Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 1.439
Filtrar
1.
BMJ Case Rep ; 14(3)2021 Mar 02.
Artigo em Inglês | MEDLINE | ID: mdl-33653852

RESUMO

The COVID-19 pandemic has dealt a devastating blow to healthcare systems globally. Approximately 3.2% of patients infected with COVID-19 require invasive ventilation during the course of the illness. Within this population, 25% of patients are affected with neurological manifestations. Among those who are affected by severe neurological manifestations, some may have acute cerebrovascular complications (5%), impaired consciousness (15%) or exhibit skeletal muscle hypokinesis (20%). The cause of the severe cognitive impairment and hypokinesis is unknown at this time. Potential causes include COVID-19 viral encephalopathy, toxic metabolic encephalopathy, post-intensive care unit syndrome and cerebrovascular pathology. We present a case of a 60 year old patient who sustained a prolonged hospitalization with COVID-19, had a cerebrovascular event and developed a persistent unexplained encephalopathy along with a hypokinetic state. He was treated successfully with modafinil and carbidopa/levodopa showing clinical improvement within 3-7 days and ultimately was able to successfully discharge home.


Assuntos
Encefalopatias , Carbidopa/administração & dosagem , Hipocinesia , Levodopa/administração & dosagem , Modafinila/administração & dosagem , Reabilitação/métodos , /isolamento & purificação , Coagulação Sanguínea , Encefalopatias/fisiopatologia , Encefalopatias/virologia , /complicações , /terapia , Estimulantes do Sistema Nervoso Central/administração & dosagem , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/etiologia , Cuidados Críticos/métodos , Combinação de Medicamentos , Humanos , Hipocinesia/diagnóstico , Hipocinesia/etiologia , Hipocinesia/terapia , /etiologia , /terapia , Imagem por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Respiração Artificial/métodos , Índice de Gravidade de Doença , Resultado do Tratamento , Desmame do Respirador/métodos
2.
JAMA ; 325(12): 1173-1184, 2021 03 23.
Artigo em Inglês | MEDLINE | ID: mdl-33755077

RESUMO

Importance: Although most critically ill patients receive invasive mechanical ventilation (IMV), few studies have characterized how IMV is discontinued in practice. Objective: To describe practice variation in IMV discontinuation internationally, associations between initial discontinuation events and outcomes, and factors associated with the use of select discontinuation strategies and failed initial spontaneous breathing trials (SBTs). Design, Setting, and Participants: Prospective, multinational, observational study of critically ill adults who received IMV for at least 24 hours from 142 intensive care units (ICUs) in 19 countries within 6 regions (27 in Canada, 23 in India, 22 in the UK, 26 in Europe, 21 in Australia/New Zealand, and 23 in the US). Exposures: Receiving IMV. Main Outcomes and Measures: Primary analyses characterized types of initial IMV discontinuation events (extubation, SBT, or tracheostomy) and associations with clinical outcomes (including duration of ventilation, ICU and hospital mortality, and ICU and hospital length of stay). Secondary analyses examined the associations between SBT outcome and SBT timing and clinical outcomes. Results: Among 1868 patients (median [interquartile range] age, 61.8 [48.9-73.1] years; 1173 [62.8%] men) 424 (22.7%) underwent direct extubation, 930 (49.8%) had an initial SBT (761 [81.8%] successful), 150 (8.0%) underwent direct tracheostomy, and 364 (19.5%) died before a weaning attempt. Across regions, there was variation in the use of written directives to guide care, daily screening, SBT techniques, ventilator modes, and the roles played by clinicians involved in weaning. Compared with initial direct extubation, patients who had an initial SBT had higher ICU mortality (20 [4.7%] vs 96 [10.3%]; absolute difference, 5.6% [95% CI, 2.6%-8.6%]), longer duration of ventilation (median of 2.9 vs 4.1 days; absolute difference, 1.2 days [95% CI, 0.7-1.6]), and longer ICU stay (median of 6.7 vs 8.1 days; absolute difference, 1.4 days [95% CI, 0.8-2.4]). Patients whose initial SBT failed (vs passed) had higher ICU mortality (29 [17.2%] vs 67 [8.8%]; absolute difference, 8.4% [95% CI, 2.0%-14.7%]), longer duration of ventilation (median of 6.1 vs 3.5 days; absolute difference, 2.6 days [95% CI, 1.6-3.6]), and longer ICU stay (median of 10.6 vs 7.7 days; absolute difference, 2.8 days [95% CI, 1.1-5.2]). Compared with patients who underwent early initial SBTs, patients who underwent late initial SBTs (>2.3 days after intubation) had longer duration of ventilation (median of 2.1 vs 6.1 days; absolute difference, 4.0 days [95% CI, 3.7-4.5]), longer ICU stay (median of 5.9 vs 10.8 days; absolute difference, 4.9 days [95% CI, 4.0-6.3]), and longer hospital stay (median of 14.3 vs 22.8 days; absolute difference, 8.5 days [95% CI, 6.0-11.0]). Conclusions and Relevance: In this observational study of invasive mechanical ventilation discontinuation in 142 ICUs in Canada, India, the UK, Europe, Australia/New Zealand, and the US from 2013 to 2016, weaning practices varied internationally. Trial Registration: ClinicalTrials.gov Identifier: NCT03955874.


