Diaphragm thickness and mobility elicited by two different modalities of inspiratory muscle loading in heart failure participants: A randomized crossover study.

OBJECTIVES: To analyze diaphragmatic thickness, at end-inspiration and end-expiration, diaphragmatic thickening index and mobility via US under two different modalities of inspiratory muscle loading, in two different modalities of inspiratory muscle loading and different load intensities at full-vital capacity maneuvers and the relationship between diaphragmatic thickness with pulmonary function tests in participants with HF. METHODS: This randomized crossover trial, enrolled with 17 HF subjects, evaluated diaphragm thickness (Tdi, mm), fractional thickness (TFdi, %), and mobility (mm) US during low and high intensities (30% and 60% of maximal inspiratory pressure-MIP) with two modalities of inspiratory muscle loading mechanical threshold loading (MTL) and tapered flow-resistive loading (TFRL). RESULTS: Both MTL and TFRL produced a increase in Tdi, but only with high intensity loading compared to baseline-2.21 (0.26) vs. 2.68 (0.33) and 2.73 (0.44) mm; p = .01. TFdi was greater than baseline under all conditions, except during low intensity of TFRL. Diaphragm mobility was greater than baseline under all conditions, and high intensity of TFRL elicited greater mobility compared to all other conditions. Additionally, baseline Tdi was moderately correlated with pulmonary function tests. CONCLUSIONS: MTL and TFRL modalities elicit similar increases in diaphragm thickness at loads, but only during high intensity loading it was greater than baseline. Diaphragm mobility was significantly greater than baseline under both loads and devices, and at high intensity compared to low intensity, although TFRL produced greater mobility compared to modalities of inspiratory muscle loading. There is an association between diaphragm thickness and pulmonary function tests.

Reducing Airway Occlusion Time Without Losing Accuracy to Predict Successful Mechanical Ventilator Liberation During the Measurement of the Timed Inspiratory Effort Index.

BACKGROUND: In 2013, a new predictor of successful mechanical ventilation liberation named timed inspiratory effort (TIE) index was devised with the normalization of the maximum inspiratory pressure (obtained within 60 s of unidirectional airway occlusion) with the time at which the value was reached. The aim of this study was to verify whether the presence of a sequence of a certain number of inspiratory effort values between 30-60 s > 1.0 cm H2O/s could predict weaning success in a performance comparable to the TIE index. METHODS: This was a retrospective observational study using 4 databases of previous studies on the TIE index. All patients receiving mechanical ventilation for ≤ 24 h were eligible. Liberation from mechanical ventilation-extubation decisions was made based on performance with spontaneous breathing trials. P < .05 was considered significant. The performance of the TIE index was evaluated by calculating the area under the receiver operating characteristics (AUROC) curve. RESULTS: From 349 eligible patients, 165 subjects were selected for analysis. The AUROC for the TIE index in the studied sample was 0.92 (95% CI 0.87-0.97, P < .001). A sequence of ≤ 4 inspiratory efforts > 1.0 cm H2O/s was found in 51.5% of the subjects, with successful ventilatory liberation occurring in 95.3%. The highest specificity values belonged to the sequence of ≤ 4 and ≤ 5 inspiratory efforts > 1.0 cm H2O/s; the highest positive predictive value and positive likelihood ratio belonged to the sequence of ≤ 4 inspiratory efforts > 1.0 cm H2O/s. The mean time that could have been spared if the procedure were interrupted after the first sequence of 4 inspiratory efforts > 1.0 cm H2O/s was 23 ± 3 s. CONCLUSIONS: The presence of a sequence of ≤ 4 inspiratory efforts > 1.0 cm H2O/s during the TIE index measurement was a reliable predictor of weaning success, which could allow timely interruption of the procedure and entail a substantial reduction in airway occlusion time.

Reliability and Validity of Maximal Respiratory Pressures.

BACKGROUND: Maximal respiratory pressure is used to assess the inspiratory and expiratory muscles strength by using maximal inspiratory pressure (PImax) and maximal expiratory pressure (PEmax). This study aimed to summarize and evaluate the reliability and validity of maximal respiratory pressure measurements. METHODS: This systematic review followed the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) recommendations and was reported by using the PRISMA checklist. Studies published before March 2023 were searched in PubMed and EMBASE databases. RESULTS: A total of 642 studies were identified by using the online search strategy and manual search (602 and 40, respectively). Twenty-three studies were included. The level of evidence for test-retest reliability was moderate for PImax and PEmax (intraclass correlation coefficient > 0.70 for both), inter-rater reliability was low for PImax and very low for PEmax (intraclass correlation coefficient > 0.70 for both), and the measurement error was very low for PImax and PEmax. In addition, concurrent validity presented a high level of evidence for PImax and PEmax (r > 0.80). CONCLUSIONS: Only concurrent validity of maximal respiratory pressure measured with the manometers evaluated in this review presented a high level of evidence. The quality of clinical studies by using maximal respiratory pressure would be improved if more high-quality studies on measurement properties, by following well established guidelines and the COSMIN initiative, were available.

