insuficiencia respiratoria grave. Material y método: Estudio prospectivo observacional de pacientes que consultan al servicio de urgencias por disnea, a los que se les asigna un nivel de gravedad II o III en el Sistema Espanñol de Triaje. Se recogen constantes, gasometría arterial y presencia o ausencia de aleteo nasal. Se registran la necesidad y los días de ingreso hospitalario. Se expresan los datos como mediana (percentil 25-75). Resultados: Se analizaron 43 pacientes con disnea (el 70% eran hombres, edad: 77 [67-82] años), de los que 7 presentaban aleteo. Los pacientes que presentaban aleteo estaban más taquipneicos (36 [34-40] versus 25 [20-28] respiraciones por minuto; p = 0,001) y más acidóticos (pH de 7,34 [7,23-7,40] versus pH de 7,42 [7,39-7,46]; p = 0,03), sin diferencias en la saturación arterial de oxígeno por pulsioximetría, la presión parcial arterial de CO2, la frecuencia cardíaca ni en la presión arterial. Todos los pacientes con aleteo nasal estaban taquipneicos. No hubo diferencias en el nu ́mero de pacientes que requirieron ingreso (6 [85,7%] en el grupo con aleteo versus 29 [80,5%] en el grupo sin aleteo; p = 0,6) ni en la duración de éste (3 [1-16] versus 6 [1-10] días; p = 0,6). Conclusión: En nuestro estudio, la presencia de aleteo nasal no es indicativa de insuficiencia respiratoria grave, aunque se asocia a taquipnea y a acidosis en pacientes con disnea (AU)

Objective: To determine if the presence of nasal flaring is indicative of severe respiratory insufficiency. Methods: Prospective observational study of patients consulting in the Emergency Department because of dyspnea whose triage level is II or III in the Spanish Triage System (MAT-SET). Vital signs, SpO2, arterial blood gases and nasal flaring presence were recorded, as well as the need for hospital admission and length of hospital stay. Data are presented as median (25-75th percentile). Results: A total of 43 patients were analyzed (70% men, aged 77 (67-82) years), 7 of whom showed nasal flaring. Those having flaring had higher respiratory rate (36 (34-40) vs. 25 (20-28) vs., p = 0.001) and were more acidotic (pH 7.34 [7.23-7.40] vs. 7.42 [7.39-7.46] vs., p = 0.03) than patients without this sign. There were no differences between groups in SpO2, PaCO2, heart rate and arterial pressure. There were no differences in the rate of hospital admission-(6 patients [85.7%] in nasal flaring group vs 29 patients [80.5%] in the non nasal flaring group [p=0,06], or in the length of the hospital stay-3 days [1-16] in nasal flaring group vs. 6 days [1-10] in the non nasal flaring group, p=0.6). All patients with nasal flaring had tachypnea. Conclusion: In our study, nasal flaring does not indicate severity in dyspneic patients in spite of its association with tachypnea and acidosis (AU)

[Utility of the detection of nasal flaring in the assessment of severity of dyspnea]. / Utilidad de la detección del aleteo nasal en la valoración de la gravedad de la disnea.

OBJECTIVE: To determine if the presence of nasal flaring is indicative of severe respiratory insufficiency. METHODS: Prospective observational study of patients consulting in the Emergency Department because of dyspnea whose triage level is II or III in the Spanish Triage System (MAT-SET). Vital signs, SpO2, arterial blood gases and nasal flaring presence were recorded, as well as the need for hospital admission and length of hospital stay. Data are presented as median (25-75th percentile). RESULTS: A total of 43 patients were analyzed (70% men, aged 77 (67-82) years), 7 of whom showed nasal flaring. Those having flaring had higher respiratory rate (36 (34-40) vs. 25 (20-28) vs., p=0.001) and were more acidotic (pH 7.34 [7.23-7.40] vs. 7.42 [7.39-7.46] vs., p=0.03) than patients without this sign. There were no differences between groups in SpO2, PaCO2, heart rate and arterial pressure. There were no differences in the rate of hospital admission-(6 patients [85.7%] in nasal flaring group vs 29 patients [80.5%] in the non nasal flaring group [p=0,06], or in the length of the hospital stay-3 days [1-16] in nasal flaring group vs. 6 days [1-10] in the non nasal flaring group, p=0.6). All patients with nasal flaring had tachypnea. CONCLUSION: In our study, nasal flaring does not indicate severity in dyspneic patients in spite of its association with tachypnea and acidosis.