Assuntos
Estado Terminal/terapia , Desmame do Respirador/métodos , Adulto , Idoso , Feminino , Humanos , Unidades de Terapia Intensiva , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Respiração Artificial , Resultado do Tratamento
3.
Medicine (Baltimore) ; 100(13): e25339, 2021 Apr 02.
Artigo em Inglês | MEDLINE | ID: mdl-33787632

RESUMO

BACKGROUND: To the best of our knowledge, no studies have evaluated the effects of inspiratory muscle training (IMT) on recovered COVID-19 patients after weaning from mechanical ventilation. Therefore, this study assessed the efficacy of IMT on recovered COVID-19 patients following mechanical ventilation. METHODS: Forty-two recovered COVID-19 patients (33 men and 9 women) weaned from mechanical ventilation with a mean age of 48.05 ±â€Š8.85 years were enrolled in this pilot control clinical study. Twenty-one patients were equipped to 2-week IMT (IMT group) and 21 matched peers were recruited as a control (control group). Forced vital capacity (FVC%), forced expiratory volume in 1 second (FEV1%), dyspnea severity index (DSI), quality of life (QOL), and six-minute walk test (6-MWT) were assessed initially before starting the study intervention and immediately after intervention. RESULTS: Significant interaction effects were observed in the IMT when compared to control group, FVC% (F = 5.31, P = .041, ηP2 = 0.13), FEV1% (F = 4.91, P = .043, ηP2 = 0.12), DSI (F = 4.56, P = .032, ηP2 = 0.15), QOL (F = 6.14, P = .021, ηP2 = 0.17), and 6-MWT (F = 9.34, P = .028, ηP2 = 0.16). Within-group analysis showed a significant improvement in the IMT group (FVC%, P = .047, FEV1%, P = .039, DSI, P = .001, QOL, P < .001, and 6-MWT, P < .001), whereas the control group displayed nonsignificant changes (P > .05). CONCLUSIONS: A 2-week IMT improves pulmonary functions, dyspnea, functional performance, and QOL in recovered intensive care unit (ICU) COVID-19 patients after consecutive weaning from mechanical ventilation. IMT program should be encouraged in the COVID-19 management protocol, specifically with ICU patients.


Assuntos
Exercícios Respiratórios/métodos , Músculos Respiratórios/fisiopatologia , Desmame do Respirador/métodos , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos , Qualidade de Vida
4.
BMC Pulm Med ; 21(1): 38, 2021 Jan 22.
Artigo em Inglês | MEDLINE | ID: mdl-33482796

RESUMO

BACKGROUND: Clinical management of COVID-19 requires close monitoring of lung function. While computed tomography (CT) offers ideal way to identify the phenotypes, it cannot monitor the patient response to therapeutic interventions. We present a case of ventilation management for a COVID-19 patient where electrical impedance tomography (EIT) was used to personalize care. CASE PRESENTATION: The patient developed acute respiratory distress syndrome, required invasive mechanical ventilation, and was subsequently weaned. EIT was used multiple times: to titrate the positive end-expiratory pressure, understand the influence of body position, and guide the support levels during weaning and after extubation. We show how EIT provides bedside monitoring of the patient´s response to various therapeutic interventions and helps guide treatments. CONCLUSION: EIT provides unique information that may help the ventilation management in the pandemic of COVID-19.


Assuntos
/diagnóstico por imagem , Impedância Elétrica , Pulmão/diagnóstico por imagem , Posicionamento do Paciente/métodos , Respiração Artificial/métodos , Tomografia/métodos , /fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Respiração com Pressão Positiva/métodos , /terapia , Desmame do Respirador/métodos
5.
Isr Med Assoc J ; 22(12): 733-735, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33381942

RESUMO

BACKGROUND: Patients diagnosed with coronavirus disease-19 (COVID-19) who deteriorate to respiratory failure and require mechanical ventilation may later need to be weaned from the ventilator and undergo a rehabilitation process. The rate of weaning COVID-19 patients from mechanical ventilation is unknown. OBJECTIVES: To present our experience with ventilator weaning of COVID-19 patients in a dedicated facility. METHODS: A retrospective cohort study was conducted of 18 patients hospitalized in a COVID-19 dedicated ventilator weaning unit. RESULTS: Eighteen patients were hospitalized in the dedicated unit between 6 April and 19 May 2020. Of these, 88% (16/18) were weaned and underwent decannulation, while two patients deteriorated and were re-admitted to the intensive care unit. The average number of days spent in our department was 12. There was no statistically significant correlation between patient characteristics and time to weaning from ventilation or with the time to decannulation. CONCLUSIONS: Despite the high mortality of COVID-19 patients who require mechanical ventilation, most of the patients in our cohort were weaned in a relatively short period of time. Further large-scale studies are necessary to assess the cost effectiveness of dedicated COVID-19 departments for ventilator weaning.