Inspiratory muscle endurance is similarly reduced in the early and late stages of chronic Chagas heart disease.

OBJECTIVE: Inspiratory muscle strength (IMS) appears to be reduced in subjects with chronic Chagas heart disease (CHD), especially in the presence of heart failure (HF). However, only one study about IMS and inspiratory muscle endurance (IME) in those with CHD without heart failure is available. This study aimed to compare IMS and IME in subjects with CHD in the presence and absence of HF. METHODS: This is a cross-sectional study in which 30 CHD adult patients were divided into CHD-CC group (initial phase of CHD, without HF; n = 15) and CHD-HF group (advanced phase of CHD, with HF; n = 15). We assessed IMS by maximum inspiratory pressure (MIP) and IME by incremental (Pthmax) and constant load (TLim) tests. Reduced IMS and IME were considered by predicted MIP values <70% and Pthmax/MIP <75%, respectively. RESULTS: Inspiratory muscle weakness (IMW) was more frequent in CHD-HF than in CHD-CC (46.7% vs. 13.3%; p = 0.05), and both groups had high frequencies of reduced IME (93.3% CHD-CC vs. 100.0% CHD-HF; p = 0.95). Age-adjusted logistic regression analysis using HF as a dependent variable showed that HF was associated with an increased chance of IMW compared with the CHD-CC group (OR = 7.47; p = 0.03; 95% CI 1.20-46.19). CONCLUSION: This study suggests that, in patients with CHD, HF is associated with IMW, and that reduction of IME is already present in the initial phase, similar to the advanced phase with HF.

Leucoencefalopatia tóxica por inhalación de heroína "Chasing the Dragon": serie de casos / Toxic Leukoencephalopathy by inhaling heroin "Chasing the Dragon": case series

RESUMEN INTRODUCCIÓN: La leucoencefalopatia tóxica es una afección que compromete la sustancia blanca por exposición a sustancias tóxicas. La heroina es una de las implicadas en el desarrollo de la leucoencefalopatia con diferencias exclusivas que suceden con la inhalación según las diversas técnicas en comparación al uso intravenoso, bien sea de la heroína o de otras sustancias psicoactivas. En esta serie describimos cinco casos, de sexo masculino, que desarrollaron leucoencefalopatia espongiforme por heroína (LEH) posterior a la inhalación de vapores, en un hospital del sistema de salud público en la ciudad de Armenia, Colombia. OBJETIVO: El objetivo de este estudio es describir las características demográficas, clínicas, hallazgos de laboratorio e imágenes diagnósticas, así como la mortalidad asociada a LEH en la muestra estudiada. MÉTODOS: Recolección de datos de historias clinicas y búsqueda de imágenes registradas en el Hospital San Juan de Dios de Armenia durante el periodo 2017-2018. RESULTADOS: Se obtienen cinco casos clínicos de pacientes usuarios de vapores inhalados de heroina, quienes ingresan con signos neurológicos de predominio motores y extrapiramidales, con el signo radiológico clásico de "Chasing the Dragon" en estudios de TC cerebral simple en todos los casos. De los cinco casos se presenta un deceso, determinando una mortalidad de 20% comparado con un 25% de mortalidad reportado en la literatura. CONCLUSIONES: La LEH suele estar subdiagnosticada dado que suele confundirse con un trastorno neuropsiquiatríco o de la conducta asociada al consumo de sustancias psicoactivas (SPA), el diagnóstico se realizó con los hallazgos típicos en las imágenes de TC cerebral simple. Se debe tener en cuenta las estadísticas sobre consumo de heroína a la hora de realizar el abordaje de un paciente con historial de consumo de SPA y los signos neurológicos para relacionarlos con esta etiologia y dar un manejo integral a estos pacientes.

ABSTRACT IlNTRODUCTION: Toxic leukoencephalopathy is a condition that compromises the encephalic white matter due to exposure to toxic substances. Heroin is one of those involved in the development of leukoencephalopathy and there are certain differences that occur with its inhalation with the different techniques compared to intravenous use, either heroin or other psychoactive substances. In this serie, we describe five cases of male sex who developed heroin spongiform leukoencephalopathy (HSLE) after inhalation of vapors, in a Hospital of the public health system in the city of Armenia, Colombia. OBJECTIVES: The objective of this study is to describe the demographic and clinical characteristics, laboratory findings and diagnostic images, as well as the mortality associated with HSLE in the sample studied. METHODS: Collection of data from medical records and search of images registered at the San Juan de Dios Hospital in Armenia during the period 2017-2018. RESULTS: Five clinical cases were obtained of patients who were users of inhaled heroin vapors and were admitted to the hospital with predominantly motor and extrapyramidal neurological signs, with simple brain CT studies showing the classic radiological sign of "Chasing the Dragon" in all five cases. One death was presented, with a mortality of 20% compared to the 25% mortality that has been reported in the scientific literature. CONCLUSIONS: HSLE is usually underdiagnosed since it is often confused with a neuropsychiatric or behavioral disorder associated with the consumption of psychoactive substances (PAS). The diagnosis was made with the typical findings in simple brain CT images. Statistics on heroin use must be considered when approaching a patient with a history of PAS use and neurological signs, to relate them to this etiology and provide comprehensive management to these patients.

