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1.
Undersea Hyperb Med ; 48(3): 279-286, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34390632

RESUMO

Sudden decompression can result in bubble formation as the result of nitrogen gas (N2) dissolved in tissue during disabled submarine escape (DISSUB). This may cause dysbaric osteonecrosis (DON), a condition in long bones where bubbles in fatty marrow result in ischemia and necrosis. Previous research has shown that oxygen (O2) pre-breathe of two hours resulted in a reduction of DON; however, effects of shorter O2 pre-breathe remain uncertain. This study's aim was to understand the effect of shorter lengths of O2 pre-breathe. Eight adult Suffolk ewes (89.5± 11.5 kg) were exposed to 33 feet of seawater (fsw) for 24 hours. They were placed randomly into four groups and exposed to either 45, 30 or 15 minutes of O2 (91-88%) pre-breathe; the controls received none. They were then rapidly decompressed. Alizarin complexone was later injected intravenously to visualize the extent of DON in the right and left long bones (radii, tibiae, femur and humeri). The 30- and 15-minute pre-breathe groups saw the greatest deposition. There was significant decrease of variance in the 45-minute group when compared with all other treatments, suggesting that 45 minutes of O2 pre-breathe is required to effectively increase confidence in the reduction of DON. Similar confidence was not reflected in the 30-minute and 15-minute groups: 45 minutes of pre-breathe was the minimum amount needed to effectively prevent against DON in DISSUB escape at 33 fsw. However, future research is needed to determine how to calculate effective dosages of O2 pre-breathe to prevent DON in any given scenario.


Assuntos
Doenças da Medula Óssea/prevenção & controle , Doença da Descompressão/complicações , Descompressão/efeitos adversos , Osteonecrose/prevenção & controle , Oxigenoterapia/métodos , Animais , Antraquinonas/administração & dosagem , Antraquinonas/farmacocinética , Doenças da Medula Óssea/diagnóstico , Doenças da Medula Óssea/metabolismo , Feminino , Fêmur , Úmero , Osteonecrose/diagnóstico , Osteonecrose/metabolismo , Rádio (Anatomia) , Distribuição Aleatória , Ovinos , Tíbia , Fatores de Tempo
2.
Cochrane Database Syst Rev ; 8: CD006822, 2021 08 16.
Artigo em Inglês | MEDLINE | ID: mdl-34397099

