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1.
Scand J Trauma Resusc Emerg Med ; 29(1): 30, 2021 Feb 08.
Artigo em Inglês | MEDLINE | ID: mdl-33557923

RESUMO

BACKGROUND: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), an emerging virus, has caused a global pandemic. Coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2, has led to high hospitalization rates worldwide. Little is known about the occurrence of in-hospital cardiac arrest (IHCA) and high mortality rates have been proposed. The aim of this study was to investigate the incidence, characteristics and outcome of IHCA during the pandemic in comparison to an earlier period. METHODS: This was a retrospective analysis of data prospectively recorded during 3-month-periods 2019 and 2020 at the University Medical Centre Hamburg-Eppendorf (Germany). All consecutive adult patients with IHCA were included. Clinical parameters, neurological outcomes and organ failure/support were assessed. RESULTS: During the study period hospital admissions declined from 18,262 (2019) to 13,994 (2020) (- 23%). The IHCA incidence increased from 4.6 (2019: 84 IHCA cases) to 6.6 (2020: 93 IHCA cases)/1000 hospital admissions. Median stay before IHCA was 4 (1-9) days. Demographic characteristics were comparable in both periods. IHCA location shifted towards the ICU (56% vs 37%, p < 0.01); shockable rhythm (VT/VF) (18% vs 29%, p = 0.05) and defibrillation were more frequent in the pandemic period (20% vs 35%, p < 0.05). Resuscitation times, rates of ROSC and post-CA characteristics were comparable in both periods. The severity of illness (SAPS II/SOFA), frequency of mechanical ventilation and frequency of vasopressor therapy after IHCA were higher during the 2020 period. Overall, 43 patients (12 with & 31 without COVID-19), presented with respiratory failure at the time of IHCA. The Horowitz index and resuscitation time were significantly lower in patients with COVID-19 (each p < 0.01). Favourable outcomes were observed in 42 and 10% of patients with and without COVID-19-related respiratory failure, respectively. CONCLUSION: Hospital admissions declined during the pandemic, but a higher incidence of IHCA was observed. IHCA in patients with COVID-19 was a common finding. Compared to patients with non-COVID-19-related respiratory failure, the outcome was improved.


Assuntos
/epidemiologia , Parada Cardíaca/epidemiologia , Idoso , Reanimação Cardiopulmonar/estatística & dados numéricos , Estudos de Coortes , Uso de Medicamentos/tendências , Cardioversão Elétrica/tendências , Feminino , Alemanha/epidemiologia , Parada Cardíaca/terapia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Pandemias , Admissão do Paciente/tendências , Respiração Artificial/tendências , Insuficiência Respiratória/epidemiologia , Estudos Retrospectivos , Vasoconstritores/uso terapêutico
2.
Respir Res ; 22(1): 37, 2021 Feb 05.
Artigo em Inglês | MEDLINE | ID: mdl-33546658

RESUMO

BACKGROUND: Comorbidities play a key role in severe disease outcomes in COVID-19 patients. However, the literature on preexisting respiratory diseases and COVID-19, accounting for other possible confounders, is limited. The primary objective of this study was to determine the association between preexisting respiratory diseases and severe disease outcomes among COVID-19 patients. Secondary aim was to investigate any correlation between smoking and clinical outcomes in COVID-19 patients. METHODS:  This is a multihospital retrospective cohort study on 1871 adult patients between March 10, 2020, and June 30, 2020, with laboratory confirmed COVID-19 diagnosis. The main outcomes of the study were severe disease outcomes i.e. mortality, need for mechanical ventilation, and intensive care unit (ICU) admission. During statistical analysis, possible confounders such as age, sex, race, BMI, and comorbidities including, hypertension, coronary artery disease, congestive heart failure, diabetes, any history of cancer and prior liver disease, chronic kidney disease, end-stage renal disease on dialysis, hyperlipidemia and history of prior stroke, were accounted for. RESULTS:  A total of 1871 patients (mean (SD) age, 64.11 (16) years; 965(51.6%) males; 1494 (79.9%) African Americans; 809 (43.2%) with ≥ 3 comorbidities) were included in the study. During their stay at the hospital, 613 patients (32.8%) died, 489 (26.1%) needed mechanical ventilation, and 592 (31.6%) required ICU admission. In fully adjusted models, patients with preexisting respiratory diseases had significantly higher mortality (adjusted Odds ratio (aOR), 1.36; 95% CI, 1.08-1.72; p = 0.01), higher rate of ICU admission (aOR, 1.34; 95% CI, 1.07-1.68; p = 0.009) and increased need for mechanical ventilation (aOR, 1.36; 95% CI, 1.07-1.72; p = 0.01). Additionally, patients with a history of smoking had significantly higher need for ICU admission (aOR, 1.25; 95% CI, 1.01-1.55; p = 0.03) in fully adjusted models. CONCLUSION:  Preexisting respiratory diseases are an important predictor for mortality and severe disease outcomes, in COVID-19 patients. These results can help facilitate efficient resource allocation for critical care services.