Minimum Alveolar Concentration of Sevoflurane as a Single Hypnotic Agent to Maintain BIS Below 50 in Patients During Normothermic Cardiopulmonary Bypass

OBJECTIVES: Minimum alveolar concentration (MAC) of volatile anesthetic agents to maintain bispectral index (BIS) below 50 in 50% of patients was defined as MACBIS50. The primary objective of this study was to determine the minimum alveolar concentration of sevoflurane as a single hypnotic agent to maintain BIS below 50 in patients during normothermic cardiopulmonary bypass. DESIGN: Prospective and observational study. SETTING: Dante Pazzanese Institute of Cardiology, Brazil. PARTICIPANTS: Eighteen consecutive patients scheduled for elective coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) under general anesthesia, American Society of Anesthesiologists physical status classes III and IV, between the ages of 40 and 70, were included in the study. METHODS: All patients underwent inhalation induction with facial mask using sevoflurane (Cristália) in 100% oxygen, pancuronium (Cristália) 0.1 mg/kg, and sufentanil (Cristália) 0.5 µg/kg intravenously (IV) administered. A single bolus dose of sufentanil, 1.0 µg/kg IV, was administered before surgical incision. MACBIS50 was calculated using the midpoint concentration of patients involving a crossover (BIS < or ≥50) according to Dixon's Up-and-Down method. The Up-and-Down sequence also was analyzed by probit test that enabled the authors to obtain the effective dose 50 (ED50) and effective dose 95 (ED95) of sevoflurane to maintain a BIS value <50, with a 95% confidence interval (95% CI) of the mean. RESULTS: A total of 15 patients were analyzed in this study. MACBIS50 of sevoflurane as a single hypnotic agent was 0.82% (95% CI 0.47-1.16) in patients aged 40 to 70 undergoing CABG during normothermic CPB. The ED50 and ED95 of sevoflurane to maintain a BIS value <50 for the same context were 0.73% (95% CI 0.45-1.00) and 1.39 (95% CI 0.42-2.37) by means of probit analysis, respectively. CONCLUSION: MACBIS50 of sevoflurane as a single hypnotic agent was 0.82% in patients undergoing CABG during normothermic CPB.

IInvestigation of possible oxidative damage caused by formaldehyde exposure in the rat's heart and aorta tissue / Investigación de posible daño oxidativo causado por la exposición al formaldehído en el corazón de la rata y tejido de la aorta

SUMMARY: Formaldehyde (FA) is a toxic substance used frequently in the field of medicine as well as in many industrial areas. Especially people working in the field of anatomy, histology, and pathology are in high risk group because of the use of the FA. Studies showing the effects of FA on the cardiovascular system are few in number. The purpose of the present study was to investigate the effects of FA exposure, which we believe can cause oxidative stress, on the heart and aorta with various biochemical analyses. A total of 24 Wistar Albino rats were used in our study. We divided the rats into 3 groups as the Control Group (CG), the group exposed to low-dose FA (avg. 1 ppm) (DDG) Group, and the group exposed to high-dose FA (avg. 10 ppm) (YDG). At the end of the subchronic FA exposure, the blood samples, heart and aorta tissues of the rats were taken and subjected to biochemical analyses. As a result of the analyses, statistically significant differences were detected between CG (2.96?0.85 ng/mg), and HDG (2.08?0.77 ng/mg) in aortic tissues in TXNIP analysis (p<0.05). In heart tissues, significant differences were detected between CG (0.73?0.27 ng/mg) and LDG (1.13?0.22 ng/mg) (p<0.05). Statistically significant differences were also detected between CG (1.98?0.31 mM/ml) and YDG (2.43?0.31 mM/ml) in serum MDA analyses (p<0.05). It was shown that subchronic application of FA to LDG rats through inhalation had no effects on apoptosis markers in heart tissues. More studies are required to show FA toxicity and the mechanism of action of pathology on the cardiovascular system. We believe that our study will contribute to clarifying the roles of mild and subchronic exposure of FA in heart and aortic tissues in terms of oxidative stress risk.

