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1.
Pneumologie ; 74(1): 46-49, 2020 Jan.
Artigo em Alemão | MEDLINE | ID: mdl-31958870

RESUMO

In 2017 the German Clinical Guideline for Treating Acute Respiratory Insufficiency with Invasive Ventilation and Extracorporeal Membrane Oxygenation: Evidence-Based Recommendations were released. This article highlights emerging data and new concepts which were introduced since 2017. Among others it summarizes the current progress made in evidence-based recommendations of mechanical ventilation and extracorporeal membrane oxygenation (ECMO). In detail, the new evidence for treating severe ARDS with ECMO, phenotyping of ARDS, early neuromuscular blockade and the application of non-invasive ventilation and high-flow oxygen therapy are discussed.


Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Guias de Prática Clínica como Assunto , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório do Adulto/terapia , Insuficiência Respiratória/diagnóstico , Doença Aguda , Humanos , Pulmão , Síndrome do Desconforto Respiratório do Adulto/diagnóstico , Insuficiência Respiratória/fisiopatologia
2.
Scand J Trauma Resusc Emerg Med ; 27(1): 111, 2019 Dec 16.
Artigo em Inglês | MEDLINE | ID: mdl-31842961

RESUMO

BACKGROUND: The national early warning score (NEWS) enables early detection of in-hospital patient deterioration and timely activation of hospital's rapid response team (RRT). NEWS was updated in 2017 to include a separate SpO2 scale for those patients with type II respiratory failure (T2RF). In this study we investigated whether NEWS with and without the new SpO2 scale for the T2RF patients is associated with immediate and in-hospital patient outcomes among the patients actually attended by the RRT. METHODS: We conducted a two-year prospective observational study including all adult RRT patients without limitations of medical treatment (LOMT) in a large Finnish university associated tertiary level hospital. According to the first vital signs measured by the RRT, we calculated NEWSs for the RRT patients and further utilized the new SpO2 scale for the patients with confirmed T2RF. We used multivariate logistic regression and area under the receiver operating characteristic analyses to test NEWS's accuracy to predict two distinct outcomes: RRT patient's I) immediate need for intensive care and/or new LOMT and 2) in-hospital death or discharge with cerebral performance category >2 and/or LOMT. RESULTS: The final cohort consisted of 886 RRT patients attended for the first time during their hospitalization. Most common reasons for RRT activation were respiratory (343, 39%) and circulatory (226, 26%) problems. Cohort's median (Q1, Q3) NEWS at RRT arrival was 8 (5, 10) and remained unchanged if the new SpO2 scale was applied for the 104 patients with confirmed T2RF. Higher NEWS was independently associated with both immediate (OR 1.28; 95% CI 1.22-1.35) and in-hospital (1.15; 1.10-1.21) adverse outcomes. Further, NEWS had fair discrimination for both the immediate (AUROC 0.73; 0.69-0.77) and in-hospital (0.68; 0.64-0.72) outcomes. Utilizing the new SpO2 scale for the patients with confirmed T2RF did not improve the discrimination capability (0.73; 0.69-0.76 and 0.68; 0.64-0.71) for these outcomes, respectively. CONCLUSIONS: We found that in patients attended by a RRT, the NEWS predicts patient's hospital outcome with moderate accuracy. We did not find any improvement using the new SpO2 scale in T2RF patients.


Assuntos
Equipe de Respostas Rápidas de Hospitais/normas , Insuficiência Respiratória/terapia , Adulto , Idoso , Estudos de Coortes , Cuidados Críticos , Diagnóstico Precoce , Estudos de Avaliação como Assunto , Feminino , Finlândia , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Estudos Prospectivos , Curva ROC , Insuficiência Respiratória/fisiopatologia , Sinais Vitais
5.
Neurology ; 93(19): e1756-e1767, 2019 11 05.
Artigo em Inglês | MEDLINE | ID: mdl-31619483