RESUMO

BACKGROUND: Croup is an acute viral respiratory infection with upper airway mucosal inflammation that may cause respiratory distress. Most cases are mild. Moderate to severe croup may require treatment with corticosteroids (the benefits of which are often delayed) and nebulised epinephrine (adrenaline) (the benefits of which may be short-lived and which can cause dose-related adverse effects including tachycardia, arrhythmias, and hypertension). Rarely, croup results in respiratory failure necessitating emergency intubation and ventilation. A mixture of helium and oxygen (heliox) may prevent morbidity and mortality in ventilated neonates by reducing the viscosity of the inhaled air. It is currently used during emergency transport of children with severe croup. Anecdotal evidence suggests that it relieves respiratory distress. This review updates versions published in 2010, 2013, and 2018. OBJECTIVES: To examine the effect of heliox compared to oxygen or other active interventions, placebo, or no treatment on relieving signs and symptoms in children with croup as determined by a croup score and rates of admission and intubation. SEARCH METHODS: We searched CENTRAL, which includes the Cochrane Acute Respiratory Infections Group Specialised Register, MEDLINE, Embase, CINAHL, Web of Science, and LILACS, on 15 April 2021. We also searched the World Health Organization International Clinical Trials Registry Platform (apps.who.int/trialsearch/) and ClinicalTrials.gov (clinicaltrials.gov) on 15 April 2021. We contacted the British Oxygen Company, a leading supplier of heliox. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs comparing the effect of heliox in comparison with placebo, no treatment, or any active intervention(s) in children with croup. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Data that could not be pooled for statistical analysis were reported descriptively. MAIN RESULTS: We included 3 RCTs involving a total of 91 children aged between 6 months and 4 years. Study duration was from 7 to 16 months, and all studies were conducted in emergency departments. Two studies were conducted in the USA and one in Spain. Heliox was administered as a mixture of 70% heliox and 30% oxygen. Risk of bias was low in two studies and high in one study because of its open-label design. We did not identify any new trials for this 2021 update. One study of 15 children with mild croup compared heliox with 30% humidified oxygen administered for 20 minutes. There may be no difference in croup score changes between groups at 20 minutes (mean difference (MD) -0.83, 95% confidence interval (CI) -2.36 to 0.70) (Westley croup score, scale range 0 to 16). The mean croup score at 20 minutes postintervention may not differ between groups (MD -0.57, 95% CI -1.46 to 0.32). There may be no difference between groups in mean respiratory rate (MD 6.40, 95% CI -1.38 to 14.18) and mean heart rate (MD 14.50, 95% CI -8.49 to 37.49) at 20 minutes. The evidence for all outcomes in this comparison was of low certainty, downgraded for serious imprecision. All children were discharged, but information on hospitalisation, intubation, or re-presenting to emergency departments was not reported. In another study, 47 children with moderate croup received one dose of oral dexamethasone (0.3 mg/kg) with either heliox for 60 minutes or no treatment. Heliox may slightly improve Taussig croup scores (scale range 0 to 15) at 60 minutes postintervention (MD -1.10, 95% CI -1.96 to -0.24), but there may be no difference between groups at 120 minutes (MD -0.70, 95% CI -1.56 to 0.16). Children treated with heliox may have lower mean Taussig croup scores at 60 minutes (MD -1.11, 95% CI -2.05 to -0.17) but not at 120 minutes (MD -0.71, 95% CI -1.72 to 0.30). Children treated with heliox may have lower mean respiratory rates at 60 minutes (MD -4.94, 95% CI -9.66 to -0.22), but there may be no difference at 120 minutes (MD -3.17, 95% CI -7.83 to 1.49). There may be a difference in hospitalisation rates between groups (odds ratio 0.46, 95% CI 0.04 to 5.41). We assessed the evidence for all outcomes in this comparison as of low certainty, downgraded due to imprecision and high risk of bias related to an open-label design. Information on heart rate and intubation was not reported. In the third study, 29 children with moderate to severe croup all received continuous cool mist and intramuscular dexamethasone (0.6 mg/kg). They were then randomised to receive either heliox (given as a mixture of 70% helium and 30% oxygen) plus one to two doses of nebulised saline or 100% oxygen plus nebulised epinephrine (adrenaline), with gas therapy administered continuously for three hours. Heliox may slightly improve croup scores at 90 minutes postintervention, but may result in little or no difference overall using repeated-measures analysis. We assessed the evidence for all outcomes in this comparison as of low certainty, downgraded due to high risk of bias related to inadequate reporting. Information on hospitalisation or re-presenting to the emergency department was not reported. The included studies did not report on adverse events, intensive care admissions, or parental anxiety. We could not pool the available data because each comparison included data from only one study. AUTHORS' CONCLUSIONS: Given the very limited available evidence, uncertainty remains regarding the effectiveness and safety of heliox. Heliox may not be more effective than 30% humidified oxygen for children with mild croup, but may be beneficial in the short term for children with moderate croup treated with dexamethasone. The effect of heliox may be similar to 100% oxygen given with one or two doses of adrenaline. Adverse events were not reported, and it is unclear if these were monitored in the included studies. Adequately powered RCTs comparing heliox with standard treatments are needed to further assess the role of heliox in the treatment of children with moderate to severe croup.


Assuntos
Obstrução das Vias Respiratórias/terapia , Crupe/terapia , Hélio/administração & dosagem , Oxigênio/administração & dosagem , Obstrução das Vias Respiratórias/etiologia , Resistência das Vias Respiratórias/efeitos dos fármacos , Criança , Pré-Escolar , Crupe/complicações , Crupe/tratamento farmacológico , Hélio/uso terapêutico , Humanos , Lactente , Oxigênio/uso terapêutico , Oxigenoterapia/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
8.
Crit Care ; 25(1): 194, 2021 06 06.
Artigo em Inglês | MEDLINE | ID: mdl-34090490