RESUMEN: El formaldehído es una sustancia tóxica que se utiliza con frecuencia en el campo de la medicina, así como en muchas áreas industriales. Especialmente las personas que trabajan en el area de la anatomía, y patología se encuentran en el grupo de alto riesgo debido al uso de esta sustancia. Pocos son los estudios que muestran los efectos del formaldehído en el sistema cardiovascular. El propósito del presente estudio fue investigar a través de análisis bioquímicos, los efectos de la exposición a formaldehído, que podría causar estrés oxidativo, en el corazón y la aorta. Se utilizaron un total de 24 ratas Albinas Wistar. Dividimos a las ratas en 3 grupos: grupo control (GC), grupo expuesto a dosis bajas de AG (promedio 1 ppm) (DDG) y grupo expuesto a dosis altas de AG (promedio 10 ppm) (YDG). Al término de la exposición a FA subcrónica, se tomaron muestras de sangre, tejido cardíaco y aorta de las ratas y se sometieron a análisis bioquímicos. Como resultado de los análisis, se detec- taron diferencias estadísticamente significativas entre GC (2,96 ? 0,85 ng / mg) y HDG (2,08 ? 0,77 ng / mg) en los tejidos aórticos en el análisis TXNIP (p <0,05). En los tejidos cardíacos se detectaron diferencias significativas entre GC (0,73 ? 0,27 ng / mg) y LDG (1,13 ? 0,22 ng / mg) (p <0,05). También se detectaron diferencias estadísticamente significativas entre CG (1,98 ? 0,31 mM / ml) y YDG (2,43 ? 0,31 mM / ml) en los análisis de MDA en suero (p <0,05). Se demostró que la aplicación subcrónica de formaldehído a ratas LDG a través de la inhalación no tuvo efectos sobre los marcadores de apoptosis en los tejidos del corazón. Se requieren más estudios para demostrar la toxicidad de los AG y el mecanismo de acción de la patología en el sistema cardiovascular. Creemos que nuestro estudio contribuirá a aclarar las funciones de la exposición leve y subcrónica de formaldehído en los tejidos cardíacos y aórticos en términos de riesgo al estrés oxidativo.

Neumonitis química grave secundaria a la inhalación de talco. A propósito de un caso pediátrico / Severe chemical pneumonitis secondary to talc inhalation. A pediatric case

El talco, un silicato de magnesio hidratado, formó parte durante décadas del cuidado tradicional de lactantes y niños pequeños. Si bien en los niños su inhalación aguda, que suele ser accidental durante el cambio de pañales, no es frecuente, es una condición potencialmente peligrosa, que puede provocar dificultad respiratoria grave e incluso cuadros mortales. Se describe el grave compromiso respiratorio por neumonitis química asociado con la inhalación accidental de talco en un lactante de 14 meses. El niño presentó un cuadro de dificultad respiratoria con requerimiento de asistencia respiratoria mecánica (ARM) durante una semana. En cuanto al tratamiento, no existe un estándar, se utilizaron antibióticos y corticoides sistémicos y aerosolterapia. No presentó complicaciones en otros órganos o sistemas. Su evolución fue favorable, se pudo externar al décimo día de internación y presentó posteriormente episodios aislados de hiperreactividad bronquial.

Talc is a hydrated magnesium silicate. It was part of traditional infant and young child care for decades. In children, its acute inhalation, generally accidental during diaper changes, although not frequent, is a potentially dangerous condition, and can cause severe respiratory distress and even death. We describe the case of a 14-month child who had an accidental inhalation of talc, chemical pneumonitis and severe respiratory compromise. The patient had acute respiratory distress syndrome requiring mechanical ventilation for one week. There is no standard treatment, we used systemic antibiotics and corticosteroids and aerosol therapy. He did not have complications in other organs or systems. He was hospitalized for ten days. In the follow up, he had isolated episodes of bronchial hyperresponsiveness.

Effects of diaphragmatic control on multiparametric analysis of the sniff nasal inspiratory pressure test and inspiratory muscle activity in healthy subjects.

BACKGROUND: We investigated the influence of diaphragmatic activation control (diaphC) on the relaxation rate, contractile properties and electrical activity of the inspiratory muscles of healthy subjects. Assessments were performed non-invasively using the sniff inspiratory pressure test (SNIP) and surface electromyography, respectively. METHODS: Twenty-two subjects (10 men and 12 women) performed 10 sniff maneuvers in two different days: with and without diaphC instructions. For the SNIP test with diaphC, the subjects were instructed to perform intense activation of the diaphragm. The tests with the best SNIP values were used for analysis. RESULTS: The maneuver with diaphC when compared to the maneuver without diaphC exhibited significant lower values for: SNIP (p <0.01), maximum relaxation rate (MRR) (p <0.01), maximum rate of pressure development (MRPD) (p <0.01), contraction times (CT) (p = 0.02) and electrical activity of the sternocleidomastoid (SCM) (p <0.01), scalene (SCL) (p = 0.01) and intercostal (CI) (p = 0.03) muscles. In addition, the decay constant (tau, τ) and relaxation time (½ RT) did not present any changes. CONCLUSION: The diaphragmatic control performed during the SNIP test influences the inspiratory pressure and the contractile properties of inspiratory muscles. This occurs due to changes in the pattern of muscle recruitment, which change force velocity characteristics of the test. Thus, instruction on diaphC should be encouraged for better performance of the SNIP test and for evaluation targeting the diaphragm muscle activity.

Unraveling the Mechanisms Underlying Irregularities in Inspiratory Rhythm Generation in a Mouse Model of Parkinson's Disease.

