Asynchronies during invasive mechanical ventilation: narrative review and update.

Invasive mechanical ventilation is a frequent therapy in critically ill patients in critical care units. To achieve favorable outcomes, patient and ventilator interaction must be adequate. However, many clinical situations could attempt against this principle and generate a mismatch between these two actors. These asynchronies can lead the patient to worst outcomes; that is why it is vital to recognize and treat these entities as soon as possible. Early detection and recognition of the different asynchronies could favor the reduction of the days of mechanical ventilation, the days of hospital stay, and intensive care and improve clinical results.

Strategies to achieve adherence to prone positioning in awake COVID-19 patients with high-flow nasal oxygen. A case series.

Introduction: The use of high-flow nasal oxygen (HFNO) is a simple method that can reduce intubation in patients with hypoxemic acute respiratory failure (ARF). Early and prolonged prone position has demonstrated benefits on mortality in mechanically ventilated patients and on intubation in awake patients with ARF. However, strategies to achieve adherence to awake prone positioning (APP) have not been previously described. Case and outcomes: We present six patients with ARF due to COVID-19 treated with HFNO and APP. The median (p25-75) of PaFiO2 upon admission was 121 (112-175). The average duration of APP on the first day was 16 h (SD 5 h). Duration (median p25-75) in APP for the following 20 days was 13 (10-18) h/day. Several strategies such as the presence of a health care team, recreational activities, adaptation of the circadian rhythm, oral nutritional support, and analgesics were used to improve prone tolerance. None of the patients suffered from delirium, all were ambulating on discharge from the ICU and none require intubation. Conclusion: The case series presented show the feasibility of prolonged use of HFNO and APP in patients with COVID-19 and severe persistent hypoxemia and described strategies to enhance adherence.

High-Flow Nasal Cannula and Standard Oxygen in Acute Hypoxemic Respiratory Failure Due to COVID-19.

BACKGROUND: The evidence regarding benefits of high-flow nasal cannula (HFNC) in patients with COVID-19 is controversial. The aim of this study was to evaluate the impact of HFNC in comparison with standard oxygen therapy on the frequency of endotracheal intubation at 28 d in subjects with acute hypoxemic respiratory failure (AHRF) secondary to SARS-CoV-2 infection. METHODS: A retrospective, age- and sex-matched-paired, cohort study was conducted in subjects with moderate-to-severe AHRF. Intervention group was treated with HFNC, and control group was treated with standard oxygen therapy. Baseline characteristics and clinical evolution were analyzed. Mantel-Haenszel test was used for categorical variables. Paired samples Wilcoxon test was used for quantitative variables. Multivariate analysis was performed using conditional multiple logistic regression. RESULTS: Eighty-four subjects were included. The median time from admission to progression of oxygen therapy to FIO2 ≥ 0.5 or HFNC was 1 (interquartile range [IQR] 0-3) d. PaO2 /FIO2 at the time of oxygen therapy progression showed a median of 150.5 (IQR 100.0-170.0) for the entire sample and was lower in HFNC group compared with control group (median 135 [IQR 96-162] vs median 158 [IQR 132-174], respectively, P = .02). Endotracheal intubation at 28 d was observed in 54.8% HFNC and 73.8% standard oxygen (unadjusted odds ratio 0.38 [95% CI 0.13-1.07], P = .069). In the multivariate analysis, presence of dyspnea at hospital admission, Sequential Organ Failure Assessment score, and PaO2 /FIO2 at time of progression of oxygen therapy to FIO2 ≥ 0.5 was identified as confounding factors for the association between the intervention group and the outcome. Use of HFNC was not an independent predictor of endotracheal intubation frequency after adjusting confounders (odds ratio 0.26 [95% CI 0.04-1.51], P = .13). CONCLUSIONS: In this study, HFNC therapy in subjects with AHRF secondary to COVID-19 was not an independent predictor of endotracheal intubation, compared with standard oxygen therapy, after adjusting for confounders.

Impact of exposure time in awake prone positioning on clinical outcomes of patients with COVID-19-related acute respiratory failure treated with high-flow nasal oxygen: a multicenter cohort study.