RESUMO

OBJECTIVE: To determine the effects of 10 years of enzyme replacement therapy (ERT) in adult patients with Pompe disease, focusing on individual variability in treatment response. METHODS: In this prospective, multicenter cohort study, we studied 30 patients from the Netherlands and France who had started ERT during the only randomized placebo-controlled clinical trial with ERT in late-onset Pompe disease (NCT00158600) or its extension (NCT00455195) in 2005 to 2008. Main outcomes were walking ability (6-minute walk test [6MWT]), muscle strength (manual muscle testing using Medical Research Council [MRC] grading), and pulmonary function (forced vital capacity [FVC] in the upright and supine positions), assessed at 3- to 6-month intervals before and after the start of ERT. Data were analyzed with linear mixed-effects models for repeated measurements. RESULTS: Median follow-up duration on ERT was 9.8 years (interquartile range [IQR] 8.3-10.2 years). At the group level, baseline 6MWT was 49% of predicted (IQR 41%-60%) and had deteriorated by 22.2 percentage points (pp) at the 10-year treatment point (p < 0.001). Baseline FVC upright was 54% of predicted (IQR 47%-68%) and decreased by 11 pp over 10 years (p < 0.001). Effects of ERT on MRC sum score and FVC supine were similar. At the individual level, 93% of patients had initial benefit of ERT. Depending on the outcome measured, 35% to 63% of patients had a secondary decline after ≈3 to 5 years. Still, at 10 years of ERT, 52% had equal or better 6MWT and/or FVC upright compared to baseline. CONCLUSIONS: The majority of patients with Pompe disease benefit from long-term ERT, but many patients experience some secondary decline after ≈3 to 5 years. Individual variation, however, is considerable. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that for the majority of adults with Pompe disease, long-term ERT positively affects, or slows deterioration in, muscle strength, walking ability, and/or pulmonary function.


Assuntos
Terapia de Reposição de Enzimas , Doença de Depósito de Glicogênio Tipo II/tratamento farmacológico , alfa-Glucosidases/uso terapêutico , Adulto , Estudos de Coortes , Feminino , Seguimentos , França , Doença de Depósito de Glicogênio Tipo II/complicações , Doença de Depósito de Glicogênio Tipo II/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Limitação da Mobilidade , Força Muscular , Debilidade Muscular/etiologia , Debilidade Muscular/fisiopatologia , Países Baixos , Ventilação não Invasiva/estatística & dados numéricos , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/fisiopatologia , Insuficiência Respiratória/terapia , Resultado do Tratamento , Capacidade Vital , Teste de Caminhada , Cadeiras de Rodas
6.
Toxicol Lett ; 316: 127-135, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31539569

RESUMO

Carfentanil (CRF) is an extremely potent opioid capable of inducing fatal respiratory depression. Naloxone (NX) and naltrexone (NTX) are opioid antagonists for which the efficacy against CRF remains largely unexplored. In this study, the effects of aerosolized CRF on respiratory function were investigated using adult male CD-1 mice. Mice were exposed to 0.4 mg/m3 of CRF for 15 min using custom whole-body plethysmograph units. Minute volume (MV), respiratory frequency (f), duty cycle (DC), and tidal volume (TV) were monitored and compared to control animals exposed to aerosolized H2O. CRF exposure induced respiratory depression, characterized by a marked decrease in MV, which was sustained throughout 24 h post-exposure. Prophylactic and therapeutic treatment with intramuscular (i.m.) NX marginally improved MV, with slight dose-dependent effects. Analogous treatment with i.m. NTX returned MV to baseline levels, with all doses and intervention times performing similarly. Despite improvements in MV, treatment administration did not reverse changes in DC, a measure of respiratory timing. Overall, NX and NTX administration alleviated volumetric aspects of opioid-induced respiratory toxicity, while changes in respiratory timing remained unresolved throughout post-exposure observation. These sustained changes and differences in recovery between two aspects of respiratory dynamics may provide insights for further exploration into the underlying mechanism of action of opioids and opioid antagonists.


Assuntos
Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/toxicidade , Fentanila/análogos & derivados , Pulmão/efeitos dos fármacos , Naloxona/administração & dosagem , Naltrexona/administração & dosagem , Antagonistas de Entorpecentes/administração & dosagem , Respiração/efeitos dos fármacos , Insuficiência Respiratória/prevenção & controle , Administração por Inalação , Aerossóis , Analgésicos Opioides/farmacocinética , Animais , Simulação por Computador , Relação Dose-Resposta a Droga , Fentanila/administração & dosagem , Fentanila/farmacocinética , Fentanila/toxicidade , Humanos , Pulmão/fisiopatologia , Masculino , Camundongos , Modelos Biológicos , Pletismografia Total , Insuficiência Respiratória/induzido quimicamente , Insuficiência Respiratória/fisiopatologia , Medição de Risco
7.
Respir Res ; 20(1): 213, 2019 Sep 26.
Artigo em Inglês | MEDLINE | ID: mdl-31554510