Assuntos
/terapia , Unidades de Terapia Intensiva , Pandemias , Respiração Artificial/métodos , Desmame do Respirador/métodos , Adulto , Idoso , Feminino , Seguimentos , Humanos , Israel/epidemiologia , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Adulto Jovem
6.
Medicine (Baltimore) ; 99(50): e23602, 2020 Dec 11.
Artigo em Inglês | MEDLINE | ID: mdl-33327327

RESUMO

BACKGROUND: COVID-19 has spread globally since its outbreak in late 2019. It mainly attacks people's respiratory system. Many patients with severe COVID-19 require a ventilator to support breathing, and their lung function is often impaired to varying degrees after ventilator weaning. Acupuncture has been reported to improve respiratory function, but there is no evidence that it can improve respiratory function in ventilator users with COVID-19 after they are removed from the machine. The protocol of the systematic review and meta-analysis will clarify safety and effectiveness of acupuncture on respiratory rehabilitation after weaning from the ventilator during the treatment of COVID-19. METHODS: We will search PubMed, EMBASE, MEDLINE, the Cochrane Library, Chinese National Knowledge Infrastructure, Chinese Biomedical Literature Database, Chinese Science and Technology Periodical Database, Wanfang Database, Clinical Trials and Chinese Clinical Trial Registry. Relevant English language and Chinese language literature will be included. A combination of subject words and free text words will be applied in the searches. The complete process will include study selection, data extraction, risk of bias assessment, and meta-analyses. We will use subgroup analysis and sensitivity analysis to explore the sources of heterogeneity if there is heterogeneity. We will use funnel charts to assess the risk of bias. Endnote X9.3 will be used to manage data screening. The statistical analysis will be completed by RevMan5.2 or Stata/SE 15.1 software. RESULTS: This study will assess safety and effectiveness of acupuncture for rehabilitation on respiratory function after weaning from the ventilator during the treatment of COVID-19. CONCLUSIONS: The conclusion of this study will give evidence to prove safety and effectiveness of acupuncture for rehabilitation on respiratory after weaning from the ventilator during the treatment of COVID-19. REGISTRATION: PROSPERO CRD42020206889.


Assuntos
Terapia por Acupuntura/métodos , Desmame do Respirador/métodos , Ensaios Clínicos como Assunto , Humanos , Metanálise como Assunto , Projetos de Pesquisa , Revisões Sistemáticas como Assunto , Resultado do Tratamento
7.
Front Med ; 14(5): 674-680, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32761492

RESUMO

We report the clinical and laboratory findings and successful management of seven patients with critical coronavirus disease 2019 (COVID-19) requiring mechanical ventilation (MV). The patients were diagnosed based on epidemiological history, clinical manifestations, and nucleic acid testing. Upon diagnosis with COVID-19 of critical severity, the patients were admitted to the intensive care unit, where they received early noninvasive-invasive sequential ventilation, early prone positioning, and bundle pharmacotherapy regimen, which consists of antiviral, anti-inflammation, immune-enhancing, and complication-prophylaxis medicines. The patients presented fever (n = 7, 100%), dry cough (n = 3, 42.9%), weakness (n = 2, 28.6%), chest tightness (n = 1, 14.3%), and/or muscle pain (n = 1, 14.3%). All patients had normal or lower than normal white blood cell count/lymphocyte count, and chest computed tomography scans showed bilateral patchy shadows or ground glass opacity in the lungs. Nucleic acid testing confirmed COVID-19 in all seven patients. The median MV duration and intensive care unit stay were 9.9 days (interquartile range, 6.5-14.6 days; range, 5-17 days) and 12.9 days (interquartile range, 9.7-17.6 days; range, 7-19 days), respectively. All seven patients were extubated, weaned off MV, transferred to the common ward, and discharged as of the writing of this report. Thus, we concluded that good outcomes for patients with critical COVID-19 can be achieved with early noninvasive-invasive sequential ventilation and bundle pharmacotherapy.


