Specific Training Improves the Detection and Management of Patient-Ventilator Asynchrony.

BACKGROUND: Patient-ventilator asynchrony is common in patients undergoing mechanical ventilation. The proportion of health-care professionals capable of identifying and effectively managing different types of patient-ventilator asynchronies is limited. A few studies have developed specific training programs, but they mainly focused on improving patient-ventilator asynchrony detection without assessing the ability of health-care professionals to determine the possible causes. METHODS: We conducted a 36-h training program focused on patient-ventilator asynchrony detection and management for health-care professionals from 20 hospitals in Latin America and Spain. The training program included 6 h of a live online lesson during which 120 patient-ventilator asynchrony cases were presented. After the 6-h training lesson, health-care professionals were required to complete a 1-h training session per day for the subsequent 30 d. A 30-question assessment tool was developed and used to assess health-care professionals before training, immediately after the 6-h training lecture, and after the 30 d of training (1-month follow-up). RESULTS: One hundred sixteen health-care professionals participated in the study. The median (interquartile range) of the total number of correct answers in the pre-training, post-training, and 1-month follow-up were significantly different (12 [8.75-15], 18 [13.75-22], and 18.5 [14-23], respectively). The percentages of correct answers also differed significantly between the time assessments. Study participants significantly improved their performance between pre-training and post-training (P < .001). This performance was maintained after a 1-month follow-up (P = .95) for the questions related to the detection, determination of cause, and management of patient-ventilator asynchrony. CONCLUSIONS: A specific 36-h training program significantly improved the ability of health-care professionals to detect patient-ventilator asynchrony, determine the possible causes of patient-ventilator asynchrony, and properly manage different types of patient-ventilator asynchrony.

[Pediatric tracheostomy: Ten year experience in an Intensive Care Unit]. / Traqueostomía en niños: Experiencia de 10 años en una Unidad de Cuidados Intensivos Pediátricos.

INTRODUCTION: Pediatric tracheostomy indications have changed over the last 30 years, from acute and transient pro cedures secondary to airway obstruction to programmed tracheostomies indicated due to the need for chronic use of mechanical ventilation (MV). OBJECTIVE: To describe indications and morbidity associated with pediatric tracheostomies during a ten-year period. PATIENTS AND METHODS: Descrip tive study. Clinical records review of discharged patients (< 15 years old) tracheostomized during their hospital stay between 2005 and 2015. Demographic and clinical variables were evaluated before and after tracheostomy, stay in intensive care unit, age at the time of the tracheostomy, indication of tracheostomy, early complications (< 7 days), late complications (> 7 days), and mortality. RESULTS: 59 children with tracheostomy were analyzed, 36 (59%) tracheostomies were performed in children under 6 months, and 39 (60%) in males. 23 (39%) had a confirmed or under study genopathy and 25 (42%) had congenital heart disease. The main indications for tracheostomy were 58% secondary to airway disease and 42% due to chronic use of MV. Within the airway disease group, subglottic steno sis, vocal cord paralysis, and tracheobronchomalacia were the principal reasons for indication, and in the group of chronic use of MV, the main causes were bronchopulmonary dysplasia and chronic lung disease. We did not find tracheostomy-related mortality. 89% of the patients were discharged with tracheostomy and 59% with chronic use of MV. The probability of being discharged with a tracheos tomy was higher in younger patients while the chronic use of MV at discharge was higher in patients with a greater number of extubation failures before tracheostomy. CONCLUSION: Tracheostomy is a safe procedure in children, where the predominant causes of indication are airway disease and the need for chronic use of MV. Most children with tracheostomies are discharged with tracheostomy and chronic use of MV. Younger children, those with difficult weaning, confirmed or suspected ge nopathy, or special health needs are at greater risk of needing tracheostomy and chronic use of MV.