BACKGROUND: In patients with COVID-19-related acute respiratory failure (ARF), awake prone positioning (AW-PP) reduces the need for intubation in patients treated with high-flow nasal oxygen (HFNO). However, the effects of different exposure times on clinical outcomes remain unclear. We evaluated the effect of AW-PP on the risk of endotracheal intubation and in-hospital mortality in patients with COVID-19-related ARF treated with HFNO and analyzed the effects of different exposure times to AW-PP. METHODS: This multicenter prospective cohort study in six ICUs of 6 centers in Argentine consecutively included patients > 18 years of age with confirmed COVID-19-related ARF requiring HFNO from June 2020 to January 2021. In the primary analysis, the main exposure was awake prone positioning for at least 6 h/day, compared to non-prone positioning (NON-PP). In the sensitivity analysis, exposure was based on the number of hours receiving AW-PP. Inverse probability weighting-propensity score (IPW-PS) was used to adjust the conditional probability of treatment assignment. The primary outcome was endotracheal intubation (ETI); and the secondary outcome was hospital mortality. RESULTS: During the study period, 580 patients were screened and 335 were included; 187 (56%) tolerated AW-PP for [median (p25-75)] 12 (9-16) h/day and 148 (44%) served as controls. The IPW-propensity analysis showed standardized differences < 0.1 in all the variables assessed. After adjusting for other confounders, the OR (95% CI) for ETI in the AW-PP group was 0.36 (0.2-0.7), with a progressive reduction in OR as the exposure to AW-PP increased. The adjusted OR (95% CI) for hospital mortality in the AW-PP group ≥ 6 h/day was 0.47 (0.19-1.31). The exposure to prone positioning ≥ 8 h/d resulted in a further reduction in OR [0.37 (0.17-0.8)]. CONCLUSION: In the study population, AW-PP for ≥ 6 h/day reduced the risk of endotracheal intubation, and exposure ≥ 8 h/d reduced the risk of hospital mortality.

Lung ultrasound as a predictor of mortality of patients with COVID-19.

OBJECTIVE: To evaluate the performance of lung ultrasound to determine short-term outcomes of patients with COVID-19 admitted to the intensive care unit. METHODS: This is a Prospective, observational study. Between July and November 2020, 59 patients were included and underwent at least two LUS assessments using LUS score (range 0-42) on day of admission, day 5th, and 10th of admission. RESULTS: Age was 66.5±15 years, APACHE II was 8.3±3.9, 12 (20%) patients had malignancy, 46 (78%) patients had a non-invasive ventilation/high-flow nasal cannula and 38 (64%) patients required mechanical ventilation. The median stay in ICU was 12 days (IQR 8.5-20.5 days). ICU or hospital mortality was 54%. On admission, the LUS score was 20.8±6.1; on day 5th and day 10th of admission, scores were 27.6±5.5 and 29.4±5.3, respectively (P=0.007). As clinical condition deteriorated the LUS score increased, with a positive correlation of 0.52, P <0.001. Patients with worse LUS on day 5th versus better score had a mortality of 76% versus 33% (OR 6.29, 95%CI 2.01-19.65, p. 0.003); a similar difference was observed on day 10. LUS score of 5th day of admission had an area under the curve of 0.80, best cut-point of 27, sensitivity and specificity of 0.75 and 0.78 respectively. CONCLUSION: These findings position LUS as a simple and reproducible method to predict the course of COVID-19 patients.

Loading of doxorubicin on poly(methyl methacrylate-co-methacrylic acid) nanoparticles and release study.

Nanoparticles (NP) of 12.7 nm in diameter of the poly(methyl methacrylate (MMA)-co-methacrylic acid (MAA)) copolymer were prepared. 13C-NMR results showed a MMA:MAA molar ratio of 0.64:0.36 in the copolymer, which is similar to the poly(MMA-co-MAA) commercially known as the FDA approved Eudragit S100 (0.67:0.33). The NP prepared in this study were loaded at pH 5 with varying amounts (from 0.54 to 6.91%) of doxorubicin (DOX), an antineoplastic drug. 1H-NMR results indicated the electrostatic interactions between the ionized carboxylic groups of the MAA units in the copolymer and the proton of the glycosidic amine in DOX. Measurements by QLS and TEM indicated that the loading destabilizes the NP, and that for increase stability, they aggregate in a reversible way, forming aggregates with a diameter up to 99.5 nm at a DOX load of 6.91%. The analysis of drug release data at pH 7.4 showed that loaded NP with at least 4.38% DOX release the drug very slowly and follows the Higuchi model; the former suggests that they could remain for long periods in the bloodstream to reach and destroy cancer cells.