Assuntos
Antivirais/administração & dosagem , Infecções por Coronavirus , Estado Terminal/terapia , Ventilação não Invasiva/métodos , Pandemias , Pneumonia Viral , Betacoronavirus/isolamento & purificação , Quimioprevenção/métodos , Técnicas de Laboratório Clínico/métodos , Infecções por Coronavirus/complicações , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/tratamento farmacológico , Infecções por Coronavirus/fisiopatologia , Infecções por Coronavirus/terapia , Cuidados Críticos/métodos , Feminino , Humanos , Pulmão/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Pneumonia Viral/complicações , Pneumonia Viral/fisiopatologia , Pneumonia Viral/terapia , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/terapia , Tomografia Computadorizada por Raios X/métodos , Desmame do Respirador/métodos
8.
Respir Care ; 65(11): 1773-1783, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32759372

RESUMO

The COVID-19 pandemic has profoundly affected health care delivery worldwide. A small yet significant number of patients with respiratory failure will require prolonged mechanical ventilation while recovering from the viral-induced injury. The majority of reports thus far have focused on the epidemiology, clinical factors, and acute care of these patients, with less attention given to the recovery phase and care of those patients requiring extended time on mechanical ventilation. In this paper, we review the procedures and methods to safely care for patients with COVID-19 who require tracheostomy, gastrostomy, weaning from mechanical ventilation, and final decannulation. The guiding principles consist of modifications in the methods of airway care to safely prevent iatrogenesis and to promote safety in patients severely affected by COVID-19, including mitigation of aerosol generation to minimize risk for health care workers.


Assuntos
Infecções por Coronavirus , Remoção de Dispositivo/métodos , Gastrostomia , Controle de Infecções , Pandemias , Pneumonia Viral , Traqueostomia , Desmame do Respirador/métodos , Betacoronavirus , Infecções por Coronavirus/complicações , Infecções por Coronavirus/cirurgia , Infecções por Coronavirus/terapia , Cuidados Críticos/métodos , Cuidados Críticos/normas , Gastrostomia/instrumentação , Gastrostomia/métodos , Humanos , Controle de Infecções/instrumentação , Controle de Infecções/métodos , Controle de Infecções/normas , Pneumonia Viral/complicações , Pneumonia Viral/cirurgia , Pneumonia Viral/terapia , Respiração Artificial/métodos , Risco Ajustado , Traqueostomia/instrumentação , Traqueostomia/métodos
9.
PLoS One ; 15(7): e0236093, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32706784

RESUMO

INTRODUCTION: Surgical and percutaneous tracheostomy remains a commonly performed procedure in the intensive care unit (ICU). Given the unique patient population in the Middle East we decided to perform a review of the procedures performed in our hospital over a two-year period. METHODS: Single centre, retrospective observational study. All tracheostomies performed between January 2016 and January 2018 were included in the study. The primary outcome was the rate of tracheostomy complications. Multivariate logistic regression analysis was used to identify the independent factors associated with complications and decannulations. RESULTS: One hundred sixty-four patients were included in the study. Percutaneous tracheostomy was performed in 99 patients (60.4%). Complications occurred in thirty-eight patients (23%). Higher Left ventricular ejection fraction (OR = 0.94, 95%CI: [0.898-0.985]) and percutaneous tracheostomy (OR = 0.107, 95%CI: [0.029-0.401]) were associated with lower complications. Good Eastern Cooperative Oncology Group (ECOG) performance status (OR = 4.1, 95%CI: [1.3-13.3]) and downsized tracheostomy tube (OR = 6.5, 95%CI: [2.0-21.0]) were associated with successful decannulations. Successful decannulation was associated with lower hospital mortality when compated to those who could not be decannulated (3.2% vs 33.3% p < 0.0001). CONCLUSION: In our older population with high comorbidities, percutaneous tracheostomies were associated with less complications than surgical tracheostomies. Patients with poor premorbid functional status and those who could not have their tracheostomy tube sucessfuly downsized were less likely to be decannulated, and had a higher mortality. This data enables physicians to inform the families of the added risks involved with tracheostomy in this patient group.


Assuntos
Remoção de Dispositivo/métodos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Traqueostomia/efeitos adversos , Desmame do Respirador/métodos , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/patologia , Prognóstico , Estudos Retrospectivos
10.
J Cardiopulm Rehabil Prev ; 40(4): 205-208, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32609464

RESUMO

DETAILS OF THE CLINICAL CASE: A 51-yr-old man underwent a respiratory rehabilitation program (RRP), after being tracheostomized and ventilated due to acute respiratory distress syndrome (ARDS) from coronavirus disease-2019 (COVID-19) infection. Respiratory care, early mobilization, and neuromuscular electrical stimulation were started in the ad hoc isolation ward of our rehabilitation center. At baseline, muscle function was consistent with intensive care unit-acquired weakness and the patient still needed mechanical ventilation (MV) and oxygen support. During the first week of RRP in isolation, the patient was successfully weaned from MV, the tracheal cannula was removed, and the walking capacity was recovered. At the end of the RRP, continued in a standard department, respiratory muscles strength increased by 7% and muscle function improved as indicated by the quadriceps size enlargement of 13% and the change of the Medical Research Council sum score from 48/60 to 58/60. DISCUSSION: Providing RRP in patients with severe COVID-19 ARDS involves risks for operators and organizational difficulties, especially in rehabilitation centers; nevertheless, its continuity is important to prevent the development of permanent disabilities in previously healthy subjects. Limited to the experience of only one patient, we were able to carry out a safe RRP during the COVID-19 pandemic, promoting the complete functional recovery of a COVID-19 young patient. SUMMARY: Most patients who develop serious consequences of COVID-19 infection risk a reduction in their quality of life. However, by organizing and directing specialized resources, subacute rehabilitation facilities could ensure the continuity of the RRPs even during the COVID-19 pandemic.