Identificación y Manejo del Gatillaje Reverso Utilizando la Gráfica Ventilatoria / Identifying and Managing of Reverse Triggering using Waveform Analysis

El gatillaje reverso es un tipo de asincronía paciente ventilador, potencialmente injuriosa, que se presenta en un gran porcentaje de pacientes ventilados mecánicamente. El gatillaje reverso es causado por la insuflación pulmonar pasiva por parte del ventilador mecánico, lo que genera una contracción diafragmática refleja. Su identificación y manejo, mediante el análisis de la gráfica ventilatoria, presenta un gran desafío para los profesionales de la salud que trabajan en Unidades de Cuidados Intensivos, debido a la gran dificultad para diagnosticarla correctamente si no se utilizan sistemas de monitorización como presión esofágica y/o la actividad eléctrica del diafragma. El objetivo de esta revisión es describir las estrategias para identificar y resolver el gatillaje reverso a partir de la evidencia científica aparecida en los últimos años.

Reverse triggering is a potentially injurious type of ventilator asynchrony (VPA) that occurs in a large percentage of mechanically ventilated patients. Reverse triggering is caused by passive lung insufflation by the mechanical ventilator, which generates a reflex diaphragmatic contraction. Its identification and management, through the analysis of the ventilatory graphics, is a great challenge for health-professionals, who work in Intensive Care Units, due to the great difficulty of correctly diagnosing it if monitoring systems such as esophageal pressure and / or the electrical activity of the diaphragm are not used. The objective of this review is to describe the strategies to identify and resolve the reverse trigger, based on the scientific evidence that has appeared in recent years.

Modificaciones en las prácticas de los kinesiólogos de cuidados Críticos durante y después de la Pandemia COVID-19 en Chile: protocolo de una Encuesta Nacional / Modifications in Critical Care Physiotherapists Practices during and after COVID-19 Pandemic in Chile: Study Protocol of a National Survey

ANTECEDENTES: El 11 de marzo de 2020, la Organización Mundial de la Salud declaró la enfermedad por coronavirus (COVID-19) como pandemia, cuyos casos y gravedad en Chile han sido elevados. Internacionalmente, los profesionales de la salud han debido adaptar sus actividades laborales hacia pacientes mecánicamente ventilados por agravamiento de los síntomas respiratorios. La terapia respiratoria y terapia física que realizan los kinesiólogos en la unidad de cuidados intensivos (UCI) es fundamental, y existe la urgencia por agrupar datos nacionales que permitan describir la situación y así prepararse para futuros aumentos de la carga asistencial en UCI. OBJETIVO: Describir las modificaciones institucionales, laborales y asistenciales, experimentadas por kinesiólogos que se desempeñan en UCI durante y después de la pandemia COVID-19 en Chile. MÉTODOS: Este es el protocolo de un estudio observacional analítico transversal, el cual recopilará información desde el inicio hasta un año iniciada la pandemia. Se incluirán todas las UCI adulto existentes y las creadas por contingencia COVID-19. Se excluirán aquellas que no hayan recibido pacientes en UCI con COVID-19 confirmado. Se aplicará una encuesta online (REDCap®) al kinesiólogo representante de cada centro, la cual recopilará la información anonimizada principalmente a través de selección múltiple y escala Likert. RESULTADOS ESPERADOS: Se espera identificar un alto porcentaje de modificaciones institucionales en las UCI de Chile, y kinesiólogos que se vieron en la necesidad decambiar sus condiciones laborales y asistenciales durante la pandemia, en comparación al período pre-pandemia;cambios que en un menor porcentaje se mantuvieron en el tiempo.

BACKGROUND: On March 11, 2020, the World Health Organization declared coronavirus disease (COVID-19) as a pandemic, whose cases and severity in Chile have been high. Worldwide, health staffs have adapted their working activities focusing mainly on mechanically ventilated patients due to respiratory decline. Respiratory therapy and physical therapy by physiotherapists in the intensive care unit (ICU) are essential, and national data needs to be collected to describe the pandemic-related context to prepare for future increases in the ICU demand. OBJECTIVE: To describe the institutional, workforce and healthcare modifications experienced by the ICU physiotherapists during and after the COVID-19 pandemic in Chile. METHODS: This is the protocol of a cross-sectional study, which will collect information from the beginning to 1 year after the pandemic begins. All existing adult ICUs and those ICUs created during the pandemic will be included. Those who have not received ICU patients with confirmed COVID-19 will be excluded. An online survey will be applied to the physiotherapists representing each ICU, which will collect the anonymous information mainly through multiple selection-choice and Likert scale.EXPECTED RESULTS: We will be expected to identify a high percentage of institutional modifications in the ICUs in Chile, and that the physiotherapists would need of changing their working and healthcare conditions during the pandemic, compared to the pre-pandemic period; changes that in a smaller percentage would be maintained over time.