RESUMO

BACKGROUND: The prevalence of pneumocystis pneumonia (PCP) and associated hypoxic respiratory failure is increasing in human immunodeficiency virus (HIV)-negative patients. However, no prior studies have evaluated the effect of early anti-PCP treatment on clinical outcomes in HIV-negative patient with severe PCP. Therefore, this study investigated the association between the time to anti-PCP treatment and the clinical outcomes in HIV-negative patients with PCP who presented with hypoxemic respiratory failure. METHODS: A retrospective observational study was performed involving 51 HIV-negative patients with PCP who presented in respiratory failure and were admitted to the intensive care unit between October 2005 and July 2018. A logistic regression model was used to adjust for potential confounding factors in the association between the time to anti-PCP treatment and in-hospital mortality. RESULTS: All patients were treated with appropriate anti-PCP treatment, primarily involving trimethoprim/sulfamethoxazole. The median time to anti-PCP treatment was 58.0 (28.0-97.8) hours. Thirty-one (60.8%) patients were treated empirically prior to confirmation of the microbiological diagnosis. However, the hospital mortality rates were not associated with increasing quartiles of time until anti-PCP treatment (P = 0.818, test for trend). In addition, hospital mortality of patients received early empiric treatment was not better than those of patients received definitive treatment after microbiologic diagnosis (48.4% vs. 40.0%, P = 0.765). In a multiple logistic regression model, the time to anti-PCP treatment was not associated with increased mortality. However, age (adjusted OR 1.07, 95% CI 1.01-1.14) and failure to initial treatment (adjusted OR 13.03, 95% CI 2.34-72.65) were independently associated with increased mortality. CONCLUSIONS: There was no association between the time to anti-PCP treatment and treatment outcomes in HIV-negative patients with PCP who presented in hypoxemic respiratory failure.


Assuntos
Soronegatividade para HIV , Pneumonia por Pneumocystis/terapia , Insuficiência Respiratória/fisiopatologia , Adulto , Fatores Etários , Idoso , Antibacterianos/uso terapêutico , Cuidados Críticos , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia por Pneumocystis/complicações , Pneumonia por Pneumocystis/mortalidade , Insuficiência Respiratória/terapia , Estudos Retrospectivos , Tempo para o Tratamento , Resultado do Tratamento , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico
8.
BMC Pulm Med ; 19(1): 160, 2019 Aug 27.
Artigo em Inglês | MEDLINE | ID: mdl-31455341

RESUMO

BACKGROUND: Diaphragmatic assessment by ultrasound (US) is a non-invasive and useful method in the clinical management of patients with Amyotrophic Lateral Sclerosis (ALS). The aim of our observational study was to evaluate the impact of serial assessment of the diaphragmatic function by US on long-term outcomes in a series of patients suffering from ALS and to correlate US indices of diaphragmatic function and respiratory function tests with these outcomes. METHODS: A cohort of 39 consecutive patients has been followed up to 24 months. Both lung volume (forced vital capacity, FVC) and diaphragmatic pressure generating capacity (by sniff inspiratory nasal pressure (SNIP) and by both US thickening fraction, ΔTdi, and the ratio of the thickening fraction between tidal volume and maximal lung capacity, ΔTmax) were recorded at baseline and every 3 months. Parameters were then correlated with outcomes (nocturnal hypoventilation, daily hypercapnia, start of ventilatory support (NIV), and death at 1 year) over time. RESULTS: The occurrence of ΔTmax > 0.75 increased the risk to start NIV (HR = 5.6, p = 0.001) and to die (HR = 3.7, p = 0.0001) compared with patients maintaining lower values. Moreover, compared with the occurrence of FVC < 50% of predicted, ΔTmax > 0.75 appeared slightly better correlated with NIV commencement within 6 months. CONCLUSIONS: Serial diaphragmatic assessment by ultrasound is a useful and accurate method to predict the initiation of NIV earlier in patients with ALS.