RESUMO

BACKGROUND: There is a limited evidence for humidified high-flow nasal cannula (HHFNC) use on inter-hospital transport. Despite this, its use during transport is increasing in children with respiratory distress worldwide. In 2015 HHFNC was implemented on a specialized pediatric retrieval team serving for Victoria. The aim of this study is to investigate the effect of the HHFNC implementation on the retrieval team on the paediatric intensive care unit (PICU) length of stay and respiratory support use. METHODS: We performed a cohort study using a comparative interrupted time-series approach controlling for patient and temporal covariates, and population-adjusted analysis. We studied 3022 children admitted to a PICU in Victoria with respiratory distress January 2010-December 2019. Patients were divided in pre-intervention era (2010-2014) and post-intervention era (2015-2019). RESULTS: 1006 children following interhospital transport and 2016 non-transport children were included. Median (IQR) age was 1.4 (0.7-4.5) years. Pneumonia (39.1%) and bronchiolitis (34.3%) were common. On retrieval, HHFNC was used in 5.0% (21/420) and 45.9% (269/586) in pre- and post-intervention era. In an unadjusted model, median (IQR) PICU length of stay was 2.2 (1.1-4.2) and 1.7 (0.9-3.2) days in the pre- and post-intervention era in transported children while the figures were 2.4 (1.3-4.9) and 2.1 (1.2-4.5) days in non-transport children. In the multivariable regression model, the intervention was associated with the reduced PICU length of stay (ratio 0.64, 95% confidential interval 0.49-0.83, p = 0.001) with the predicted reduction of PICU length of stay being - 10.6 h (95% confidential interval - 16.9 to - 4.3 h), and decreased respiratory support use (- 25.1 h, 95% confidential interval - 47.9 to - 2.3 h, p = 0.03). Sensitivity analyses including a model excluding less severe children showed similar results. In population-adjusted analyses, respiratory support use decreased from 4837 to 3477 person-hour per year in transported children over the study era, while the reduction was 594 (from 9553 to 8959) person-hour per year in non-transport children. With regard to the safety, there were no escalations of respiratory support mode during interhospital transport. CONCLUSIONS: The implementation of HHFNC on interhospital transport was associated with the reduced PICU length of stay and respiratory support use among PICU admissions with respiratory distress.


Assuntos
Umidificadores/normas , Oxigenoterapia/normas , Insuficiência Respiratória/terapia , Adolescente , Cânula , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Umidificadores/estatística & dados numéricos , Lactente , Unidades de Terapia Intensiva Pediátrica/organização & administração , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Análise de Séries Temporais Interrompida , Modelos Lineares , Masculino , Oxigenoterapia/instrumentação , Oxigenoterapia/métodos , Transferência de Pacientes/métodos , Transferência de Pacientes/normas , Transferência de Pacientes/estatística & dados numéricos , Insuficiência Respiratória/fisiopatologia , Estudos Retrospectivos , Vitória
9.
Scand J Trauma Resusc Emerg Med ; 29(1): 81, 2021 Jun 21.
Artigo em Inglês | MEDLINE | ID: mdl-34154631

RESUMO

BACKGROUND: Thoracic trauma is commonplace and accounts for 50-70% of the injuries found in severe trauma. Little information is available in the literature as to timing of endotracheal intubation. The main objective of this study was to assess the accuracy of the ROX index in predicting successful standard oxygen (SO) therapy outcomes, and in pre-empting intubation. METHODS: Patient selection included all thoracic trauma patients treated with standard oxygen who were admitted to a Level I trauma center between January 1, 2013 and April 30, 2020. Successful standard SO outcomes were defined as non-requirement of invasive mechanical ventilation within the 7 first days after thoracic trauma. RESULTS: One hundred seventy one patients were studied, 49 of whom required endotracheal intubation for acute respiratory distress (28.6%). A ROX index score ≤ 12.85 yielded an area under the ROC curve of 0.88 with a 95% CI [0.80-0.94], 81.63sensitivity, 95%CI [0.69-0.91] and 88.52 specificity, 95%CI [0.82-0.94] involving a Youden index of 0.70. Patients with a median ROX index greater than 12.85 within the initial 24 h were less likely to require mechanical ventilation within the initial 7 days of thoracic trauma. CONCLUSION: We have shown that a ROX index greater than 12.85 at 24 h was linked to successful standard oxygen therapy outcomes in critical thoracic trauma patients. It is our belief that an early low ROX index in the initial phase of trauma should heighten vigilance on the part of the attending intensivist, who has a duty to optimize management.


Assuntos
Oxigenoterapia/métodos , Traumatismos Torácicos/terapia , Adulto , Idoso , Feminino , Humanos , Intubação Intratraqueal/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Oxigênio/metabolismo , Respiração Artificial/estatística & dados numéricos , Síndrome do Desconforto Respiratório/terapia , Estudos Retrospectivos , Resultado do Tratamento
10.
Crit Care Med ; 49(7): e693-e700, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-34135285

RESUMO

OBJECTIVES: Severe acute respiratory syndrome coronavirus 2 is transmitted through aerosols and droplets. Nasal high-flow therapy could possibly increase the spreading of exhalates from patients. The aim of this study is to investigate whether nasal high-flow therapy affects the range of the expiratory plume compared with spontaneous breathing. DESIGN: Interventional experiment on single breaths of a healthy volunteer. SETTING: Research laboratory at the Bauhaus-University Weimar. SUBJECTS: A male subject. INTERVENTIONS: Videos and images from a schlieren optical system were analyzed during spontaneous breathing and different nasal high-flow rates. MEASUREMENTS AND MAIN RESULTS: The maximal exhalation spread was 0.99, 2.18, 2.92, and 4.1 m during spontaneous breathing, nasal high-flow of 20 L/min, nasal high-flow of 40 L/min, and nasal high-flow of 60 L/min, respectively. Spreading of the expiratory plume in the sagittal plane can completely be blocked with a surgical mask. CONCLUSIONS: Nasal high-flow therapy increases the range of the expiratory air up to more than 4 meters. The risk to pick up infectious particles could be increased within this range. Attachment of a surgical mask over the nasal high-flow cannula blocks the expiratory airstream.