Assuntos
Afro-Americanos , /terapia , Transtornos Respiratórios/mortalidade , Transtornos Respiratórios/terapia , Idoso , Estudos de Coortes , Feminino , Mortalidade Hospitalar/tendências , Hospitalização/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Cobertura de Condição Pré-Existente , Transtornos Respiratórios/diagnóstico , Respiração Artificial/mortalidade , Respiração Artificial/tendências , Estudos Retrospectivos , Resultado do Tratamento
3.
Br J Anaesth ; 126(3): 578-589, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33454051

RESUMO

BACKGROUND: Patients with coronavirus disease 2019 (COVID-19) requiring mechanical ventilation have high mortality and resource utilisation. The ability to predict which patients may require mechanical ventilation allows increased acuity of care and targeted interventions to potentially mitigate deterioration. METHODS: We included hospitalised patients with COVID-19 in this single-centre retrospective observational study. Our primary outcome was mechanical ventilation or death within 24 h. As clinical decompensation is more recognisable, but less modifiable, as the prediction window shrinks, we also assessed 4, 8, and 48 h prediction windows. Model features included demographic information, laboratory results, comorbidities, medication administration, and vital signs. We created a Random Forest model, and assessed performance using 10-fold cross-validation. The model was compared with models derived from generalised estimating equations using discrimination. RESULTS: Ninety-three (23%) of 398 patients required mechanical ventilation or died within 14 days of admission. The Random Forest model predicted pending mechanical ventilation with good discrimination (C-statistic=0.858; 95% confidence interval, 0.841-0.874), which is comparable with the discrimination of the generalised estimating equation regression. Vitals sign data including SpO2/FiO2 ratio (Random Forest Feature Importance Z-score=8.56), ventilatory frequency (5.97), and heart rate (5.87) had the highest predictive utility. In our highest-risk cohort, the number of patients needed to identify a single new case was 3.2, and for our second quintile it was 5.0. CONCLUSION: Machine learning techniques can be leveraged to improve the ability to predict which patients with COVID-19 are likely to require mechanical ventilation, identifying unrecognised bellwethers and providing insight into the constellation of accompanying signs of respiratory failure in COVID-19.


Assuntos
/diagnóstico , Tomada de Decisão Clínica/métodos , Aprendizado de Máquina/tendências , Respiração Artificial/tendências , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos
5.
Arch. bronconeumol. (Ed. impr.) ; 56(12): 792-800, dic. 2020. tab, graf
Artigo em Inglês | IBECS | ID: ibc-199073

RESUMO

AIM: We examined fifteen years trends (2001-2015) in the use of non-invasive ventilation (NIV), invasive mechanical ventilation (IMV) or both (NIV+IMV) among patients hospitalized for community acquired pneumonia (CAP). We also analyzed trends overtime and the influence of patient factors in the in-hospital mortality (IHM) after receiving NIV, IMV or NIV + IMV. METHODS: Observational retrospective epidemiological study. Our data source was the Spanish National Hospital Discharge Database. RESULTS: Over a total of 1,486,240 hospitalized patients with CAP, we identified 56,158 who had received ventilator support in Spain over the study period. Of them, 54.82% received NIV, 37.04% IMV and 8.14% both procedures. The use of NIV and NIV + IMV increased significantly (p < 0.001) over time (from 0.91 to 12.84 per 100.000 inhabitant and from 0.23 to 1.19 per 100.000 inhabitants, respectively), while the IMV utilization decreased (from 3.55 to 2.79 per 100,000 inhabitants; p < 0.001). Patients receiving NIV were the oldest and had the highest mean value in the Charlson comorbidity index (CCI) score and readmission rate. Patients who received only IMV had the highest IHM. Factors associated with IHM for all groups analyzed included age, comorbidities and readmission. IHM decreased significantly over time in patients with CAP who received NIV, IMV and NIV + IMV. CONCLUSIONS: We found an increase in NIV use and a decline in IMV utilization in patients hospitalized for CAP over the study period. Patients receiving NIV were the oldest and had the highest CCI score and readmission rate. IHM decreased significantly over time in patients with CAP who received NIV, IMV and NIV + IMV