Assuntos
Esclerose Amiotrófica Lateral/diagnóstico por imagem , Diafragma/diagnóstico por imagem , Diafragma/fisiopatologia , Insuficiência Respiratória/fisiopatologia , Ultrassonografia , Idoso , Esclerose Amiotrófica Lateral/complicações , Esclerose Amiotrófica Lateral/fisiopatologia , Feminino , Humanos , Estimativa de Kaplan-Meier , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Ventilação não Invasiva , Estudos Prospectivos , Insuficiência Respiratória/etiologia , Tempo para o Tratamento , Capacidade Vital
9.
Injury ; 50(8): 1440-1447, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31285055

RESUMO

INTRODUCTION: Older adults enduring a polytrauma have an increased mortality risk. Apart from age, the role of other predisposing factors on mortality are mainly described for the total polytrauma population. This study aimed to describe the mortality pattern of older polytrauma patients, its associated risk factors, and the role and etiology of in-hospital complications. METHODS: An eight-year retrospective cohort was constructed from 380 polytrauma patients aged ≥65 in a Dutch level 1 trauma center and linked to the national trauma database (DTR). Demographics, injury characteristics, comorbidity, clinical characteristics, in-hospital mortality, mortality etiology and complications scored according to the Clavien-Dindo classification were analyzed. Primary outcome was the identification of risk factors associated with in-hospital mortality, followed by identification of in-hospital complications and their nature. RESULTS: Overall in-hospital mortality was 36.3%, rising significantly with age. For patients aged ≥85 in-hospital mortality was 60.8%. Polytrauma patients aged ≥75 showed a peak of late-onset deaths one week following trauma. Age, a Glasgow coma score ≤8, coagulopathy, acidosis, injury severity score and the presence of a large subdural hematoma were significant risk factors influencing in-hospital mortality. Respiratory failure was the most prevalent severe and fatal complication. The proportion of fatal complications grew significantly with age (p < 0.01). CONCLUSIONS: Age is strongly associated with in-hospital mortality in polytraumatized elderly. Coagulopathy, acidosis, a low Glasgow coma score, presence of a large subdural hematoma and injury severity score were independently of age associated with an increased mortality. Patients older than 75 years showed a unique trimodal distribution of mortality with a late onset one week following the initial trauma. Elderly were more susceptible for fatal complications. Respiratory failure was the most prevalent severe and fatal complication. Aggressive monitoring and treatment of the pulmonary status is therefore of utmost importance.


Assuntos
Mortalidade Hospitalar/tendências , Traumatismo Múltiplo/mortalidade , Insuficiência Respiratória/mortalidade , Centros de Traumatologia , Escala Resumida de Ferimentos , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Traumatismo Múltiplo/complicações , Traumatismo Múltiplo/fisiopatologia , Sistema de Registros , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/fisiopatologia , Estudos Retrospectivos , Distribuição por Sexo
10.
Spine (Phila Pa 1976) ; 44(15): 1057-1063, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31335789

RESUMO

STUDY DESIGN: Retrospective clinical study of individuals with osteogenesis imperfecta (OI). OBJECTIVE: To assess the relationship between severity of scoliosis and pulmonary function, and to assess the relationship between restrictive lung disease and self-reported quality of life in individuals with OI. SUMMARY OF BACKGROUND DATA: OI is a heritable connective tissue disorder characterized by osteopenia and a predisposition to fracture. Respiratory insufficiency is a leading cause of mortality. Literature on pulmonary function in this population has shown a negative correlation between percent-predicted vital capacity and severity of scoliosis. However, it has been suggested that decreased pulmonary function in OI may be due to intrinsic pulmonary disease, in addition to the impact of vertebral compression fractures and scoliosis. METHODS: Anterior-posterior spine radiographs and pulmonary function tests from 30 individuals with OI were reviewed. Radiographs were evaluated for scoliosis, defined as a curve ≥ 10°. If more than one curve was present, the largest curve was used. Pulmonary function was defined as the forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio. Restrictive pulmonary disease was defined as FEV1/FVC > 80%, while obstructive disease was defined as FEV1/FVC < 70%. Bivariate correlation analysis was performed, using Spearman rho correlation coefficient (P < 0.05). Quality of life was assessed by SF-36. RESULTS: The mean age was 27.6 years (range: 12-42 yrs). 57.6% were female. OI type IV was the most common (46.7%), followed by OI type III (33.3%), OI type I (10%), OI type IX (6.67% each), and OI type VIII (3.33%). Pulmonary comorbidity was present in 40% of individuals, while 6.67% had a cardiac comorbidity. The correlation between scoliosis and pulmonary function was weak and not significant (R = -0.059, P = 0.747). CONCLUSION: Pulmonary function is not significantly correlated with scoliosis, supporting the hypothesis that decreased pulmonary function is intrinsic to OI and/or chest wall deformities, rather than secondary to scoliosis. LEVEL OF EVIDENCE: 4.