Factores asociados con mortalidad por infección respiratoria aguda en una población de niños menores de cinco años residentes en la ciudad de Bogotá / Factors Affecting Mortality from Acute Respiratory Infections in a Population of Children under Five Years Living in the city of Bogota

Introducción: Las infecciones respiratorias agudas (IRA), principalmente la neumonía y en segundo lugar la bronquiolitis, son la causa infecciosa más frecuente de muerte en niños menores de cinco años de edad. Objetivo: Determinar el papel de potenciales factores de riesgo como predictores de mortalidad por infección respiratoria aguda. Método: Estudio observacional analítico de casos y controles con 258 pacientes pediátricos menores de cinco años con enfermedad respiratoria aguda atendidos en cuatro hospitales de la zona suroriental de Bogotá. Resultados: Los hallazgos de acidosis metabólica, acidemia al momento del ingreso a la unidad de cuidado intensivo (UCI) y el antecedente de ingreso a la UCI en los meses de marzo, abril y mayo, respecto al ingreso en los demás meses del año, fueron predictores de la mortalidad. Entre tanto, la presencia de aleteo nasal y la administración de antibióticos en la segunda consulta, mostraron reducir el riesgo de mortalidad. Palabras clave: neumonía, mortalidad, infección, enfermedad pulmonar intersticial.

Introduction: In acute respiratory infections (ARI), pneumonia in the first place and bronchiolitis in the second place are the most common infectious cause of death in children under five years old. Objective: To establish the role of potential risk factors as predictors of mortality from acute respiratory infection. Method: An observational/analytic case-control study was conducted with 258 pediatric patients younger than five years old with acute respiratory disease (ARD) treated at four south-eastern hospitals in Bogotá. Results: Findings of metabolic acidosis and acidemia at ICU admission, as well as patients’ clinical history at ICU admission were taken as mortality predictors in the months of March, April and May, with regard to their admission in other months, and the presence of nasal flaring and the administration of antibiotics at the second consultation decreased mortality risk. Key words: Pneumonia, mortality, infection, interstitial lung disease.

Capacitação de técnicos/auxiliares de enfermagem: repercussão nos registros de enfermagem relacionados ao atendimento pré-hospitalar móvel / Capacitación de técnicos y auxiliares de enfermería en la atención pre-hospitalaria móvil: repercusiones en los registros de enfermería / Training of nursing technicians/assistants in mobile pre-hospital healthcare: results from nursing records

OBJETIVO: Avaliar o impacto de um curso de capacitação na melhoria dos registros realizados por técnicos/auxiliares de enfermagem no atendimento pré-hospitalar a crianças menores de cinco anos com dificuldade respiratória. MÉTODOS: Estudo prospectivo exploratório, realizado no Serviço de Atendimento Móvel de Urgências - Recife. Foram incluídas as fichas de atendimentos realizados por Unidades de Suporte Básico a crianças menores de cinco anos com quadro de dificuldade respiratória, totalizando 148 ocorrências em 2006, antes do curso de capacitação e 113 em 2007/2008 após a capacitação de técnicos/auxiliares de enfermagem. RESULTADOS: Observou-se mudança significativa na qualidade da informação registrada, passando os sinais de gravidade respiratória a serem avaliados com maior freqüência, como o uso da musculatura acessória, batimento de asa de nariz, agitação, retração xifóide e sibilos expiratórios (p<0,01). CONCLUSÃO: O curso de capacitação implementado proporcionou melhor comunicação com a central médica de regulação no repasse objetivo dos sinais de dificuldade respiratória, favorecendo a adoção de condutas apropriadas.