OBJETIVO: Estudiamos las tendencias a lo largo de 15 años (2001-2015) en el uso de la ventilación no invasiva (VNI), la ventilación mecánica invasiva (VMI) o ambas (VNI + VMI) en los pacientes hospitalizados por neumonía adquirida en la comunidad (NAC). También analizamos las tendencias en el tiempo y la influencia de los factores del paciente en la mortalidad hospitalaria (MH) después de recibir VNI, VMI o VNI + VMI. MÉTODOS: Estudio epidemiológico retrospectivo observacional. Nuestra fuente de datos fue el Registro de Altas de los Hospitales (CMBD) del Sistema Nacional de Salud. RESULTADOS: En un total de 1.486.240 pacientes hospitalizados por NAC, identificamos a 56.158 que habían recibido soporte ventilatorio en España durante el período a estudio. De ellos, el 54,82% recibió VNI, el 37,04% VMI y el 8,14% ambos procedimientos. El uso de VNI y VNI + VMI aumentó significativamente (p < 0,001) con el tiempo (de 0,91 a 12,84 por habitante y de 0,23 a 1,19 por cada 100.000 habitantes, respectivamente), mientras que la utilización de la VMI disminuyó (de 3,55 a 2,79 por cada 100.000 habitantes; p < 0,001). Los pacientes que recibieron VNI fueron los más ancianos y presentaban el valor medio más alto de puntuación en el índice de comorbilidad de Charlson (CCI, por sus siglas en inglés) y en la tasa de reingreso. Los pacientes que recibieron solo VMI presentaron la MH más alta. Los factores asociados a la MH para todos los grupos analizados incluyeron la edad, las comorbilidades y el reingreso. La MH disminuyó significativamente con el tiempo en los pacientes con NAC que recibieron VNI, VMI y VNI + VMI. CONCLUSIONES: Encontramos un aumento en el uso de VNI y una disminución en la utilización de VMI en pacientes hospitalizados por NAC durante el período a estudio. Los pacientes que recibieron VNI fueron los más ancianos y tenían la puntuación más alta en el CCI y la tasa de reingreso más elevada. La MH disminuyó significativamente con el tiempo en los pacientes con NAC que recibieron VNI, VMI y VNI + VMI


Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Infecções Comunitárias Adquiridas/terapia , Pneumonia/terapia , Respiração Artificial/tendências , Estudos Retrospectivos , Pneumonia/mortalidade , Infecções Comunitárias Adquiridas/mortalidade , Respiração Artificial/mortalidade , Mortalidade Hospitalar , Estatísticas não Paramétricas , Hospitalização , Distribuição por Idade e Sexo , Fatores de Tempo , Espanha/epidemiologia , Comorbidade
6.
Curr Opin Anaesthesiol ; 33(6): 774-780, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33060384

RESUMO

PURPOSE OF REVIEW: Airway management, mechanical ventilation, and treatment of systemic poisoning in burn patients with inhalation injury remains challenging. This review summarizes new concepts as well as open questions. RECENT FINDINGS: Several life-threatening complications, such as airway patency impairment and respiratory insufficiency, can arise in burn patients and require adequate and timely airway management. However, unnecessary endotracheal intubation should be avoided. Direct visual inspection via nasolaryngoscopy can guide appropriate airway management decisions. In cases of lower airway injury, bronchoscopy is recommended to remove casts and estimate the extent of the injury in intubated patients. Several mechanical ventilation strategies have been studied. An interesting modality might be high-frequency percussive ventilation. However, to date, there is no sound evidence that patients with inhalation injury should be ventilated with modes other than those applied to non-burn patients. In all burn patients exposed to enclosed fire, carbon monoxide as well as cyanide poisoning should be suspected. Carbon monoxide poisoning should be treated with an inspiratory oxygen fraction of 100%, whereas cyanide poisoning should be treated with hydroxocobalamin. SUMMARY: Burn patients need specialized care that requires specific knowledge about airway management, mechanical ventilation, and carbon monoxide and cyanide poisoning.