Assuntos
Infecções por Coronavirus/terapia , Pneumonia Viral/terapia , Terapia Respiratória/métodos , Desmame do Respirador/métodos , Infecções por Coronavirus/diagnóstico , Estudos de Viabilidade , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Isolamento de Pacientes , Pneumonia Viral/diagnóstico , Recuperação de Função Fisiológica , Centros de Reabilitação , Respiração Artificial/métodos , Testes de Função Respiratória , Medição de Risco , Índice de Gravidade de Doença , Traqueostomia/métodos , Resultado do Tratamento
11.
A A Pract ; 14(7): e01247, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32539281

RESUMO

We report weaning from mechanical ventilation with no coughing in a patient with coronavirus disease 2019 (COVID-19). Substituting the endotracheal tube for a supraglottic airway (SGA), which is less stimulating to the trachea, can reduce coughing with weaning from mechanical ventilation and extubation. Personal protective equipment is in short supply worldwide. Reducing spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is beneficial in terms of occupational health of health care workers.


Assuntos
Extubação/métodos , Manuseio das Vias Aéreas/instrumentação , Infecções por Coronavirus/terapia , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Pneumonia Viral/terapia , Desmame do Respirador/instrumentação , Idoso , Manuseio das Vias Aéreas/métodos , Betacoronavirus , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Tosse , Humanos , Intubação Intratraqueal , Masculino , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Respiração Artificial , Desmame do Respirador/métodos
12.
J Cardiothorac Vasc Anesth ; 34(7): 1727-1732, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32418832

RESUMO

The COVID-19 pandemic is spreading globally. COVID-19 has an effect on the systemic state, cardiopulmonary function and primary disease of patients undergoing surgery. COVID-19's high contagiousness makes anesthesia and intraoperative management more difficult. This expert consensus aims to comprehensively introduce the application of perioperative ultrasound in COVID-19 patients, including pulmonary ultrasound and anesthesia management, ultrasound and airway management, ultrasound-guided regional anesthesia and echocardiography for COVID-19 patients.


Assuntos
Anestesia/métodos , Betacoronavirus , Infecções por Coronavirus/diagnóstico por imagem , Assistência Perioperatória/métodos , Pneumonia Viral/diagnóstico por imagem , Ultrassonografia/métodos , Manuseio das Vias Aéreas/métodos , Anestesia por Condução/métodos , Doenças Cardiovasculares/complicações , Doenças Cardiovasculares/diagnóstico por imagem , Infecções por Coronavirus/complicações , Infecções por Coronavirus/transmissão , Ecocardiografia/métodos , Hemodinâmica , Humanos , Pulmão/diagnóstico por imagem , Pneumopatias/diagnóstico por imagem , Pneumopatias/microbiologia , Pandemias , Pneumonia Viral/complicações , Pneumonia Viral/transmissão , Traqueotomia/métodos , Ultrassonografia de Intervenção/métodos , Desmame do Respirador/métodos
13.
Head Neck ; 42(7): 1392-1396, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32342565

RESUMO

The severe acute respiratory syndrome (SARS)-CoV-2 pandemic continues to produce a large number of patients with chronic respiratory failure and ventilator dependence. As such, surgeons will be called upon to perform tracheotomy for a subset of these chronically intubated patients. As seen during the SARS and the SARS-CoV-2 outbreaks, aerosol-generating procedures (AGP) have been associated with higher rates of infection of medical personnel and potential acceleration of viral dissemination throughout the medical center. Therefore, a thoughtful approach to tracheotomy (and other AGPs) is imperative and maintaining traditional management norms may be unsuitable or even potentially harmful. We sought to review the existing evidence informing best practices and then develop straightforward guidelines for tracheotomy during the SARS-CoV-2 pandemic. This communication is the product of those efforts and is based on national and international experience with the current SARS-CoV-2 pandemic and the SARS epidemic of 2002/2003.