Parkinson's disease (PD) is a neurodegenerative disorder anatomically characterized by a progressive loss of dopaminergic neurons in the substantia nigra compacta (SNpc). Much less known, yet clinically very important, are the detrimental effects on breathing associated with this disease. Consistent with the human pathophysiology, the 6-hydroxydopamine hydrochloride (6-OHDA) rodent model of PD shows reduced respiratory frequency (fR) and NK1r-immunoreactivity in the pre-Bötzinger complex (preBötC) and PHOX2B+ neurons in the retrotrapezoid nucleus (RTN). To unravel mechanisms that underlie bradypnea in PD, we employed a transgenic approach to label or stimulate specific neuron populations in various respiratory-related brainstem regions. PD mice were characterized by a pronounced decreased number of putatively rhythmically active excitatory neurons in the preBötC and adjacent ventral respiratory column (VRC). Specifically, the number of Dbx1 and Vglut2 neurons was reduced by 47.6% and 17.3%, respectively. By contrast, inhibitory Vgat+ neurons in the VRC, as well as neurons in other respiratory-related brainstem regions, showed relatively minimal or no signs of neuronal loss. Consistent with these anatomic observations, optogenetic experiments identified deficits in respiratory function that were specific to manipulations of excitatory (Dbx1/Vglut2) neurons in the preBötC. We conclude that the decreased number of this critical population of respiratory neurons is an important contributor to the development of irregularities in inspiratory rhythm generation in this mouse model of PD.SIGNIFICANCE STATEMENT We found a decreased number of a specific population of medullary neurons which contributes to breathing abnormalities in a mouse model of Parkinson's disease (PD).

Agua aerosolizada por el embudo y la cola de novia del dique San Roque como potencial vía de inhalación y/o ingesta por pobladores y turistas expuestos / Water aerosolized by the funnel and bridal tail of the San Roque dam as a potential route of inhalation and/or ingestion by exposed residents and tourists

El virus SARS-CoV-2 es excretado vía fecal por portadores asintomáticos (1). Se ha confirmado. el hallazgo de su genoma, tanto en aguas residuales como superficiales de la cuenca del lago San Roque mediante un estudio financiado por el Observatorio de Salud en colaboración con el Instituto de Virología de Córdoba (2). Además, se ha determinado fehacientemente en el agua del embalse, la presencia de enterovirus viables, cianobacterias, cianotoxinas y demás indicadores de contaminación fecal con niveles superiores a los permitidos en las Directrices Sanitarias del Ministerio de Salud de la Nación para uso seguro de aguas recreativas (Resol Min 25/2016)(3)(4). Por medio del presente trabajo, se confirmó que las personas podrían estar expuestas a la potencial inhalación y/o ingesta de agua que pueda contener cianobacterias y cianotoxinas en un contexto recreativo particular como es la visita turística o laboral a un fenómeno hídrico donde se aerosoliza agua durante un afloramiento cianobacteriano (5). No se detectó la presencia de Sars cov2, enterovirus y otros indicadores de contaminación fecal, en el agua aerosolizada por el embudo y la cola de novia del Dique San Roque, de la ciudad cordobesa de Villa Carlos Paz, aunque sí en el agua recreativa en diferentes puntos del embalse (6). Pero el número de turistas expuestos, la cercanía al fenómeno de vaporización de agua a lugares de venta de comida ambulante y la magnitud del fenómeno, sumado a la alerta nacional por cianobacterias emitida por el Ministerio de Salud de la Nación, tornan de mayor relevancia los hallazgos relacionados a cianobacterias y cianotoxinas. La necesidad de un monitoreo permanente de lo niveles de estos agentes existentes en agua aerosolizada por el embudo y la cola de novia del embalse, resulta evidente, ya que como se mencionó anteriormente, es un lugar sumamente concurrido por pobladores, comerciantes de comida al paso y turistas que llegan junto a susmfamilias a disfrutar de dicho espectáculo hídrico, generando un potencial riesgo de inhalación o ingesta (7). Se tomaron muestras de agua colindantes al paredón del dique, a la toma de agua para la ciudad de Córdoba y en otros sitos que resultaron de la condensación de dichos aerosoles. En el laboratorio se analizó la presencia del genoma de Sars-CoV2, entero-virus, cianobacterias, cianotoxinas y otros indicadores de contaminación fecal. Se hallaron cianobacterias en el 85% de las muestras analizadas y se confirmó la presencia de cianotoxinas en el 95% de las mismas. Este conocimiento posibilitaría al estado, implementar estrategias de prevención de patologías relacionadas a la contaminación fecal del agua y detectar de forma temprana potenciales vías de inhalación de cianobacterias y cianotoxinas, tanto en pobladores como en turistas expuestos que visitan el embalse, aplicando acciones de promoción y prevención en dicho lugar, durante el fenómeno mencionado, para disminuir al mínimo el contacto de las personas con los aerosolesmexpulsados. Resulta pertinente, además, sugerir al Ministerio de Salud de la Nación que agregue notas preventivas en las Directrices Sanitarias para Uso Seguro de Aguas Recreativas (8), en estemparticular uso recreativo y turístico del agua. Estos hallazgos demuestran que se exponen a un potencial riesgo por inhalación las personas expuestas a este fenómeno hídrico en la ciudadn cordobesa de Villa Carlos Paz y/o posiblemente en otros lugares con semejantes características en el resto del país (9).