Assuntos
Manuseio das Vias Aéreas/tendências , Queimaduras por Inalação/terapia , Respiração Artificial/tendências , Lesão por Inalação de Fumaça/terapia , Manuseio das Vias Aéreas/métodos , Queimaduras/terapia , Intoxicação por Monóxido de Carbono/terapia , Fogo , Humanos , Respiração Artificial/métodos , Terapia Respiratória , Lesão por Inalação de Fumaça/complicações
7.
Pediatrics ; 146(4)2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32917845

RESUMO

OBJECTIVES: To explore and define contemporary trends in the use of invasive mechanical ventilation (IMV) and noninvasive ventilation (NIV) in the treatment of children with asthma. METHODS: We performed a serial cross-sectional analysis using data from the Pediatric Health Information System. We examined 2014-2018 admission abstracts from patients aged 2 to 17 years who were admitted to member hospitals with a primary diagnosis of asthma. We report temporal trends in IMV use, NIV use, ICU admission, length of stay, and mortality. RESULTS: Over the study period, 48 hospitals reported 95 204 admissions with a primary diagnosis of asthma. Overall, IMV use remained stable at 0.6% between 2014 and 2018 (interquartile range [IQR]: 0.3%-1.1% and 0.2%-1.3%, respectively), whereas NIV use increased from 1.5% (IQR: 0.3%-3.2%) to 2.1% (IQR: 0.3%-5.6%). There was considerable practice variation among centers, with NIV rates more than doubling within the highest quartile of users (from 4.8% [IQR: 2.8%-7.5%] to 13.2% [IQR: 7.4%-15.2%]; P < .02). ICU admission was more common among centers with high NIV use, but centers with high NIV use did not differ from lower-use centers in mortality, IMV use, or overall average length of stay. CONCLUSIONS: The use of IMV is at historic lows, and NIV has replaced it as the primary mechanical support mode for asthma. However, there is considerable variability in NIV use. Increased NIV use was not associated with a change in IMV rates, which remained stable. Higher NIV use was associated with increased ICU admissions. NIV's precise contribution to the cost and quality of care remains to be determined.


Assuntos
Asma/terapia , Ventilação não Invasiva/tendências , Respiração Artificial/tendências , Adolescente , Asma/mortalidade , Criança , Pré-Escolar , Estudos Transversais , Feminino , Humanos , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Unidades de Terapia Intensiva Pediátrica/tendências , Tempo de Internação/tendências , Masculino , Fatores de Tempo
8.
Med. intensiva (Madr., Ed. impr.) ; 44(6): 333-343, ago.-sept. 2020. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-194812

RESUMO

OBJETIVO: Los objetivos principales son describir la práctica de la ventilación mecánica en un periodo de 18 años en México y estimar los cambios en la mortalidad de los pacientes críticos con ventilación mecánica invasiva (VMI). DISEÑO: Subanálisis retrospectivo de un estudio prospectivo y observacional en 1998, 2004, 2010 y 2016. ÁMBITO: Unidades de Cuidados Intensivos (UCI) de México. PARTICIPANTES: Pacientes adultos que ingresaron consecutivamente en la UCI, durante un mes y que recibieron VMI durante más de 12 h o ventilación mecánica no invasiva durante más de una hora. El seguimiento se realizó hasta 28 días después de la inclusión. INTERVENCIONES: Ninguna. VARIABLES DE INTERÉS: Edad, sexo, gravedad al ingreso estimada por el SAPS II, parámetros de la gasometría arterial diaria, variables de tratamiento y complicaciones, fecha y estado al alta de la UCI y del hospital. RESULTADOS: Se incluyó a 959 pacientes en 81 UCI. El volumen corriente (VC) ha disminuido significativamente tanto en pacientes con criterios de SDRA (de 8,5 ml/kg de peso estimado en 1998 a 6 ml/kg en 2016; p < 0,001) como en enfermos sin SDRA (de 9 ml/kg de peso estimado en 1998 a 6ml/kg en 2016; p < 0,001). La estrategia ventilatoria protectora (definida como VC < 6 ml/kg o < 8 ml/kg y una presión meseta < 30 cmH2O) fue: 19% en 1998, 44% en 2004, 58% en 2010 y 75% en 2016 (p < 0,001). La mortalidad ajustada en UCI a lo largo de los 4 periodos fue: en 2004, oportunidad relativa (OR) 1,05 (IC 95%: 0,73-1,72; p = 0,764); en 2010, OR 1,68 (IC 95%: 1,13-2,48; p = 0,009); en 2016, OR 0,85 (IC 95%: 0,60-1,20; p = 0,368). CONCLUSIONES: La práctica clínica de la VMI en las UCI de México se ha modificado a lo largo de un periodo de 18 años. El cambio más significativo es la estrategia ventilatoria basada en VC bajos. Estos cambios no se han asociado a cambios significativos en la mortalidad