Assuntos
Cânula , Expiração , Oxigenoterapia/métodos , Ventilação Pulmonar , Adulto , Transmissão de Doença Infecciosa/prevenção & controle , Voluntários Saudáveis , Humanos , Masculino , Microscopia de Vídeo , Taxa Respiratória , Volume de Ventilação Pulmonar
11.
Crit Care ; 25(1): 209, 2021 06 14.
Artigo em Inglês | MEDLINE | ID: mdl-34127046

RESUMO

BACKGROUND: The effect of awake prone positioning on intubation rates is not established. The aim of this trial was to investigate if a protocol for awake prone positioning reduces the rate of endotracheal intubation compared with standard care among patients with moderate to severe hypoxemic respiratory failure due to COVID-19. METHODS: We conducted a multicenter randomized clinical trial. Adult patients with confirmed COVID-19, high-flow nasal oxygen or noninvasive ventilation for respiratory support and a PaO2/FiO2 ratio ≤ 20 kPa were randomly assigned to a protocol targeting 16 h prone positioning per day or standard care. The primary endpoint was intubation within 30 days. Secondary endpoints included duration of awake prone positioning, 30-day mortality, ventilator-free days, hospital and intensive care unit length of stay, use of noninvasive ventilation, organ support and adverse events. The trial was terminated early due to futility. RESULTS: Of 141 patients assessed for eligibility, 75 were randomized of whom 39 were allocated to the control group and 36 to the prone group. Within 30 days after enrollment, 13 patients (33%) were intubated in the control group versus 12 patients (33%) in the prone group (HR 1.01 (95% CI 0.46-2.21), P = 0.99). Median prone duration was 3.4 h [IQR 1.8-8.4] in the control group compared with 9.0 h per day [IQR 4.4-10.6] in the prone group (P = 0.014). Nine patients (23%) in the control group had pressure sores compared with two patients (6%) in the prone group (difference - 18% (95% CI - 2 to - 33%); P = 0.032). There were no other differences in secondary outcomes between groups. CONCLUSIONS: The implemented protocol for awake prone positioning increased duration of prone positioning, but did not reduce the rate of intubation in patients with hypoxemic respiratory failure due to COVID-19 compared to standard care. TRIAL REGISTRATION: ISRCTN54917435. Registered 15 June 2020 ( https://doi.org/10.1186/ISRCTN54917435 ).


Assuntos
COVID-19/terapia , Oxigenoterapia/métodos , Posicionamento do Paciente/métodos , Decúbito Ventral , Insuficiência Respiratória/prevenção & controle , Adulto , COVID-19/complicações , Humanos , Unidades de Terapia Intensiva , Intubação Intratraqueal/efeitos adversos , Masculino , Pessoa de Meia-Idade , Insuficiência Respiratória/etiologia , Vigília
12.
Br J Anaesth ; 127(1): 133-142, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33933271

RESUMO

BACKGROUND: We aimed to determine whether high-flow nasal oxygen could reduce the incidence of decreased peripheral oxygen saturation (SpO2) compared with standard oxygen in patients at risk of hypoxaemia undergoing gastrointestinal endoscopy under deep sedation. METHODS: This was a multicentre, randomised controlled trial with blinded assessment of the primary outcome evaluating high-flow nasal oxygen (gas flow 70 L min-1, inspired oxygen fraction 0.50) or standard oxygen delivered via nasal cannula or face mask (6 L min-1) or nasopharyngeal tube (5 L min-1) in patients at risk of hypoxaemia (i.e. >60 yr old, or with underlying cardiac or respiratory disease, or with ASA physical status >1, or with obesity or sleep apnoea syndrome) undergoing gastrointestinal endoscopy. The primary endpoint was the incidence of SpO2 ≤92%. Secondary outcomes included prolonged or severe desaturations, need for manoeuvres to maintain free upper airways, and other adverse events. RESULTS: In 379 patients, a decrease in SpO2 ≤92% occurred in 9.4% (18/191) for the high-flow nasal oxygen group, and 33.5% (63/188) for the standard oxygen groups (adjusted absolute risk difference, -23.4% [95% confidence interval (CI), -28.9 to -16.7]; P<0.001). Prolonged desaturation (>1 min) and manoeuvres to maintain free upper airways were less frequent in the high-flow nasal oxygen group than in the standard oxygen group (7.3% vs 14.9%, P=.02, and 11.1% vs 32.4%, P<0.001). CONCLUSIONS: In patients at risk of hypoxaemia undergoing gastrointestinal endoscopy under deep sedation, use of high-flow nasal oxygen significantly reduced the incidence of peripheral oxygen desaturation. CLINICAL TRIAL REGISTRATION: NCT03829293.