Assuntos
Tomada de Decisão Clínica , Infecções por Coronavirus/epidemiologia , Mortalidade Hospitalar/tendências , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Síndrome Respiratória Aguda Grave/terapia , Traqueotomia/métodos , Infecções por Coronavirus/prevenção & controle , Cuidados Críticos/métodos , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Emergências , Feminino , Seguimentos , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Internacionalidade , Intubação Intratraqueal , Masculino , Saúde do Trabalhador , Pandemias/prevenção & controle , Segurança do Paciente , Pneumonia Viral/prevenção & controle , Respiração Artificial/métodos , Medição de Risco , Vírus da SARS/patogenicidade , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Desmame do Respirador/métodos
14.
Dtsch Arztebl Int ; 117(12): 197-204, 2020 Mar 20.
Artigo em Inglês | MEDLINE | ID: mdl-32343653

RESUMO

BACKGROUND: To accommodate the increasing number of patients requiring prolonged weaning from mechanical ventilation, specialized weaning centers have been established for patients in whom weaning on the intensive care unit (ICU) was unsuccessful. METHODS: This study aimed to determine both the outcome of treatment and the factors associated with prolonged weaning in patients who were transferred from the ICU to specialized weaning centers in Germany during the period 2011 to 2015, based on a nationwide registry covering all specialized weaning centers currently going through the process of accreditation by the German Respiratory Society. RESULTS: Of 11 424 patients, 7346 (64.3%) were successfully weaned, of whom 2236 were switched to long-term non-invasive ventilation; 1658 (14.5%) died in the weaning unit; and 2420 (21.2%) could not be weaned. The duration of weaning decreased significantly from 22 to 18 days between 2011 and 2015 (p <0.0001). Multivariate analysis revealed that the factor most strongly associated with in-hospital mortality was advanced age (odds ratio [OR] 11.07, 95% confidence interval [6.51; 18.82], p <0.0001). The need to continue with invasive ventilation was most strongly associated with the duration mechanical ventilation prior to transfer from the ICU (OR 4.73 [3.25; 6.89]), followed by a low body mass index (OR 0.38 [0.26; 0.58]), pre-existing neuromuscular disorders (OR 2.98 [1.88; 4.73]), and advanced age (OR 2.96 [1.87; 4.69]) (each p <0.0001). CONCLUSION: Weaning duration has decreased over time, but prolonged weaning is still unsuccessful in one third of patients.Overall, the results warrant the establishment of specialized weaning centers. Variables associated with death and weaningfailure can be integrated into ICU decision-making processes.


Assuntos
Desmame do Respirador/métodos , Idoso , Feminino , Alemanha/epidemiologia , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Fatores de Tempo
15.
Ann Phys Rehabil Med ; 63(4): 376-378, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32315800
16.
Zhonghua Er Ke Za Zhi ; 58(4): 284-289, 2020 Apr 02.
Artigo em Chinês | MEDLINE | ID: mdl-32234134

RESUMO

Objective: To investigate the sedation weaning strategies in critically ill patients with mechanical ventilation in pediatric intensive care unit (PICU) and to explore the effect of different sedative weaning patterns on withdrawal syndrome. Methods: A single-center prospective cohort study was conducted from April 1, 2016 to April 30, 2017. One hundred and twelve patients who required mechanical ventilation and benzodiazepines and (or) opioids for at least 5 consecutive days in PICU of Shanghai Children's Medical Center were enrolled. Twenty patients (17.9%) had an intermittent weaning pattern, defined as a 50% or greater increase in daily benzodiazepine and (or) opioid dose after the start of weaning, and the remaining 92 cases (82.1%) had a steady weaning pattern. The demographic and clinical features, duration and dose of sedative and analgesics, and the incidence of withdrawal syndrome were evaluated. Mann-Whitney U test was used for comparison about clinical features between different weaning pattern groups and children with withdrawal syndrome or not. Logistic regression was used to explore the risk factors of withdrawal syndrome. Results: Among the 112 patients, 46 (41.1%) had withdrawal syndrome. The patients with the intermittent weaning pattern had a high score of pediatric risk of mortality Ⅲ (PRISM-Ⅲ) (10.0 (3.5, 12.0) vs. 6.0 (2.0, 10.0), U=654.50, P=0.043) and were prone to re-intubation (35.0% (7/20) vs. 7.6% (7/92), P=0.003). The patients with withdrawal syndrome had longer duration of sedation (19.5 (16.8, 24.3) vs. 10.0 (7.0, 17.3) days, U=743.50, P<0.01), higher incidence of intermittent weaning pattern (32.6% (15/46) vs. 7.6% (5/66),χ(2)=11.58, P=0.001), longer PICU hospitalization (19.0 (15.8, 25.3) vs. 12.0 (8.8, 17.0) days, U=755.00, P<0.01) and higher cost (89 (57,109) vs. 53 (32, 79) thousand yuan, U=804.00, P<0.01). Logistic regression showed that intermittent weaning pattern (odds ratio (OR)=4.85, 95% confidence interval (CI) 1.39-16.91, P=0.013), perioperative period of liver transplantation (OR=6.97, 95%CI 1.25-39.04, P=0.027) and a cumulative dose of midazolam ≥ 34.7 mg/kg (OR=8.12, 95%CI 3.09-21.37, P<0.01) were risk factors of withdrawal syndrome. Conclusions: Withdrawal syndrome is more likely to occur in children who are intermittently weaned from sedation. Steady weaning strategy may help prevent iatrogenic withdrawal syndrome.