OBJECTIVE: The main study objectives were to describe the practice of mechanical ventilation over an 18-year period in Mexico, and estimate changes in mortality among critical patients subjected to invasive mechanical ventilation (IMV). DESIGN: A retrospective subanalysis of a prospective observational study conducted in 1998, 2004, 2010 and 2016 was carried out. SETTING: Intensive Care Units (ICUs) in Mexico. PARTICIPANTS: Adult patients consecutively enrolled in the ICU during one month and who underwent IMV for more than 12hours or noninvasive mechanical ventilation for more than one hour. Follow-up was performed up to a maximum of 28 days after inclusion. INTERVENTIONS: None. PRINCIPAL VARIABLES OF INTEREST: Age, sex, severity upon admission as estimated by SAPS II, parameters of daily arterial blood gases, treatment and complication variables, date and status at discharge from the ICU and from hospital. RESULTS: A total of 959 patients were included in 81 ICUs. Tidal volume (vt) decreased significantly both in patients with acute respiratory distress syndrome (ARDS) criteria (estimated 8.5 ml/kg b.w. in 1998 to 6 ml/kg in 2016; P < 0.001) and in patients without ARDS (estimated 9 ml/kg b.w. in 1998 to 6 ml/kg in 2016; P < 0.001). The ventilatory protective strategy (defined as vt < 6 ml/kg or < 8 ml/kg and a plateau pressure < 30 cmH2O) was: 19% in 1998, 44% in 2004, 58% in 2010 and 75% in 2016 (P < 0.001). The adjusted mortality rate in ICU over the 4 periods was: in 2004, odds ratio (OR) 1.05 (95% confidence interval, 95% CI: 0.73-1.72; P = 0.764); in 2010, OR 1.68 (95% CI: 1.13-2.48; P = 0.009); in 2016, OR 0.85 (95%CI: 0.60-1.20; P = 0.368). CONCLUSIONS: The clinical practice of IMV in Mexican ICUs has been modified over a period of 18 years. The most significant change is the ventilatory strategy based on low vt. These changes have not been associated with significant changes in mortality


Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Respiração Artificial/métodos , Medicina Baseada em Evidências , Mortalidade Hospitalar , Respiração Artificial/tendências , México , Estudos Retrospectivos , Estudos Prospectivos , Análise de Variância , Razão de Chances , Fatores de Risco , Síndrome do Desconforto Respiratório do Adulto/epidemiologia , Respiração com Pressão Positiva
9.
J Antimicrob Chemother ; 75(11): 3359-3365, 2020 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-32829390

RESUMO

BACKGROUND: Remdesivir is a prodrug with in vitro activity against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Its clinical efficacy in patients with COVID-19 under mechanical ventilation remains to be evaluated. METHODS: This study includes patients under mechanical ventilation with confirmed SARS-CoV-2 infection admitted to the ICU of Pesaro hospital between 29 February and 20 March 2020. During this period, remdesivir was provided on a compassionate use basis. Clinical characteristics and outcome of patients treated with remdesivir were collected retrospectively and compared with those of patients hospitalized in the same time period. RESULTS: A total of 51 patients were considered, of which 25 were treated with remdesivir. The median (IQR) age was 67 (59-75.5) years, 92% were men and symptom onset was 10 (8-12) days before admission to ICU. At baseline, there was no significant difference in demographic characteristics, comorbidities and laboratory values between patients treated and not treated with remdesivir. Median follow-up was 52 (46-57) days. Kaplan-Meier curves showed significantly lower mortality among patients who had been treated with remdesivir (56% versus 92%, P < 0.001). Cox regression analysis showed that the Charlson Comorbidity Index was the only factor that had a significant association with higher mortality (OR 1.184; 95% CI 1.027-1.365; P = 0.020), while the use of remdesivir was associated with better survival (OR 3.506; 95% CI 1.768-6.954; P < 0.001). CONCLUSIONS: In this study the mortality rate of patients with COVID-19 under mechanical ventilation is confirmed to be high. The use of remdesivir was associated with a significant beneficial effect on survival.