Assuntos
Pneumopatias/etiologia , Osteogênese Imperfeita/complicações , Insuficiência Respiratória/etiologia , Escoliose/complicações , Escoliose/etiologia , Adolescente , Adulto , Criança , Feminino , Fraturas por Compressão/complicações , Humanos , Pulmão/fisiopatologia , Pneumopatias/fisiopatologia , Masculino , Qualidade de Vida , Radiografia , Testes de Função Respiratória , Insuficiência Respiratória/fisiopatologia , Estudos Retrospectivos , Escoliose/diagnóstico por imagem , Fraturas da Coluna Vertebral/complicações , Parede Torácica/fisiopatologia , Capacidade Vital , Adulto Jovem
11.
Trials ; 20(1): 450, 2019 Jul 22.
Artigo em Inglês | MEDLINE | ID: mdl-31331372

RESUMO

BACKGROUND: Noninvasive ventilation (NIV) is indicated to treat respiratory acidosis due to exacerbation of chronic obstructive pulmonary disease (COPD). Recent nonrandomized studies also demonstrated some physiological effects of high-flow nasal therapy (HFNT) in COPD patients. We designed a prospective, unblinded, multicenter, randomized controlled trial to assess the noninferiority of HFNT compared to NIV with respect to the reduction of arterial partial pressure of carbon dioxide (PaCO2) in patients with hypercapnic acute respiratory failure with mild-to-moderate respiratory acidosis. METHODS: We will enroll adult patients with acute hypercapnic respiratory failure, as defined by arterial pH between 7.25 and 7.35 and PaCO2 ≥ 55 mmHg. Patients will be randomly assigned 1:1 to receive NIV or HFNT. NIV will be applied through a mask with a dedicated ventilator in pressure support mode. Positive end-expiratory pressure will be set at 3-5 cmH2O with inspiratory support to obtain a tidal volume between 6 and 8 ml/kg of ideal body weight. HFNT will be initially set at a temperature of 37 °C and a flow of 60 L/min. At 2 and 6 h we will assess arterial blood gases, vital parameters, respiratory rate, treatment intolerance and failure, need for endotracheal intubation, time spent under mechanical ventilation (both invasive and NIV), intensive care unit and hospital length of stay, and hospital mortality. Based on an α error of 5% and a ß error of 80%, with a standard deviation for PaCO2 equal to 15 mmHg and a noninferiority limit of 10 mmHg, we computed a sample size of 56 patients. Considering potential drop-outs and nonparametric analysis, the final computed sample size was 80 patients (40 per group). DISCUSSION: HFNT is more comfortable than NIV in COPD patients recovering from an episode of exacerbation. If HFNT would not be inferior to NIV, HFNT could be considered as an alternative to NIV to treat COPD patients with mild-to-moderate respiratory acidosis. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03370666 . Registered on December 12, 2017.


Assuntos
Hipercapnia/terapia , Pulmão/fisiopatologia , Ventilação não Invasiva , Oxigenoterapia/métodos , Doença Pulmonar Obstrutiva Crônica/terapia , Insuficiência Respiratória/terapia , Doença Aguda , Estudos de Equivalência como Asunto , Humanos , Hipercapnia/diagnóstico , Hipercapnia/fisiopatologia , Itália , Estudos Multicêntricos como Assunto , Ventilação não Invasiva/efeitos adversos , Oxigenoterapia/efeitos adversos , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
14.
J Bone Joint Surg Am ; 101(12): 1109-1118, 2019 Jun 19.
Artigo em Inglês | MEDLINE | ID: mdl-31220028