Reactive airways dysfunction syndrome following inhalation of hydrogen chloride vapor

Hydrogen chloride is available commercially as an anhydrous gas or an aqueous solution, hydrochloric acid. Exposure to this gas has been associated with the development of reactive airways dysfunction syndrome. However, there are few published reports. A 37-year-old woman developed progressive bronchospasm and acute respiratory failure after cleaning an enclosed space with an unknown concentration of hydrochloric acid gas from a cleaning substance. She had no prior history of asthma or atopy. Severe bronchospasm developed, leading to hypoxemia and diffuse interstitial infiltrates, necessitating orotracheal intubation and admission to the intensive care unit. Asthma-like symptoms such as cough, wheezing, and dyspnea; requiring bronchodilators, and repeated hospitalizations are persistent a year after the accident. Pulmonary function testing showed mild airflow obstruction.

Abordagem Farmacocinética -Farmacodinâmica (PK/PD) Em Pacientes Sépticos Grandes Queimados: Avaliação do Meropenem Em Adultos Jovens Após 1g Q8h, Infusão Estendida / Pharmacokinetic -Pharmacodynamic Approach (PK/PD) In Septic Burn Young Adult Patients: Meropenem 1g q8h, extended infusion

Introdução: O Meropenem é um carbapenêmico de amplo espectro, prescrito na terapia do choque séptico nos pacientes graves adultos de UTI, com infecções graves causadas por patógenos Gram-negativos susceptíveis. Objetivo: Avaliar a efetividade do Meropenem em pacientes sépticos queimados, investigar a farmacocinética na fase precoce e na fase tardia durante o curso do choque séptico e o impacto no desfecho clínico. Ética, Casuística e Procedimentos: Aprovação ética, registro CAAE07525118.3.0000.0068; nenhum conflito de interesse declarado foi obtido dos autores. Após assinatura do TCLE pelo responsável legal, o paciente foi incluído no protocolo. Investigou-se a população de 15 pacientes sépticos grandes queimados, adultos de ambos os gêneros (10 M/ 5F) com função renal preservada (Clcr> 50 ml/min). As características demográficas da população de pacientes incluídos foram idade de 37(33 -41) anos, 71(59,5 - 80,0) kg e índice de massa corpórea de 24,3(20,6-24,7) kg/m2, medianas (interquartil). Registrou-se o escore SAPS*3 54(47-59) de admissão dos pacientes na UTI; a superfície corpórea total queimada foi de 33% (18,3-34,4), SCTQ medianas (interquartil). A lesão inalatória e o uso de vasopressores foram registrados em 12/15 pacientes após trauma térmico/ elétrico (10/5). Após intubação orotraqueal, a ventilação mecânica foi registrada em 13/15 pacientes. A terapia empírica do choque séptico com Meropenem no regime de 1g q8h, por infusão estendida de 3 horas, foi iniciada após a coleta das culturas. Realizou-se coleta seriada de amostras sanguíneas para dosagem sérica do antimicrobiano por cromatografia líquida. Aplicou-se o modelo aberto monocompartimental para estudo da farmacocinética e estimativa dos parâmetros, meia vida biológica, depuração total corporal e volume de distribuição. A abordagem farmacocinética-farmacodinâmica (PK-PD) foi baseada na dosagem sérica do Meropenem e na taxa de eliminação, para estimativa do índice de predição de efetividade (% ƒ Δ?T> CIM), considerando o novo alvo terapêutico de 100% ƒ Δ?T> CIM. Utilizou-se estatística não paramétrica pela aplicação do teste de Wilcoxon para dados pareados e testes de correlação linear. Resultados e Discussão: Registrou-se alteração dos parâmetros farmacocinéticos nos pacientes sépticos investigados frente aos dados reportados para voluntários sadios. Evidenciou-se redução na taxa de eliminação e da depuração total corporal; o prolongamento da meia vida biológica ocorreu pelo aumento do volume de distribuição. Estas alterações impactaram estendendo a cobertura do Meropenem, na fase precoce do choque séptico, contra os patógenos de susceptibilidade intermediária com CIM 4 mg/L. Conclusão: A cobertura do Meropenem foi garantida contra os patógenos isolados até CIM 2 mg/L para todos os pacientes. Adicionalmente, ocorreu a erradicação de patógenos de susceptibilidade intermediária CIM 4 mg/L, pela cobertura que foi atingida apenas na fase precoce do choque séptico. Então, a abordagem PK / PD contribui para a obtenção do resultado