Assuntos
Cânula , Endoscopia Gastrointestinal/métodos , Hipnóticos e Sedativos/administração & dosagem , Hipóxia/etiologia , Hipóxia/prevenção & controle , Oxigenoterapia/métodos , Idoso , Endoscopia Gastrointestinal/efeitos adversos , Feminino , Humanos , Hipnóticos e Sedativos/efeitos adversos , Hipóxia/diagnóstico , Masculino , Pessoa de Meia-Idade , Oxigenoterapia/instrumentação , Fatores de Risco , Método Simples-Cego
13.
Oxid Med Cell Longev ; 2021: 6648199, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33968298

RESUMO

Introduction: Mortality among critically ill COVID-19 patients remains relatively high despite different potential therapeutic modalities being introduced recently. The treatment of critically ill patients is a challenging task, without identified credible predictors of mortality. Methods: We performed an analysis of 160 consecutive patients with confirmed COVID-19 infection admitted to the Respiratory Intensive Care Unit between June 23, 2020, and October 2, 2020, in University Hospital Center Bezanijska kosa, Belgrade, Serbia. Patients on invasive, noninvasive ventilation and high flow oxygen therapy with moderate to severe ARDS, according to the Berlin definition of ARDS, were selected for the study. Demographic data, past medical history, laboratory values, and CT severity score were analyzed to identify predictors of mortality. Univariate and multivariate logistic regression models were used to assess potential predictors of mortality in critically ill COVID-19 patients. Results: The mean patient age was 65.6 years (range, 29-92 years), predominantly men, 68.8%. 107 (66.9%) patients were on invasive mechanical ventilation, 31 (19.3%) on noninvasive, and 22 (13.8%) on high flow oxygen therapy machine. The median total number of ICU days was 10 (25th to 75th percentile: 6-18), while the median total number of hospital stay was 18 (25th to 75th percentile: 12-28). The mortality rate was 60% (96/160). Univariate logistic regression analysis confirmed the significance of age, CRP, and lymphocytes at admission to hospital, serum albumin, D-dimer, and IL-6 at admission to ICU, and CT score. Serum albumin, D-dimer, and IL-6 at admission to ICU were independently associated with mortality in the final multivariate analysis. Conclusion: In the present study of 160 consecutive critically ill COVID-19 patients with moderate to severe ARDS, IL-6, serum albumin, and D-dimer at admission to ICU, accompanied by chest CT severity score, were marked as independent predictors of mortality.


Assuntos
Transtornos da Coagulação Sanguínea/complicações , COVID-19/complicações , COVID-19/mortalidade , Síndrome da Liberação de Citocina/complicações , Oxigenoterapia/métodos , Síndrome do Desconforto Respiratório/complicações , SARS-CoV-2/genética , Adulto , Idoso , Idoso de 80 Anos ou mais , Transtornos da Coagulação Sanguínea/sangue , Transtornos da Coagulação Sanguínea/virologia , COVID-19/epidemiologia , COVID-19/terapia , Cuidados Críticos , Estado Terminal , Síndrome da Liberação de Citocina/sangue , Síndrome da Liberação de Citocina/virologia , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Humanos , Unidades de Terapia Intensiva , Interleucina-6/sangue , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Reação em Cadeia da Polimerase em Tempo Real , Respiração Artificial , Síndrome do Desconforto Respiratório/sangue , Síndrome do Desconforto Respiratório/virologia , Sérvia/epidemiologia , Albumina Sérica Humana/análise , Índice de Gravidade de Doença , Resultado do Tratamento
14.
Can Respir J ; 2021: 6638048, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34055113