Assuntos
Monofosfato de Adenosina/análogos & derivados , Alanina/análogos & derivados , Antivirais/uso terapêutico , Betacoronavirus , Infecções por Coronavirus/mortalidade , Unidades de Terapia Intensiva , Pneumonia Viral/mortalidade , Respiração Artificial/mortalidade , Monofosfato de Adenosina/uso terapêutico , Idoso , Alanina/uso terapêutico , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/terapia , Feminino , Seguimentos , Humanos , Unidades de Terapia Intensiva/tendências , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/terapia , Respiração Artificial/tendências , Estudos Retrospectivos , Resultado do Tratamento
10.
J Antimicrob Chemother ; 75(9): 2657-2660, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32688374

RESUMO

BACKGROUND: The combination lopinavir/ritonavir is recommended to treat HIV-infected patients at the dose regimen of 400/100 mg q12h, oral route. The usual lopinavir trough plasma concentrations are 3000-8000 ng/mL. A trend towards a 28 day mortality reduction was observed in COVID-19-infected patients treated with lopinavir/ritonavir. OBJECTIVES: To assess the plasma concentrations of lopinavir and ritonavir in patients with severe COVID-19 infection and receiving lopinavir/ritonavir. PATIENTS AND METHODS: Mechanically ventilated patients with COVID-19 infection included in the French COVID-19 cohort and treated with lopinavir/ritonavir were included. Lopinavir/ritonavir combination was administered using the usual adult HIV dose regimen (400/100 mg q12h, oral solution through a nasogastric tube). A half-dose reduction to 400/100 mg q24h was proposed if lopinavir Ctrough was >8000 ng/mL, the upper limit considered as toxic and reported in HIV-infected patients. Lopinavir and ritonavir pharmacokinetic parameters were determined after an intensive pharmacokinetic analysis. Biological markers of inflammation and liver/kidney function were monitored. RESULTS: Plasma concentrations of lopinavir and ritonavir were first assessed in eight patients treated with lopinavir/ritonavir. Median (IQR) lopinavir Ctrough reached 27 908 ng/mL (15 928-32 627). After the dose reduction to 400/100 mg q24h, lopinavir/ritonavir pharmacokinetic parameters were assessed in nine patients. Lopinavir Ctrough decreased to 22 974 ng/mL (21 394-32 735). CONCLUSIONS: In mechanically ventilated patients with severe COVID-19 infections, the oral administration of lopinavir/ritonavir elicited plasma exposure of lopinavir more than 6-fold the upper usual expected range. However, it remains difficult to safely recommend its dose reduction without compromising the benefit of the antiviral strategy, and careful pharmacokinetic and toxicity monitoring are needed.


Assuntos
Betacoronavirus , Infecções por Coronavirus/sangue , Unidades de Terapia Intensiva/tendências , Lopinavir/sangue , Pneumonia Viral/sangue , Respiração Artificial/tendências , Ritonavir/sangue , Administração Oral , Infecções por Coronavirus/tratamento farmacológico , Inibidores do Citocromo P-450 CYP3A/administração & dosagem , Inibidores do Citocromo P-450 CYP3A/sangue , Quimioterapia Combinada , Feminino , Humanos , Lopinavir/administração & dosagem , Masculino , Pessoa de Meia-Idade , Pandemias , Soluções Farmacêuticas/administração & dosagem , Soluções Farmacêuticas/farmacocinética , Pneumonia Viral/tratamento farmacológico , Estudos Prospectivos , Ritonavir/administração & dosagem
11.
Crit Care ; 24(1): 158, 2020 04 17.
Artigo em Inglês | MEDLINE | ID: mdl-32303255