RESUMO

BACKGROUND: Patients with congenital scoliosis often have restrictive pulmonary dysfunction on static pulmonary function testing (PFT). Although frequently asymptomatic during daily activities, these patients are generally assumed to have reduced exercise capacity. The aim of this study was to use dynamic cardiopulmonary exercise testing (CPET) to investigate exercise capacity and its association with spinal deformity in patients with congenital scoliosis. METHODS: Sixty patients with congenital scoliosis who underwent preoperative spinal radiography, PFT, and CPET were included from January 2014 to November 2017. The impact of thoracic spinal deformity and rib anomalies on pulmonary function and physical capacity was investigated. RESULTS: A significant deterioration in pulmonary function with increases in the severity of the major thoracic curve was demonstrated by the forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and total lung capacity (all p < 0.001). The ratio of FEV1 to FVC was similar regardless of thoracic curve severity. A smaller tidal volume during exercise testing reflected restrictive dysfunction in the patients with the most severe curves. CPET also revealed a significant trend of faster breathing by patients with a severe thoracic curve (p < 0.001). Exercise capacity indicators such as work rate (p = 0.019), heart rate (p = 0.015), and oxygen saturation (p = 0.006) were significantly reduced only in patients with a thoracic curve of >100°. Pulmonary dysfunction was the major contributor to exercise intolerance. Compared with mild pulmonary dysfunction, moderate and severe dysfunction was associated with an abnormal breathing pattern and lower work rate (p = 0.032) and peak oxygen intake (p = 0.042), indicating worse exercise tolerance. CONCLUSIONS: Congenital scoliosis leads to restrictive pulmonary dysfunction, which reduces the tidal volume and forces patients to accelerate respiratory rates during exercise. Patients with a thoracic curve of >100° are unable to compensate and have significantly reduced exercise capacity. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Tolerância ao Exercício/fisiologia , Pulmão/fisiologia , Escoliose/fisiopatologia , Adolescente , Adulto , Criança , Teste de Esforço , Feminino , Volume Expiratório Forçado/fisiologia , Humanos , Masculino , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/fisiopatologia , Capacidade Vital/fisiologia , Adulto Jovem
15.
Int J Chron Obstruct Pulmon Dis ; 14: 1229-1237, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31239658

RESUMO

Background: High-flow nasal cannula (HFNC) oxygen therapy in acute hypoxic respiratory failure is becoming increasingly popular. However, evidence to support the use of HFNC in acute respiratory failure (ARF) with hypercapnia is limited. Methods: Chronic obstructive pulmonary disease (COPD) patients with moderate hypercapnic ARF (arterial blood gas pH 7.25-7.35, PaCO2>50 mmHg) who received HFNC or non-invasive ventilation (NIV) in the intensive care uint from April 2016 to March 2018 were analyzed retrospectively. The endpoint was treatment failure, defined as either invasive ventilation, or a switch to the other study treatment (NIV for patients in the NFNC group, and vice-versa), and 28-day mortality. Results: Eighty-two COPD patients (39 in the HFNC group and 43 in the NIV group) were enrolled in this study. The mean age was 71.8±8.2 and 54 patients (65.9%) were male. The treatment failed in 11 out of 39 patients with HFNC (28.2%) and in 17 of 43 patients with NIV (39.5%) (P=0.268). No significant differences were found for 28-day mortality (15.4% in the HFNC group and 14% in the NIV group, P=0.824). During the first 24 hrs of treatment, the number of nursing airway care interventions in the HFNC group was significantly less than in the NIV group, while the duration of device application was significantly longer in the HFNC group (all P<0.05). Skin breakdown was significantly more common in the NIV group (20.9% vs 5.1%, P<0.05). Conclusion: Among COPD patients with moderate hypercarbic ARF, the use of HFNC compared with NIV did not result in increased rates of treatment failure, while there were fewer nursing interventions and skin breakdown episodes reported in the HFNC group.


Assuntos
Cânula , Hipercapnia/terapia , Pulmão/fisiopatologia , Ventilação não Invasiva , Oxigenoterapia/instrumentação , Doença Pulmonar Obstrutiva Crônica/terapia , Insuficiência Respiratória/terapia , Administração Intranasal , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Hipercapnia/diagnóstico , Hipercapnia/mortalidade , Hipercapnia/fisiopatologia , Masculino , Pessoa de Meia-Idade , Ventilação não Invasiva/efeitos adversos , Ventilação não Invasiva/mortalidade , Oxigenoterapia/efeitos adversos , Oxigenoterapia/mortalidade , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/mortalidade , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/mortalidade , Insuficiência Respiratória/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Falha de Tratamento
16.
Neurology ; 93(3): e306-e316, 2019 07 16.
Artigo em Inglês | MEDLINE | ID: mdl-31182506