RESUMO

Background: High-flow nasal cannula (HFNC) oxygen therapy has been recommended for use in coronavirus disease 2019 (COVID-19) patients with acute respiratory failure and many other clinical conditions. HFNC devices produced by different manufacturers may have varied performance. Whether there is a difference in these devices and the extent of the differences in performance remain unknown. Methods: Four HFNC devices (AIRVO 2, TNI softFlow 50, HUMID-BH, and OH-70C) and a ventilator with an HFNC module (bellavista 1000) were evaluated. The flow was set at 20, 25, 30, 35, 40, 45, 50, 60, 70, and 80 L/min, and the FiO2 was set at 21%, 26%, 30%, 35%, 40%, 45%, 50%, 60%, 70%, 80%, and 90%. Then, one side of the cannulas was clipped to simulate the compression, bending, or blocking of the nasal cannulas. The flow and FiO2 of the delivered gas were recorded and compared among settings and devices. Results: The actual-flow and actual-FiO2 delivered by different settings and devices varied. AIRVO 2 had superior performance in flow and FiO2 accuracy. bellavista 1000 and OH-70C had good performance in the accuracy of actual-flows and actual-FiO2, respectively. bellavista 1000 and HUMID-BH had a larger flow range from 10 to 80 L/min, but only bellavista 1000 could provide a stable flow with an excessive resistance up to 60 L/min. TNI softFlow 50 had the best flow compensation and could provide sufficient flow with excessive resistance at 20-50 L/min. Conclusions: The variation in flow, FiO2 settings, and devices could influence the actual-flow and actual-FiO2 delivered. AIRVO 2 and OH-70C showed better FiO2 accuracy. TNI softFlow 50, bellavista 1000, and HUMID-BH could lower the risk of insufficient flow support due to accidental compression or blocking of the cannulas. In addition, ventilators with HFNC modules provided comparable flow and FiO2 and could be an alternative to standalone HFNC devices.


Assuntos
Injúria Renal Aguda/terapia , COVID-19 , Cânula , Inalação/fisiologia , Oxigenoterapia , Injúria Renal Aguda/etiologia , Análise de Variância , COVID-19/complicações , COVID-19/terapia , Cânula/classificação , Cânula/normas , Pesquisa Comparativa da Efetividade , Humanos , Teste de Materiais/métodos , Pressões Respiratórias Máximas , Oxigenoterapia/instrumentação , Oxigenoterapia/métodos , SARS-CoV-2 , Volume de Ventilação Pulmonar/fisiologia
15.
Recenti Prog Med ; 112(5): 378-386, 2021 05.
Artigo em Italiano | MEDLINE | ID: mdl-34003190

RESUMO

High-flow nasal cannula (HFNC) are an oxygen therapy device developed in the last years for the treatment of patients with acute or acute on chronic hypoxemic respiratory failure with different etiology and severity (including covid-19 pneumonia). HFNC combine the possibility of delivering high flows of gases, actively humidified and heated, with the use of a comfortable nasal interface, resulting generally well tolerated by most patients. In light of these characteristics, together with the simplicity of use and versatility, they have spread not only in intensive and semi-intensive care units but also in general medical ward in which they can play an important role in the treatment of elderly, frail patients with comorbidity where other more aggressive and invasive methods of ventilations are not indicated or not practicable.


Assuntos
Cânula , Oxigenoterapia/instrumentação , Insuficiência Respiratória/terapia , Acidose Respiratória/complicações , Acidose Respiratória/terapia , COVID-19/complicações , COVID-19/terapia , Cuidados Críticos/métodos , Desenho de Equipamento , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/terapia , Humanos , Hipóxia/complicações , Hipóxia/terapia , Medicina Interna , Oxigenoterapia/métodos , Cuidados Paliativos , Edema Pulmonar/complicações , Edema Pulmonar/terapia , Insuficiência Respiratória/complicações
16.
Ann Intern Med ; 174(7): 952-966, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33900793

RESUMO

BACKGROUND: Use of high-flow nasal oxygen (HFNO) for treatment of adults with acute respiratory failure (ARF) has increased. PURPOSE: To assess HFNO versus noninvasive ventilation (NIV) or conventional oxygen therapy (COT) for ARF in hospitalized adults. DATA SOURCES: English-language searches of MEDLINE, Embase, CINAHL, and Cochrane Library from January 2000 to July 2020; systematic review reference lists. STUDY SELECTION: 29 randomized controlled trials evaluated HFNO versus NIV (k = 11) or COT (k = 21). DATA EXTRACTION: Data extraction by a single investigator was verified by a second, 2 investigators assessed risk of bias, and evidence certainty was determined by consensus. DATA SYNTHESIS: Results are reported separately for HFNO versus NIV, for HFNO versus COT, and by initial or postextubation management. Compared with NIV, HFNO may reduce all-cause mortality, intubation, and hospital-acquired pneumonia and improve patient comfort in initial ARF management (low-certainty evidence) but not in postextubation management. Compared with COT, HFNO may reduce reintubation and improve patient comfort in postextubation ARF management (low-certainty evidence). LIMITATIONS: Trials varied in populations enrolled, ARF causes, and treatment protocols. Trial design, sample size, duration of treatment and follow-up, and results reporting were often insufficient to adequately assess many outcomes. Protocols, clinician and health system training, cost, and resource use were poorly characterized. CONCLUSION: Compared with NIV, HFNO as initial ARF management may improve several clinical outcomes. Compared with COT, HFNO as postextubation management may reduce reintubations and improve patient comfort; HFNO resulted in fewer harms than NIV or COT. Broad applicability, including required clinician and health system experience and resource use, is not well known. PRIMARY FUNDING SOURCE: American College of Physicians. (PROSPERO: CRD42019146691).