Background: Meropenem is a carbapenêmic, agent largely prescribed to septic patients in the Intensive Care Units with severe infections caused by Gram-negative susceptible strains. Objective: To evaluate Meropenem effectiveness in ICU septic burn patients and to investigate pharmacokinetic changes that could impact the desired outcome by eradication of Gram-negative strains of intermediate susceptibility. Ethics, Casuistry and Methods: Ethical approval register CAEE 07525118.3.0000.0068was obtained; no conflicts of interest to declare were obtained from all authors. Fifteen burn adult patients of both genders (10 M/ 5F) with preserved renal function (Clcr> 50 ml/min) were investigated after TCLE signed. Demographic characteristics of patients included were: 37(33 -41) years, 71(59.5- 80.0) kg, 24.3 (20.6-24.7) kg/m2 body mass index, medians (quartiles). ICU patients admission was based on SAPS*3 score of 54(47-59), 33% (18.3-34.4) TBSA medians (quartiles). Inhalation injury and vasopressors requirements were in 12/15 patients after fire/electricity (10/5, proportion). Mechanical ventilation was necessary in 13/15 patients. Antimicrobial therapy of septic shock with meropenem 1g q8h 3 hours infusion started, after cultures collection. A serial of blood samples was collected from the central catheter after a minimum of 48 hours of Meropenem therapy for drug serum measurements by liquid chromatography. One compartment open model was applied to estimate PK data related to the elimination rate constant, biological half-life, total body clearance and volume of distribution PK/PD approach was based on serum trough levels and elimination rate constant to estimate the predictive index of drug effectiveness (% fΔT>CIM), based on the new PK/PD target 100% fΔT>CIM. Non parametric statistics was applied, Wilcoxon test for paired data and linear correlations. Results: Pharmacokinetic changes occurred in septic burn patients investigated by comparison with results reported in healthy volunteers as follows by the reduction on elimination rate constant and also on total body clearance, in spite of preserved renal function for all patients included. In addition, a prolongation of biological half-life occurred as a consequence of increases on volume of distribution. Pharmacodynamics was impacted by PK changes only at the earlier period of septic shock, once pathogens isolated of intermediate susceptibility up to MIC 4 mg/L were eradicated. Conclusion: Meropenem effectiveness was guaranteed against Gram-negative up to MIC 2 mg/L strains isolated for all patients. In addition, eradication of pathogens of intermediate susceptibility MIC 4 mg/L strains occurred only at the earlier period of septic shock. Then, PK/PD approach contributes to desired outcome achievement

Guia prático de aerossolterapia na criança e no adolescente: Documento conjunto da Associação Brasileira de Alergia e Imunologia e Sociedade Brasileira de Pediatria / Practical guide to aerosol therapy in children and adolescents: Joint document from the Brazilian Association of Allergy and Immunology and the Brazilian Society of Pediatrics

A via inalatória é a mais adequada para o tratamento das doenças respiratórias. Muitos fatores influenciam na deposição pulmonar do fármaco inalado, e, consequentemente, no sucesso terapêutico, desde fatores relacionados ao indivíduo, como questões anatômicas das vias aéreas, dinâmica respiratória, doença de base e técnica correta, até situações relacionadas às questões aerodinâmicas das partículas que compõem o aerossol, como o tamanho (diâmetro aerodinâmico mediano de massa) e a homogeneidade das partículas (desvio padrão geométrico). Nos últimos anos os dispositivos inalatórios se aperfeiçoaram, buscando atender às características necessárias que garantam uma deposição pulmonar satisfatória dos fármacos. A escolha do dispositivo inalatório deve ser individualizada, e o conhecimento das particularidades de cada dispositivo e das vantagens e desvantagens instrumentaliza o profissional na decisão, e impacta diretamente no sucesso terapêutico da medicação utilizada.

The inhalation route is the most adequate for the treatment of respiratory diseases. Many factors influence pulmonary deposition of the inhaled drug and, consequently, therapeutic success. They include individual factors such as airway anatomy, respiratory dynamics, underlying disease, and correct technique, as well as factors related to the aerodynamics of aerosol particles such as size (mass median aerodynamic diameter) and homogeneity of the particles (geometric standard deviation). In recent years, inhalation devices have improved to comply with the necessary characteristics that guarantee a satisfactory pulmonary deposition of drugs. The choice of the inhalation device must be individualized, and the knowledge about the features of each device and their advantages and disadvantages instrumentalizes health professionals in the decision and impacts directly the therapeutic success of the medication used.

Review of indoor aerosol generation, transport, and control in the context of COVID-19.

The coronavirus disease-2019 (COVID-19) pandemic has heightened the awareness of aerosol generation by human expiratory events and their potential role in viral respiratory disease transmission. Concerns over high severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) viral burden of mucosal surfaces has raised questions about the aerosol-generating potential and dangers of many otorhinolaryngologic procedures. However, the risks of aerosol generation and associated viral transmission by droplet or airborne routes for many otorhinolaryngology procedures are largely unknown. Indoor aerosol and droplet viral respiratory transmission risk is influenced by 4 factors: (1) aerosol or droplet properties; (2) indoor airflow; (3) virus-specific factors; and (4) host-specific factors. Herein we elaborate on known aerosol vs droplet properties, indoor airflow, and aerosol-generating events to provide context for risks of aerosol infectious transmission. We also provide simple but typically effective measures for mitigating the spread and inhalation of viral aerosols in indoor settings. Understanding principles of infectious transmission, aerosol and droplet generation, as well as concepts of indoor airflow, will assist in the integration of new data on SARS-CoV-2 transmission and activities that can generate aerosol to best inform on the need for escalation or de-escalation from current societal and institutional guidelines for protection during aerosol-generating procedures.