RESUMO

BACKGROUND: Severe traumatic brain injury (TBI) patients often develop acute respiratory failure. Optimal ventilator strategies in this setting are not well established. We performed an international survey to investigate the practice in the ventilatory management of TBI patients with and without respiratory failure. METHODS: An electronic questionnaire, including 38 items and 3 different clinical scenarios [arterial partial pressure of oxygen (PaO2)/inspired fraction of oxygen (FiO2) > 300 (scenario 1), 150-300 (scenario 2), < 150 (scenario 3)], was available on the European Society of Intensive Care Medicine (ESICM) website between November 2018 and March 2019. The survey was endorsed by ESICM. RESULTS: There were 687 respondents [472 (69%) from Europe], mainly intensivists [328 (48%)] and anesthesiologists [206 (30%)]. A standard protocol for mechanical ventilation in TBI patients was utilized by 277 (40%) respondents and a specific weaning protocol by 198 (30%). The most common tidal volume (TV) applied was 6-8 ml/kg of predicted body weight (PBW) in scenarios 1-2 (72% PaO2/FIO2 > 300 and 61% PaO2/FiO2 150-300) and 4-6 ml/kg/PBW in scenario 3 (53% PaO2/FiO2 < 150). The most common level of highest positive end-expiratory pressure (PEEP) used was 15 cmH2O in patients with a PaO2/FiO2 ≤ 300 without intracranial hypertension (41% if PaO2/FiO2 150-300 and 50% if PaO2/FiO2 < 150) and 10 cmH2O in patients with intracranial hypertension (32% if PaO2/FiO2 150-300 and 33% if PaO2/FiO2 < 150). Regardless of the presence of intracranial hypertension, the most common carbon dioxide target remained 36-40 mmHg whereas the most common PaO2 target was 81-100 mmHg in all the 3 scenarios. The most frequent rescue strategies utilized in case of refractory respiratory failure despite conventional ventilator settings were neuromuscular blocking agents [406 (88%)], recruitment manoeuvres [319 (69%)] and prone position [292 (63%)]. CONCLUSIONS: Ventilatory management, targets and practice of adult severe TBI patients with and without respiratory failure are widely different among centres. These findings may be helpful to define future investigations in this topic.


Assuntos
Lesões Encefálicas Traumáticas/terapia , Cuidados Críticos/organização & administração , Respiração Artificial/métodos , Adulto , Idoso , Lesões Encefálicas Traumáticas/fisiopatologia , Distribuição de Qui-Quadrado , Cuidados Críticos/tendências , Europa (Continente) , Feminino , Humanos , Internacionalidade , Masculino , Pessoa de Meia-Idade , Respiração Artificial/tendências , Inquéritos e Questionários
12.
Am J Cardiol ; 125(11): 1678-1687, 2020 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-32278463

RESUMO

Infective Endocarditis (IE) is associated with high mortality and morbidity. The data on contemporary trends and health care utilization remain scarce for IE. Consequently, we used the National Inpatient Sample database from 2002 to 2016 to study burden of IE. Risk-adjusted rates were calculated using an Analysis of Covariance with the Generalized Linear Model. Trends were assessed with linear regression and Pearson's Chi-square modeling, where appropriate. Binomial logistic regression was used for computing predictors of in-hospital mortality. We identified 523,432 hospitalizations for native valve IE. Risk-adjusted mortality decreased from 16.7% in 2002 to 9.7% in 2016 (p <0.01). The risk-adjusted length of stay decreased from 17.4 days in 2002 to 13.4 days in 2016 (p <0.01). Mean cost of stay adjusted for risk factors and inflation increased from 112,702$ in 2002 to 164,767$ in 2016 (p <0.01). Valve replacement increased from 10.2% in 2002 in to 13.4% in 2016, (p <0.01). Independent predictors of mortality included age (OR, 1.02 [1.02 to 1.020], p <0.01), female gender (OR, 1.07 [1.05 to 1.09], p <0.01), Blacks (OR, 1.28 [1.24 to 1.31], p <0.01), Hispanics (OR, 1.15 [1.11 to 1.19], p <0.01) and patients with co-morbid conditions like congestive heart failure (OR, 1.78 [1.74 to 1.82], p <0.01), renal failure (OR, [1.69 [1.65 to 1.73], p <0.01) and weight loss (OR, 1.40 [1.36 to 1.43], p <0.01). In summary, in-hospital mortality from native valve IE has been decreasing but total hospitalization and average cost of stay has increased.