Assuntos
Ventilação não Invasiva/métodos , Oxigenoterapia/métodos , Insuficiência Respiratória/terapia , Doença Aguda , Adulto , Causas de Morte , Pressão Positiva Contínua nas Vias Aéreas , Cuidados Críticos , Dispneia/etiologia , Pneumonia Associada a Assistência à Saúde , Mortalidade Hospitalar , Humanos , Ventilação com Pressão Positiva Intermitente , Intubação Intratraqueal , Tempo de Internação , Avaliação de Resultados em Cuidados de Saúde , Estudos Prospectivos , Insuficiência Respiratória/complicações , Estados Unidos
17.
Ann Intern Med ; 174(7): 977-984, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33900796

RESUMO

DESCRIPTION: The American College of Physicians (ACP) developed this guideline to provide clinical recommendations on the appropriate use of high-flow nasal oxygen (HFNO) in hospitalized patients for initial or postextubation management of acute respiratory failure. It is based on the best available evidence on the benefits and harms of HFNO, taken in the context of costs and patient values and preferences. METHODS: The ACP Clinical Guidelines Committee based these recommendations on a systematic review on the efficacy and safety of HFNO. The patient-centered health outcomes evaluated included all-cause mortality, hospital length of stay, 30-day hospital readmissions, hospital-acquired pneumonia, days of intubation or reintubation, intensive care unit (ICU) admission and ICU transfers, patient comfort, dyspnea, delirium, barotrauma, compromised nutrition, gastric dysfunction, functional independence at discharge, discharge disposition, and skin breakdown. This guideline was developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. TARGET AUDIENCE AND PATIENT POPULATION: The target audience is all clinicians, and the target patient population is adult patients with acute respiratory failure treated in a hospital setting (including emergency departments, hospital wards, intermediate or step-down units, and ICUs). RECOMMENDATION 1A: ACP suggests that clinicians use high-flow nasal oxygen rather than noninvasive ventilation in hospitalized adults for the management of acute hypoxemic respiratory failure (conditional recommendation; low-certainty evidence). RECOMMENDATION 1B: ACP suggests that clinicians use high-flow nasal oxygen rather than conventional oxygen therapy for hospitalized adults with postextubation acute hypoxemic respiratory failure (conditional recommendation; low-certainty evidence).


Assuntos
Oxigenoterapia/métodos , Insuficiência Respiratória/terapia , Doença Aguda , Extubação , Pressão Positiva Contínua nas Vias Aéreas , Hospitalização , Humanos , Respiração com Pressão Positiva Intermitente , Ventilação não Invasiva/economia , Avaliação de Resultados em Cuidados de Saúde , Oxigenoterapia/efeitos adversos , Oxigenoterapia/economia , Preferência do Paciente
18.
Crit Care ; 25(1): 135, 2021 04 09.
Artigo em Inglês | MEDLINE | ID: mdl-33836812

RESUMO

BACKGROUND: High-flow nasal cannula oxygenation (HFNC) and noninvasive positive-pressure ventilation (NPPV) possibly decrease tracheal reintubation rates better than conventional oxygen therapy (COT); however, few large-scale studies have compared HFNC and NPPV. We conducted a network meta-analysis (NMA) to compare the effectiveness of three post-extubation respiratory support devices (HFNC, NPPV, and COT) in reducing the mortality and reintubation risk. METHODS: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Ichushi databases were searched. COT, NPPV, and HFNC use were assessed in patients who were aged ≥ 16 years, underwent invasive mechanical ventilation for > 12 h for acute respiratory failure, and were scheduled for extubation after spontaneous breathing trials. The GRADE Working Group Approach was performed using a frequentist-based approach with multivariate random-effect meta-analysis. Short-term mortality and reintubation and post-extubation respiratory failure rates were compared. RESULTS: After evaluating 4631 records, 15 studies and 2600 patients were included. The main cause of acute hypoxic respiratory failure was pneumonia. Although NPPV/HFNC use did not significantly lower the mortality risk (relative risk [95% confidence interval] 0.75 [0.53-1.06] and 0.92 [0.67-1.27]; low and moderate certainty, respectively), HFNC use significantly lowered the reintubation risk (0.54 [0.32-0.89]; high certainty) compared to COT use. The associations of mortality with NPPV and HFNC use with respect to either outcome did not differ significantly (short-term mortality and reintubation, relative risk [95% confidence interval] 0.81 [0.61-1.08] and 1.02 [0.53-1.97]; moderate and very low certainty, respectively). CONCLUSION: NPPV or HFNC use may not reduce the risk of short-term mortality; however, they may reduce the risk of endotracheal reintubation. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION: PROSPERO (registration number: CRD42020139112, 01/21/2020).