OBJECTIVE: To evaluate the impact of a program for capacitation of associate degree nurses and licensed practical nurses in improving the documentation of respiratory care for children less than 5 years old in pre-hospital mobile units. METHODS: A quasi-experimental, prospective, and comparative one-group before and after design was used to conduct the study. The study was conducted in the Pre-Hospital Mobile Units of Recife. The sample consisted of 148 children's records in 2006 before the initiation of the program of capacitation and 113 children's records in 2007 and 2008 after the implementation of the program. RESULTS: There was a statistical significant change after the implementation of the program regarding to quality documentation and the frequency of respiratory system assessment, such as the use of the accessory respiratory muscle, nose flaring, agitation, xiphoid process retraction, and wheezes (p < .01). CONCLUSIONS: The implementation of the program of capacitation of associate degree nurses and licensed practical nurses improved communication, nursing care, documentation, and respiratory assessment of children in pre-hospital mobile units.

OBJETIVO: Evaluar el impacto de un curso de capacitación para la mejoría de los registros realizados por técnicos/auxiliares de enfermería en la atención pre hospitalaria a niños menores de cinco años con dificultad respiratoria. MÉTODOS: Se trata de un estudio prospectivo exploratorio, realizado en el Servicio de Atención Móvil de Urgencias - Recife. Fueron incluídas las fichas de atención realizadas por Unidades de Soporte Básico a niños menores de cinco años con cuadro de dificuldad respiratoria, con un total de 148 ocurrencias en el 2006, antes del curso de capacitación y 113 en 2007/2008 después de la capacitación de técnicos/auxiliares de enfermería. RESULTADOS: Se observó un cambio significativo en la calidad de la información registrada, pasando las señales de gravedad respiratoria a ser evaluados con mayor frecuencia, como el uso de la musculatura accesoria, aleteo nasal, agitación, retracción xifoide y sibilancias expiratorias (p<0,01). CONCLUSIÓN: El curso de capacitación implementado proporcionó mejor comunicación con la central médica de regulación en el repaso objetivo de las señales de dificultad respiratoria, favoreciendo la adopción de conductas apropiadas.

[Arrhythmias in patients with obstructive sleep apnea]. / Szívritmuszavarok obstruktív alvási apnoéban.

The authors summarize the current knowledge on the types, prevalence, reasons, diagnosis and current therapy of arrhythmias occurring in patients with obstructive sleep apnea. Most of the patients with obstructive sleep apnea have nocturnal bradycardia (5-50%), paroxysmal tachyarrhythmia (atrial 35%; ventricular 0-15%), or both. The frequency of rhythm disturbances associated with the severity of the sleeping disorder. It is important to recognize the factors predisposing to arrhythmias and the early appropriate therapy of patients is essential, in order to protect patients from life threatening arrhythmias which may worsen the clinical outcome.

Ventilación no invasiva / Not invasive ventilation

Se presenta el caso de una paciente femenina de 15 años de edad, que sufre accidente automovilístico, y se ingresa con diagnóstico de fractura cerrada de tibia y peroné izquierdos y se realiza inmovilización del sitio de fractura. A las 8 horas de estadía en el servicio se diagnostica un embolismo pulmonar graso por la presencia de macroglobulinemia grasa, hipoxemia moderada, cianosis subungueal, aleteo nasal, tiraje intercostal generalizado, polipnea de 64 respiraciones al minuto, sin estertores a la auscultación y frecuencia cardiaca de 140 latidos por minuto, con tensión arterial de 100/60. Se realiza la técnica de ventilación no invasiva acoplándose al ventilador: Servo I en CPAP de 8 cm de agua. Se observó mejoría: La frecuencia cardiaca bajó a 100 por minuto y la respiratoria a 24 por minuto, desapareció el aleteo nasal y disminuyó el tiraje intercostal, la saturación de O2 por oxímetro de pulso llegó a 97 por ciento y la presión parcial de oxígeno a 89 mmHg. Se desacopló cada 3 horas por 15 minutos para aspirar secreciones y alimentar por vía nasogástrica. Las gasometrías evolutivas mostraron un ascenso progresivo en las cifras de tensión arterial de oxígeno. Pasadas las 48 horas de ventilada se continuó disminuyendo parámetros hasta desconectar a la paciente del ventilador. Mantuvo una evolución favorable y egresó de cuidados intensivos a los 7 días. No presentó complicaciones relacionadas con la ventilación no invasiva (AU)