[Predictive model preparation for surgical wound infection in adult patients undergoing total hip arthroplasty in high complexity hospital for years 2012 and 2014]. / Confección de un modelo predictor para infección de herida operatoria en pacientes adultos intervenidos de artroplastía total de cadera en un hospital de alta complejidad, años 2012 y 2014.

INTRODUCTION: Operative wound infections of patients undergoing total hip arthroplasty have an incidence from 2% to 5%, generating impact on hospital stay, resource use, prolonged antibiotic therapy, including temporary or definitive sequelae. OBJECTIVE: To generate a predictive model for surgical wound infection in patients undergoing total hip arthroplasty between 2012 and 2014 at the High Complexity Hospital. MATERIAL AND METHOD: Cohort of patients with total hip arthroplasty. A description of the epidemiological variables was made and a predictive model was generated by means of logistic regression. RESULTS: 441 patients were analyzed. The predictive model obtained included the variables: days of post-operative stay (OR 1.11 IC95% [1.03 - 1.20]), transfusion of at least one unit of red blood cells (OR 3.13 IC95% [1.17 - 10.86]), diagnosis of previous depression to surgery (OR 5.75 IC95% [1.32 - 25.32], non-compliance with antibioprophylaxis administration time (OR 5.46 IC95% [1.68 - 17.78], P < 0.001) and pseudo R2 = 0.2293. Score point of 13 points with sensitivity 44.4%, specificity of 91.6%, LR (+) 5.29, LR (-) 0.61, 1 to 6 points "low risk", 7 to 12 points "medium risk", 13 to 18 points "high risk", from 19 points as "maximum risk". CONCLUSION: the model presents a good predictive capacity of operative wound infection and adequately represents the cohort under study.

Confección de un modelo predictor para infección de herida operatoria en pacientes adultos intervenidos de artroplastía total de cadera en un hospital de alta complejidad, años 2012 y 2014 / Predictive model preparation for surgical wound infection in adult patients undergoing total hip arthroplasty in high complexity hospital for years 2012 and 2014

Resumen Introducción: Las infecciones de herida operatoria de pacientes intervenidos de artroplastía total de cadera, presentan una incidencia desde 2 a 5%, generando impacto en la estadía hospitalaria, uso de recursos, antibioterapia prolongada y secuelas temporales o definitivas. Objetivo: Generar un modelo predictivo para la infección de herida operatoria en pacientes intervenidos de artroplastía total de cadera, entre los años 2012 y 2014, en un hospital de alta complejidad. Material y Método: Cohorte de pacientes con artroplastía total de cadera. Se efectuó la descripción de las variables epidemiológicas y se generó un modelo predictivo por regresión logística. Resultados: Se analizaron 441 pacientes. El modelo predictivo obtenido incluyó las variables: días de estadía post operatoria (OR 1,11 IC95% [1,03-1,20]), transfusión de al menos una unidad de glóbulos rojos (OR 3,13 IC95% [1,17-10,86]), diagnóstico de depresión previo a la cirugía (OR 5,75 IC95% [1,32-25,32], incumplimiento del tiempo de administración de la antibioprofilaxis (OR 5,46 IC95% [1,68-17,78]; p < 0,001) y pseudo R2 = 0,2293. Punto de corte de "score" de 13 puntos con sensibilidad 44,4%, especificidad de 91,6%, LR (+) 5,29, LR (-) 0,61, considerando además la siguiente clasificación: 1 a 6 puntos "bajo riesgo", 7 a 12 puntos "mediano riesgo", 13 a 18 puntos "alto riesgo", desde 19 puntos como "máximo riesgo". Conclusión: El modelo presenta una buena capacidad de predicción de infección de herida operatoria y representa adecuadamente a la cohorte en estudio.