RESUMO

OBJECTIVE: We sought to examine prevalence and predictors of noninvasive ventilation (NIV) in a composite cohort of patients with amyotrophic lateral sclerosis (ALS) followed in a clinical trials setting (Pooled Resource Open-Access ALS Clinical Trials database). METHODS: NIV initiation and status were ascertained from response to question 12 of the revised ALS Functional Rating Scale (ALSFRS-R). Factors affecting NIV use in patients with forced vital capacity (FVC) ≤50% of predicted were examined. Predictors of NIV were evaluated by Cox proportional hazard models and generalized linear mixed models. RESULTS: Among 1,784 patients with 8,417 simultaneous ALSFRS-R and FVC% measures, NIV was used by 604 (33.9%). Of 918 encounters when FVC% ≤50%, NIV was reported in 482 (52.5%). Independent predictors of NIV initiation were lower FVC% (hazard ratio [HR] 1.27, 95% confidence interval [CI] 1.17-1.37 for 10% drop), dyspnea (HR 2.62, 95% CI 1.87-3.69), orthopnea (HR 4.09, 95% CI 3.02-5.55), lower bulbar and gross motor subscores of ALSFRS-R (HRs 1.09 [95% CI 1.03-1.14] and 1.13 [95% CI 1.07-1.20], respectively, per point), and male sex (HR 1.73, 95% CI 1.31-2.28). Adjusted for other variables, bulbar onset did not significantly influence time to NIV (HR 0.72, 95% CI 0.47-1.08). Considerable unexplained variability in NIV use was found. CONCLUSION: NIV use was lower than expected in this ALS cohort that was likely to be optimally managed. Absence of respiratory symptoms and female sex may be barriers to NIV use. Prospective exploration of factors affecting adoption of NIV may help bridge this gap and improve care in ALS.


Assuntos
Esclerose Amiotrófica Lateral/terapia , Ventilação não Invasiva/estatística & dados numéricos , Insuficiência Respiratória/terapia , Idoso , Esclerose Amiotrófica Lateral/complicações , Esclerose Amiotrófica Lateral/fisiopatologia , Estudos de Coortes , Dispneia/etiologia , Dispneia/fisiopatologia , Feminino , Humanos , Estimativa de Kaplan-Meier , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Cooperação do Paciente , Modelos de Riscos Proporcionais , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/fisiopatologia , Fatores Sexuais , Fatores de Tempo , Capacidade Vital
18.
Trials ; 20(1): 336, 2019 Jun 08.
Artigo em Inglês | MEDLINE | ID: mdl-31176375

RESUMO

BACKGROUND: The benefit of pulmonary rehabilitation (PR) in symptomatic chronic obstructive pulmonary disease (COPD) is well known. However, advanced patients with chronic respiratory failure (CRF), a category excluded from most studies, are frequently unable to sustain a work-load sufficiently high to obtain the full benefit of PR on exercise tolerance. Recent studies involving heated and humidified high flow oxygen therapy (HFOT) showed positive effects on breathing pattern and ventilatory efficiency during effort. We thus plan to compare, in COPD patients with CRF undergoing a high-intensity exercise programme, the effect of using HFOT versus standard oxygen delivery via Venturi Mask (V-mask), at the same inspiratory oxygen fraction, on improving exercise endurance. METHODS/DESIGN: This is a multicentre randomised controlled trial that will involve 156 COPD inpatients with CRF recruited from seven PR hospitals. Patients will be randomised to one of two groups - V-mask versus HFOT. All patients will undergo the same high-intensity exercise programme using either of the oxygen delivery devices as per their group allocation. Training will consist of 20 sessions, over 1 month (5 sessions per week) within the hospitalisation period. Anthropometric and clinical data, including body mass index, diagnosis, spirometry and comorbidities (Cumulative Rating Scale) will be collected at baseline. At baseline and at the end of the exercise programme (primary assessment time) evaluation will include exercise tolerance (Constant Work Rate Exercise Test) (primary outcome), functional capacity (6-min walk test), maximal inspiratory pressure/maximal expiratory pressure, peripheral muscle strength (biceps and quadriceps) by manual dynamometer, respiratory exchanges (blood gases analysis), disability (Barthel Index and Barthel Dyspnoea Index), impact of disease (COPD Assessment test), and quality of life (Maugeri Respiratory Failure Scale-26). At the end of the training period, patient satisfaction will be evaluated. DISCUSSION: This study will add knowledge about the exercise response in advanced COPD with CRF and verify if an alternative tool, namely HFOT, can increase the benefit obtained from PR. TRIAL REGISTRATION: ClinicalTrials.gov ID NET03322787 Registered: 6 November 2017.