Assuntos
Hipnóticos e Sedativos/administração & dosagem , Unidades de Terapia Intensiva Pediátrica , Respiração Artificial , Síndrome de Abstinência a Substâncias/etiologia , Desmame do Respirador/métodos , Analgésicos Opioides , Criança , China , Humanos , Estudos Prospectivos
17.
Intensive Crit Care Nurs ; 58: 102808, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32115334

RESUMO

OBJECTIVES: Family caregivers of patients requiring prolonged mechanical ventilation may experience physical and psychological morbidity associated with a protracted intensive care unit experience. Our aim was to explore potentially modifiable support needs and care processes of importance to family caregivers of patients requiring prolonged mechanical ventilation and transition from the intensive care unit to a specialised weaning centre. RESEARCH METHODOLOGY/DESIGN: A longitudinal qualitative descriptive interview study. Data was analysed using directed content analysis. SETTING: A 6-bed specialised weaning centre in Toronto, Canada. FINDINGS: Eighteen family caregivers completed interviews at weaning centre admission (100%), and at two-weeks (40%) and three-months after discharge (22%) contributing 29 interviews. Caregivers were primarily women (61%) and spouses (50%). Caregivers perceived inadequate informational, emotional, training, and appraisal support by health care providers limiting understanding of prolonged ventilation, participation in care and decision-making, and readiness for weaning centre transition. Participants reported long-term physical and psychological health changes including alterations to sleep, energy, nutrition and body weight. CONCLUSIONS: Deficits in informational, emotional, training, and appraisal support of family caregivers of prolonged mechanical ventilation patients may increase caregiver burden and contribute to poor health outcomes. Strategies for providing support and maintaining family caregiver health-related quality of life are needed.


Assuntos
Cuidadores/psicologia , Qualidade de Vida/psicologia , Fatores de Tempo , Desmame do Respirador/métodos , Adulto , Idoso , Feminino , Hospitalização , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Entrevistas como Assunto/métodos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Ontário , Pesquisa Qualitativa , Respiração Artificial/efeitos adversos , Respiração Artificial/métodos
18.
Anesthesiology ; 132(6): 1482-1493, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32217876

RESUMO

BACKGROUND: Difficult weaning frequently develops in ventilated patients and is associated with poor outcome. In neurally adjusted ventilatory assist, the ventilator is controlled by diaphragm electrical activity, which has been shown to improve patient-ventilator interaction. The objective of this study was to compare neurally adjusted ventilatory assist and pressure support ventilation in patients difficult to wean from mechanical ventilation. METHODS: In this nonblinded randomized clinical trial, difficult-to-wean patients (n = 99) were randomly assigned to neurally adjusted ventilatory assist or pressure support ventilation mode. The primary outcome was the duration of weaning. Secondary outcomes included the proportion of successful weaning, patient-ventilator asynchrony, ventilator-free days, and mortality. Weaning duration was calculated as 28 days for patients under mechanical ventilation at day 28 or deceased before day 28 without successful weaning. RESULTS: Weaning duration in all patients was statistically significant shorter in the neurally adjusted ventilatory assist group (n = 47) compared with the pressure support ventilation group (n = 52; 3.0 [1.2 to 8.0] days vs. 7.4 [2.0 to 28.0], mean difference: -5.5 [95% CI, -9.2 to -1.4], P = 0.039). Post hoc sensitivity analysis also showed that the neurally adjusted ventilatory assist group had shorter weaning duration (hazard ratio, 0.58; 95% CI, 0.34 to 0.98). The proportion of patients with successful weaning from invasive mechanical ventilation was higher in neurally adjusted ventilatory assist (33 of 47 patients, 70%) compared with pressure support ventilation (25 of 52 patients, 48%; respiratory rate for neurally adjusted ventilatory assist: 1.46 [95% CI, 1.04 to 2.05], P = 0.026). The number of ventilator-free days at days 14 and 28 was statistically significantly higher in neurally adjusted ventilatory assist compared with pressure support ventilation. Neurally adjusted ventilatory assist improved patient ventilator interaction. Mortality and length of stay in the intensive care unit and in the hospital were similar among groups. CONCLUSIONS: In patients difficult to wean, neurally adjusted ventilatory assist decreased the duration of weaning and increased ventilator-free days.