Introduction: Operative wound infections of patients undergoing total hip arthroplasty have an incidence from 2% to 5%, generating impact on hospital stay, resource use, prolonged antibiotic therapy, including temporary or definitive sequelae. Objective: To generate a predictive model for surgical wound infection in patients undergoing total hip arthroplasty between 2012 and 2014 at the High Complexity Hospital. Material and Method: Cohort of patients with total hip arthroplasty. A description of the epidemiological variables was made and a predictive model was generated by means of logistic regression. Results: 441 patients were analyzed. The predictive model obtained included the variables: days of post-operative stay (OR 1.11 IC95% [1.03 - 1.20]), transfusion of at least one unit of red blood cells (OR 3.13 IC95% [1.17 - 10.86]), diagnosis of previous depression to surgery (OR 5.75 IC95% [1.32 - 25.32], non-compliance with antibioprophylaxis administration time (OR 5.46 IC95% [1.68 - 17.78], P < 0.001) and pseudo R2 = 0.2293. Score point of 13 points with sensitivity 44.4%, specificity of 91.6%, LR (+) 5.29, LR (-) 0.61, 1 to 6 points "low risk", 7 to 12 points "medium risk", 13 to 18 points "high risk", from 19 points as "maximum risk". Conclusion: the model presents a good predictive capacity of operative wound infection and adequately represents the cohort under study.

Concordancia entre kinesiólogos para evaluar el inflado del balón en ventilación mecánica pediátrica mediante técnica de volumen de oclusión mínima / Agreement between Kinesiologists for evaluate balloon inflation in pediatric mechanical ventilation using the technique of minimal occlusion volume

INTRODUCCIÓN: La medición del balón de los tubos traqueales actualmente usados en los pacientes pediátricos en ventilación mecánica (VM) no posee valores de referencia para presión, volumen y tipo de ́cuffµ, con falta de acuerdo y riesgos asociados a su uso diario. Nuestro objetivo fue evaluar el grado de concordancia en presión, volumen y fuga tras inflado de ́cuff con prueba de volumen de oclusión mínimo (TVOM) entre Kinesiólogos de la Unidad de Cuidados Intensivos (UCI) Pediátrica del Hospital Clínico de la Universidad Católica (UC). METODOS: Estudio observacional, analítico, transversal. Se realizaron 32 mediciones de Cuff por 4 Kinesiólogos del equipo de Terapia Respiratoria UC, obteniendo 128 mediciones totales a 32 pacientes en VM con tubo traqueal entre junio y septiembre del 2016. Las mediciones fueron obtenidas en semanas consecutivas, la técnica utilizada fue TVOM, registrando tipo de tubo, volumen (mL), presión (cmH2O), y volumen corriente (mL) del ventilador mecánico para el cálculo de fuga mínima. Para evaluar la concordancia se utilizó un modelo de regresión lineal mixto y coeficiente de variabilidad interclásico. El análisis de datos se hizo con el software Stata 14.2. RESULTADOS: Concordancia para volumen 0,71 (IC95% 0,59 2 0,83), presión 0,6 (IC95% 0,44 2 0,75). CONCLUSIÓN: Existe concordancia considerable para la TVOM en el inflado de ́cuff presión y moderada en volumen.

INTRODUCCTION: Cuff measurement of tracheal tubes currently used in pediatric patients on mechanical ventilation (MV) does not have reference values for pressure and volume, with lack of agreement, consensus and risks associated with daily use. Our objective was to quantify concordance in pressure-volume after inflation of ́cuffµ with minimum occlusion volume technique (MOVT) among Physical Therapists (PT) of the Pediatric Intensive Care Unit (PICU) of the Hospital Clínico Red de Salud Christus-UC, Santiago Chile. METHODS: Study design: observational, analytical, transversal. 32 ́cuffµ measurements were taken by 4 PT from the UC Respiratory Therapy Team, obtaining 128 total measurements in 32 patients with tracheal tube VM between June and September 2016. The measurements were obtained in consecutive weeks, the technique used was MOVT, registering tube type, volume (mL), pressure (cmH2O), and tidal volume (mL) of the mechanical ventilator for the calculation of leak. To evaluate the agreement were used a mixed linear regression model and interclass correlation coefficient. The statistics analysis was done with the software Stata 14.2. RESULTS: Concordance for volume 0.71 (IC95% 0.59-0.83), pressure 0.6 (IC95% 0.44-0.75). CONCLUSIONS: The agreement between evaluators with the MOVT to inflate "cuff" in pediatric patients in MV among physical- therapist was considerable (between moderate-almost perfect) for volume and moderate for pressure.