Assuntos
Cânula , Terapia por Exercício , Tolerância ao Exercício , Pulmão/fisiopatologia , Oxigenoterapia/instrumentação , Doença Pulmonar Obstrutiva Crônica/terapia , Respiração , Insuficiência Respiratória/terapia , Administração Intranasal , Humanos , Itália , Estudos Multicêntricos como Assunto , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
19.
J Med Case Rep ; 13(1): 150, 2019 May 20.
Artigo em Inglês | MEDLINE | ID: mdl-31104633

RESUMO

BACKGROUND: Guillain-Barré syndrome is an autoimmune disorder in which autoantibodies mainly affect the peripheral nervous system. Autonomic dysfunction is a common and severe complication of Guillain-Barré syndrome. Cardiomyopathy, though, is a rare complication in Guillain-Barré syndrome, with only a few cases reported in the literature. CASE PRESENTATION: We present a case of a 65-year-old Greek woman with Guillain-Barré syndrome who developed cardiomyopathy shortly after admission to the intensive care unit due to respiratory deterioration. Her estimated left ventricular ejection fraction upon admission was 20%. The result of coronary angiography was negative for coronary artery disease, and cardiac magnetic resonance imaging excluded myocarditis. Her clinical condition improved with supportive therapy, and her estimated left ventricular ejection fraction at discharge was normal. CONCLUSIONS: Clinicians should be aware of this potentially lethal complication of Guillain-Barré syndrome and the therapeutic options, because early diagnosis can improve prognosis. Routine electrocardiographic and echocardiographic assessments should be performed in patients with Guillain-Barré syndrome presenting with hemodynamic instability.


Assuntos
Síndrome de Guillain-Barré/fisiopatologia , Insuficiência Respiratória/fisiopatologia , Cardiomiopatia de Takotsubo/fisiopatologia , Idoso , Anti-Hipertensivos/uso terapêutico , Cardiotônicos/uso terapêutico , Dobutamina/uso terapêutico , Ecocardiografia , Feminino , Furosemida/uso terapêutico , Síndrome de Guillain-Barré/complicações , Síndrome de Guillain-Barré/diagnóstico , Síndrome de Guillain-Barré/tratamento farmacológico , Humanos , Ramipril/uso terapêutico , Insuficiência Respiratória/tratamento farmacológico , Insuficiência Respiratória/etiologia , Cardiomiopatia de Takotsubo/diagnóstico , Cardiomiopatia de Takotsubo/tratamento farmacológico , Cardiomiopatia de Takotsubo/etiologia , Resultado do Tratamento
20.
Paediatr Respir Rev ; 30: 13-15, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31130422

RESUMO

Duchenne muscular dystrophy [DMD] is the most common inherited myopathy and is caused by a defect in the dystrophin gene on the X chromosome causing production of a dysfunctional dystrophin protein. Over the last decade there have been advances in disease modifying pharmacotherapy beyond the widely used strategy of corticosteroids into products to impact both dystrophin production itself and also some of the downstream effects of absent of dysfunctional dystrophin. This manuscript will explore the respiratory progression of DMD including some proposed functional and clinical correlations and the overlap between loss of function in different muscle groups. Options for symptomatic treatment and support are presented and direction as to when the different options should be considered is provided. The manuscript will also review the currently available and late phase developmental pharmacotherapies for DMD.


Assuntos
Distrofia Muscular de Duchenne/fisiopatologia , Insuficiência Respiratória/fisiopatologia , Progressão da Doença , Glucocorticoides/uso terapêutico , Humanos , Morfolinos/uso terapêutico , Distrofia Muscular de Duchenne/complicações , Distrofia Muscular de Duchenne/tratamento farmacológico , Oxidiazóis/uso terapêutico , Prednisona/uso terapêutico , Pregnenodionas/uso terapêutico , Testes de Função Respiratória , Insuficiência Respiratória/tratamento farmacológico , Insuficiência Respiratória/etiologia
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