Lung ultrasound as a predictor of mortality of patients with COVID-19 / Ultrassonografia pulmonar como preditor de mortalidade em pacientes com COVID-19

ABSTRACT Objective To evaluate the performance of lung ultrasound to determine short-term outcomes of patients with COVID-19 admitted to the intensive care unit. Methods This is a Prospective, observational study. Between July and November 2020, 59 patients were included and underwent at least two LUS assessments using LUS score (range 0-42) on day of admission, day 5th, and 10th of admission. Results Age was 66.5±15 years, APACHE II was 8.3±3.9, 12 (20%) patients had malignancy, 46 (78%) patients had a non-invasive ventilation/high-flow nasal cannula and 38 (64%) patients required mechanical ventilation. The median stay in ICU was 12 days (IQR 8.5-20.5 days). ICU or hospital mortality was 54%. On admission, the LUS score was 20.8±6.1; on day 5th and day 10th of admission, scores were 27.6±5.5 and 29.4±5.3, respectively (P=0.007). As clinical condition deteriorated the LUS score increased, with a positive correlation of 0.52, P <0.001. Patients with worse LUS on day 5th versus better score had a mortality of 76% versus 33% (OR 6.29, 95%CI 2.01-19.65, p. 0.003); a similar difference was observed on day 10. LUS score of 5th day of admission had an area under the curve of 0.80, best cut-point of 27, sensitivity and specificity of 0.75 and 0.78 respectively. Conclusion These findings position LUS as a simple and reproducible method to predict the course of COVID-19 patients.

RESUMO Objetivo Avaliar o desempenho da ultrassonografia pulmonar para determinar a evolução em curto prazo de pacientes com COVID-19 internados na unidade de terapia intensiva. Métodos Este é um estudo prospectivo e observacional. Entre julho e novembro de 2020, 59 pacientes foram incluídos e submetidos a pelo menos duas avaliações LUS usando o escore LUS (variação de 0-42) no dia da admissão, dia 5 e 10 de admissão. Resultados A idade foi de 66,5 ± 15 anos, APACHE II foi de 8,3 ± 3,9, 12 (20%) pacientes tinham malignidade, 46 (78%) pacientes tinham ventilação não invasiva / cânula nasal de alto fluxo e 38 (64%) pacientes ventilação mecânica necessária. A mediana de permanência na UTI foi de 12 dias (IQR 8,5-20,5 dias). A mortalidade na UTI ou hospitalar foi de 54%. Na admissão, o escore LUS era de 20,8 ± 6,1; no dia 5 e no dia 10 de admissão, os escores foram 27,6 ± 5,5 e 29,4 ± 5,3, respectivamente (P = 0,007). Com a deterioração do quadro clínico, o escore LUS aumentou, com correlação positiva de 0,52, P <0,001. Pacientes com pior LUS no dia 5 versus melhor pontuação tiveram mortalidade de 76% versus 33% (OR 6,29, IC 95% 2,01-19,65, p. 0,003); uma diferença semelhante foi observada no dia 10. O escore LUS do 5º dia de admissão teve uma área sob a curva de 0,80, melhor ponto de corte de 27, sensibilidade e especificidade de 0,75 e 0,78, respectivamente. Conclusão Esses achados posicionam o LUS como um método simples e reprodutível para predizer a evolução de pacientes com COVID-19.

Dental multisection CT for the placement of oral implants: technique and applications.

Dental computed tomography (CT) is a diagnostic examination for the preoperative evaluation of patients who will undergo placement of oral implants. It can be performed with multidetector CT or more recently with cone-beam CT. The growing older population and the consequent development of edentulism have increased the number of imaging studies performed for preoperative evaluation of dental implantation. Thus, radiologists are becoming more frequently involved in this type of testing. Dental CT is superior to conventional x-ray techniques because superimposition and distortion are eliminated; therefore, possible complications such as injury of the neurovascular bundle and perforation of the maxillary sinuses can be avoided. This noninvasive and fast method provides accurate information about the positions of important structures to allow one to determine the implant required. Dental CT enables analysis of the state, quality, and quantity of bone on two-dimensional and three-dimensional reformatted images, and its high spatial resolution allows exact measurements of the length and width of the alveolar ridge. Inclusion of all this information in the radiology report facilitates achievement of a successful implantation.