Inspiratory Muscle Training Potentiates the Beneficial Effects of Proportional Assisted Ventilation on Exertional Dyspnea and Exercise Tolerance in COPD: A Proof-of-Concept Randomized and Controlled Trial.

During pulmonary rehabilitation, a subset of subjects with COPD requires adjunct therapy to achieve high-intensity training. Both noninvasive ventilation (NIV) and inspiratory muscle training (IMT) are available to assist these subjects. We aimed to prime the respiratory muscles before NIV with IMT, anticipating additive effects for maximal exercise tolerance (Tlim) and dyspnea/leg fatigue relief throughout the exercise as primary outcomes. Changes in the respiratory pattern were secondary outcomes. COPD subjects performed a total of four identical constant work rate tests on a cycle ergometer at 75% of maximum work rate, under control ventilation (SHAM, 4 cm H2O) or proportional assisted ventilation (PAV, individually adjusted), before and after 10 sessions of high-intensity IMT (three times/week) during 30 days. Two-way RM ANOVA with appropriate corrections were performed. Final analysis in nine subjects showed improved Tlim (Δ = 111 s) and lower minute-ventilation (Δ = 4 L.min-1) at exhaustion, when comparing the IMT effects within the PAV modality (p = 0.001 and p = 0.036, respectively) and improved Tlim for PAV vs. SHAM (PAV main-effect, p = 0.001; IMT main-effect, p = 0.006; PAV vs. IMT interaction, p = 0.034). In addition, IMT + PAV association, compared to PAV alone, resulted in lower respiratory frequency (IMT main-effect, p = 0.009; time main-effect, p < 0.0001; IMT vs. time interaction, p = 0.242) and lower inspiratory time related to duty cycle (IMT main-effect, p = 0.018; time main-effect, p = 0.0001; IMT vs. time interaction, p = 0.004) throughout exercise. The addition of IMT prior to a PAV-supported aerobic bout potentiates exercise tolerance and dyspnea relief and induces favourable changes in ventilatory pattern in severe COPD during high-intensity training (Brazilian Registry of Clinical Trials, number RBR-6n3dzz).

Inspiratory muscles contributions to postural control in healthy older women.

It was hypothesized that induced inspiratory muscles effort, by an acute inspiratory resistance load (IRL) use, increases the postural sway and the neuromuscular activity of postural muscles in older adults. Fifteen older women breathed spontaneously, controlled (15 cycles/minute), and with acute IRL (15 cycles/minute and target load of 30 % of maximal inspiratory pressure) in random order. The breathing tasks were performed in an orthostatic position (eyes closed) during one minute on a baropodometer plate to acquire center-of-pressure (COP) oscillations and with electromyography (EMG) recording. The root mean square (RMS) of EMG was calculated. COP oscillations were higher with IRL use than spontaneous and controlled breathing tasks, but not between spontaneous and controlled conditions. EMG activity of Tibialis anterior and Soleus muscles were higher with IRL use in comparison to spontaneous and controlled breathing conditions. In conclusion, IRL use influenced the postural control through increased postural sway and neuromuscular compensation of the lower limbs in older women.

Effects of acute inspiratory loading during treadmill running on cerebral, locomotor and respiratory muscle oxygenation in women soccer players.

Respiratory limitation can be a primary mechanism for exercise cessation in female athletes. This study aimed to assess the effects of inspiratory loading (IL) on intercostal muscles (IM), vastus lateralis (VL) and cerebral (Cox) muscles oxygenation in women soccer players during high-intensity dynamic exercise. Ten female soccer players were randomized to perform in order two constant-load tests on a treadmill until the exhaustion time (Tlim) (100 % of maximal oxygen uptake- V˙O2). They breathed freely or against a fixed inspiratory loading (IL) of 41 cm H2O (∼30 % of maximal inspiratory pressure). Oxygenated (Δ[OxyHb]), deoxygenated (Δ[DeoxyHb]), total hemoglobin (Δ[tHb]) and tissue saturation index (ΔTSI) were obtained by NIRs. Also, blood lactate [La-] was obtained. IL significantly reduced Tlim (224 ± 54 vs 78 ± 20; P < 0.05) and increased [La-], V˙O2, respiratory cycles and dyspnea when corrected to Tlim (P < 0.05). IL also resulted in decrease of Δ[OxyHb] of Cox and IM during exercise compared with rest condition. In addition, decrease of Δ[OxyHb] was observed on IM during exercise when contrasted with Sham (P < 0.05). Furthermore, significant higher Δ[DeoxyHb] of IM and significant lower Δ[DeoxyHb] of Cox were observed when IL was applied during exercise in contrast with Sham (P < 0.05). These results were accompanied with significant reduction of Δ[tHb] and ΔTSI of IM and VL when IL was applied (P < 0.05). High-intensity exercise with IL decreased respiratory and peripheral muscle oxygenation with negative impact on exercise performance. However, the increase in ventilatory work did not impact cerebral oxygenation in soccer players.