Assuntos
Extubação/métodos , Oxigenoterapia/normas , Insuficiência Respiratória/terapia , Extubação/efeitos adversos , Humanos , Oxigenoterapia/métodos , Insuficiência Respiratória/fisiopatologia , Desmame do Respirador/métodos
19.
Am J Respir Crit Care Med ; 204(3): 294-302, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-33794131

RESUMO

Rationale: Respiratory support (noninvasive ventilation or high-flow nasal cannula) applied at the time of extubation has been reported to reduce reintubation rates, but concerns regarding effectiveness have limited uptake into practice.Objectives: To determine if providing postextubation respiratory support to all patients undergoing extubation in a medical ICU would decrease the incidence of reintubation.Methods: We conducted a pragmatic, two-armed, cluster-crossover trial of adults undergoing extubation from invasive mechanical ventilation between October 1, 2017, and March 31, 2019, in the medical ICU of an academic medical center. Patients were assigned to either protocolized postextubation respiratory support (a respiratory therapist-driven protocol in which patients with suspected hypercapnia received noninvasive ventilation and patients without suspected hypercapnia received high-flow nasal cannula) or usual care (postextubation management at the discretion of treating clinicians). The primary outcome was reintubation within 96 hours of extubation.Measurements and Main Results: A total of 751 patients were enrolled. Of the 359 patients assigned to protocolized support, 331 (92.2%) received postextubation respiratory support compared with 66 of 392 patients (16.8%) assigned to usual care, a difference driven by differential use of high-flow nasal cannula (74.7% vs. 2.8%). A total of 57 patients (15.9%) in the protocolized support group experienced reintubation compared with 52 patients (13.3%) in the usual care group (odds ratio, 1.23; 95% confidence interval, 0.82 to 1.84; P = 0.32).Conclusions: Among a broad population of critically ill adults undergoing extubation from invasive mechanical ventilation at an academic medical center, protocolized postextubation respiratory support, primarily characterized by an increase in the use of high-flow nasal cannula, did not prevent reintubation compared with usual care.Clinical trial registered with www.clinicaltrials.gov (NCT0328831).


Assuntos
Extubação/métodos , Cânula , Hipercapnia/terapia , Hipóxia/terapia , Intubação Intratraqueal/estatística & dados numéricos , Ventilação não Invasiva/métodos , Oxigenoterapia/métodos , Insuficiência Respiratória/terapia , Adulto , Idoso , Protocolos Clínicos , Transtornos da Consciência/terapia , Estudos Cross-Over , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória , Resultado do Tratamento
20.
Lancet Respir Med ; 9(8): 933-936, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33915103

RESUMO

The 2012 Berlin definition of acute respiratory distress syndrome (ARDS) provided validated support for three levels of initial arterial hypoxaemia that correlated with mortality in patients receiving ventilatory support. Since 2015, high-flow nasal oxygen (HFNO) has become widely used as an effective therapeutic support for acute respiratory failure, most recently in patients with severe COVID-19. We propose that the Berlin definition of ARDS be broadened to include patients treated with HFNO of at least 30 L/min who fulfil the other criteria for the Berlin definition of ARDS. An expanded definition would make the diagnosis of ARDS more widely applicable, allowing patients at an earlier stage of the syndrome to be recognised, independent of the need for endotracheal intubation or positive-pressure ventilation, with benefits for the testing of early interventions and the study of factors associated with the course of ARDS. We identify key questions that could be addressed in refining an expanded definition of ARDS, the implementation of which could lead to improvements in clinical practice and clinical outcomes for patients.


Assuntos
COVID-19 , Oxigenoterapia/métodos , Insuficiência Respiratória , COVID-19/sangue , COVID-19/diagnóstico , COVID-19/terapia , Diagnóstico Precoce , Humanos , Seleção de Pacientes , Insuficiência Respiratória/sangue , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/terapia , SARS-CoV-2 , Índice de Gravidade de Doença , Tempo para o Tratamento/normas
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