Assuntos
Suporte Ventilatório Interativo/estatística & dados numéricos , Respiração com Pressão Positiva/estatística & dados numéricos , Desmame do Respirador/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Suporte Ventilatório Interativo/métodos , Masculino , Respiração com Pressão Positiva/métodos , Taxa Respiratória , Desmame do Respirador/métodos
19.
J Bras Pneumol ; 46(4): e20190005, 2020.
Artigo em Inglês, Português | MEDLINE | ID: mdl-32215452

RESUMO

OBJECTIVE: The aim of this study was to describe practices for weaning from mechanical ventilation (MV), in terms of the use of protocols, methods, and criteria, in pediatric ICUs (PICUs), neonatal ICUs (NICUs), and mixed neonatal/pediatric ICUs (NPICUs) in Brazil. METHODS: This was a cross-sectional survey carried out by sending an electronic questionnaire to a total of 298 NICUs, PICUs, and NPICUs throughout Brazil. RESULTS: Completed questionnaires were assessed for 146 hospitals, NICUs accounting for 49.3% of the questionnaires received, whereas PICUs and NPICUs accounted for 35.6% and 15.1%, respectively. Weaning protocols were applied in 57.5% of the units. In the NICUs and NPICUs that used weaning protocols, the method of MV weaning most commonly employed (in 60.5% and 50.0%, respectively) was standardized gradual withdrawal from ventilatory support, whereas that employed in most (53.0%) of the PICUs was spontaneous breathing trial (SBT). During the SBTs, the most common ventilation mode, in all ICUs, was pressure-support ventilation (10.03 ± 3.15 cmH2O) with positive end-expiratory pressure. The mean SBT duration was 35.76 ± 29.03 min in the NICUs, compared with 76.42 ± 41.09 min in the PICUs. The SBT parameters, weaning ventilation modes, and time frame considered for extubation failure were not found to be dependent on the age profile of the ICU population. The findings of the clinical evaluation and arterial blood gas analysis are frequently used as criteria to assess readiness for extubation, regardless of the age group served by the ICU. CONCLUSIONS: In Brazil, the clinical practices for weaning from MV and extubation appear to vary depending on the age group served by the ICU. It seems that weaning protocols and SBTs are used mainly in PICUs, whereas gradual withdrawal from ventilatory support is more widely used in NICUs and NPICUs.


Assuntos
Unidades de Terapia Intensiva Pediátrica/normas , Respiração Artificial/métodos , Desmame do Respirador/métodos , Brasil , Criança , Estudos Transversais , Pesquisas sobre Serviços de Saúde , Humanos , Recém-Nascido , Respiração Artificial/estatística & dados numéricos , Insuficiência Respiratória/terapia , Inquéritos e Questionários
20.
Anesthesiology ; 132(5): 1114-1125, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32084029

RESUMO

BACKGROUND: The assessment of diaphragm function with diaphragm ultrasound seems to bring important clinical information to describe diaphragm work and weakness. When the diaphragm is weak, extradiaphragmatic muscles may play an important role, but whether ultrasound can also assess their activity and function is unknown. This study aimed to (1) evaluate the feasibility of measuring the thickening of the parasternal intercostal and investigate the responsiveness of this muscle to assisted ventilation; and (2) evaluate whether a combined evaluation of the parasternal and the diaphragm could predict failure of a spontaneous breathing trial. METHODS: First, an exploratory evaluation of the parasternal in 23 healthy subjects. Second, the responsiveness of parasternal to several pressure support levels were studied in 16 patients. Last, parasternal activity was compared in presence or absence of diaphragm dysfunction (assessed by magnetic stimulation of the phrenic nerves and ultrasound) and in case of success/failure of a spontaneous breathing trial in 54 patients. RESULTS: The parasternal was easily accessible in all patients. The interobserver reproducibility was good (intraclass correlation coefficient, 0.77 (95% CI, 0.53 to 0.89). There was a progressive decrease in parasternal muscle thickening fraction with increasing levels of pressure support (Spearman ρ = -0.61 [95% CI, -0.74 to -0.44]; P < 0.0001) and an inverse correlation between parasternal muscle thickening fraction and the pressure generating capacity of the diaphragm (Spearman ρ = -0.79 [95% CI, -0.87 to -0.66]; P < 0.0001). The parasternal muscle thickening fraction was higher in patients with diaphragm dysfunction: 17% (10 to 25) versus 5% (3 to 8), P < 0.0001. The pressure generating capacity of the diaphragm, the diaphragm thickening fraction and the parasternal thickening fraction similarly predicted failure or the spontaneous breathing trial. CONCLUSIONS: Ultrasound assessment of the parasternal intercostal muscle is feasible in the intensive care unit and provides novel information regarding the respiratory capacity load balance.


Assuntos
Diafragma/diagnóstico por imagem , Músculos Intercostais/diagnóstico por imagem , Respiração Artificial/métodos , Ultrassonografia de Intervenção/métodos , Desmame do Respirador/métodos , Adulto , Diafragma/fisiologia , Feminino , Humanos , Músculos Intercostais/fisiologia , Masculino , Adulto Jovem
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...