Ability of ICU Health-Care Professionals to Identify Patient-Ventilator Asynchrony Using Waveform Analysis.

BACKGROUND: Waveform analysis by visual inspection can be a reliable, noninvasive, and useful tool for detecting patient-ventilator asynchrony. However, it is a skill that requires a properly trained professional. METHODS: This observational study was conducted in 17 urban ICUs. Health-care professionals (HCPs) working in these ICUs were asked to recognize different types of asynchrony shown in 3 evaluation videos. The health-care professionals were categorized according to years of experience, prior training in mechanical ventilation, profession, and number of asynchronies identified correctly. RESULTS: A total of 366 HCPs were evaluated. Statistically significant differences were found when HCPs with and without prior training in mechanical ventilation (trained vs non-trained HCPs) were compared according to the number of asynchronies detected correctly (of the HCPs who identified 3 asynchronies, 63 [81%] trained vs 15 [19%] non-trained, P < .001; 2 asynchronies, 72 [65%] trained vs 39 [35%] non-trained, P = .034; 1 asynchrony, 55 [47%] trained vs 61 [53%] non-trained, P = .02; 0 asynchronies, 17 [28%] trained vs 44 [72%] non-trained, P < .001). HCPs who had prior training in mechanical ventilation also increased, nearly 4-fold, their odds of identifying ≥2 asynchronies correctly (odds ratio 3.67, 95% CI 1.93-6.96, P < .001). However, neither years of experience nor profession were associated with the ability of HCPs to identify asynchrony. CONCLUSIONS: HCPs who have specific training in mechanical ventilation increase their ability to identify asynchrony using waveform analysis. Neither experience nor profession proved to be a relevant factor to identify asynchrony correctly using waveform analysis.

What is the effect of chest physiotherapy in hospitalized children with pneumonia?

Chest physiotherapy is applied in clinical practice for the treatment of pneumonia. However, its use is still controversial. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified one systematic review including two relevant randomized controlled trials. We combined the evidence using meta-analysis and generated a summary of findings table following the GRADE approach. We concluded it is unclear whether chest physiotherapy increases or decreases the length of hospitalization, severity, or the time to clinical improvement in children with pneumonia because the certainty of the evidence is very low.

La kinesioterapia respiratoria es ampliamente utilizada en la práctica clínica para el tratamiento de la neumonía, sin embargo, su efecto en niños con neumonia aún es controvertido. Utilizando la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en 30 bases de datos, identificamos una revisión sistemática que incluye dos estudios aleatorizados pertinentes a la pregunta. Realizamos un metanálisis y tablas de resumen de los resultados utilizando el método GRADE. Concluimos que existe incertidumbre sobre si la kinesioterapia respiratoria tiene algún efecto sobre el tiempo de hospitalización, severidad y resolución clínica en niños con neumonía porque la certeza de la evidencia es muy baja.

Medición de la intensidad de campo eléctrico de los equipos de onda corta / Measurement of the electric field intensity of short wave equipments

El presente estudio descriptivo transversal tiene por objetivo determinar el cumplimiento de las recomendaciones de emisión de ondas electromagnéticas en equipos de onda corta (27,12 MHz) terapéutica de los servicios de salud pública de la región metropolitana durante el año 2003. Luego de la medición y registro de la intensidad de campo eléctrico (V/Mt) en el campo cercano (1 metro del foco) en la población de equipos de onda corta en funcionamiento, los resultados obtenidos indicaron que en el total de equipos de la Región Metropolitana (N = 47), el 97,87 por ciento (n = 46) cumple con la recomendación internacional de la ICNIRP (International on Non-ionizing Radiation Protection) a nivel ocupacional (61 V/Mt) de intensidad de campo eléctrico (Nivel de Confianza 95 por ciento).