Assuntos
Endocardite/epidemiologia , Custos de Cuidados de Saúde/tendências , Implante de Prótese de Valva Cardíaca/tendências , Mortalidade Hospitalar/tendências , Adulto , Idoso , Endocardite/economia , Endocardite/mortalidade , Feminino , Humanos , Incidência , Tempo de Internação/tendências , Modelos Lineares , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Respiração Artificial/economia , Respiração Artificial/tendências , Choque Séptico/economia , Choque Séptico/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Estados Unidos/epidemiologia
13.
Spine (Phila Pa 1976) ; 45(9): E515-E524, 2020 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-32282654

RESUMO

MINI: In this study, respiratory function at the time of extubation can be useful optimal clinical guidelines for weaning and extubation attempts in patients with acute cervical spinal cord injury. Serum thiobarbituric acid-reactive substances level at admission can be a useful predictor for severity in acute cervical patients with spinal cord injury. STUDY DESIGN: Patients who had suffered from acute blunt cervical spinal cord injury (SCI) and admitted our hospital within 24 hours after injury were included in the study. OBJECTIVE: We compared the respiratory function and serum reactive oxidative stress (ROS) after acute cervical SCI, and tried to find out the valuable predictors of weaning in patients with acute cervical SCI. SUMMARY OF BACKGROUND DATA: Ventilation impairment is a major complication of acute cervical SCI. Evidence of oxygen radical formation in secondary injury from animal SCI models demonstrates an immediate postinjury increase in ROS production after SCI. We hypothesize that the serum ROS is associated with the severity of patients with acute cervical SCI. METHODS: Thirty-eight adult patients who had acute cervical SCI and 58 healthy volunteers were enrolled. Respiratory function at admission, at the time of extubation and at 48 hours after extubation, serum oxidative stress, Injury Severity Score and Japanese Orthopaedic Association score at admission were compared. RESULTS: The most notable predictor of mechanical ventilation more than 48 hours was serum thiobarbituric acid-reactive substances (TBARS) level at admission (P = 0.027), and the cut-off value of serum TBARS level was 731.7 µmol/L (sensitivity 87.5% and specificity 78.9%). For the reventilation ≤5 days, the notable predictors were respiratory function at the time of extubation (maximal inspiratory pressure, P = 0.040; maximal expiratory pressure, P = 0.020; and tidal volume, P = 0.036) and serum TBARS level at admission (P = 0.013), the cut-off value of serum TBARS level at admission was 762.3 µmol/L (sensitivity 100% and specificity 90.0%). CONCLUSION: In this study, respiratory function (maximal inspiratory pressure, maximal expiratory pressure, and tidal volume) at the time of extubation can be useful optimal clinical guidelines for weaning and extubation attempts in patients with acute cervical SCI. Serum TBARS level at admission can be a useful predictor for severity in acute cervical SCI patients. LEVEL OF EVIDENCE: 3.


Assuntos
Extubação/tendências , Escala de Gravidade do Ferimento , Respiração Artificial/tendências , Mecânica Respiratória/fisiologia , Traumatismos da Medula Espinal/terapia , Adulto , Extubação/métodos , Vértebras Cervicais/lesões , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Lesões do Pescoço/sangue , Lesões do Pescoço/diagnóstico , Lesões do Pescoço/terapia , Estudos Prospectivos , Respiração Artificial/métodos , Traumatismos da Medula Espinal/sangue , Traumatismos da Medula Espinal/diagnóstico , Substâncias Reativas com Ácido Tiobarbitúrico/metabolismo
14.
Circ Heart Fail ; 13(2): e006661, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-32059628

RESUMO

BACKGROUND: There are few studies evaluating regional disparities in the care of acute myocardial infarction-cardiogenic shock (AMI-CS). METHODS AND RESULTS: Using the National Inpatient Sample from 2000 to 2016, we identified adults with a primary diagnosis of AMI and concomitant CS admitted to the United States census regions of Northeast, Midwest, South, and West. Interhospital transfers were excluded. End points of interest included in-hospital mortality, use of coronary angiography, percutaneous coronary intervention, mechanical circulatory support, hospitalization costs, length of stay, and discharge disposition. Multivariable regression was used to adjust for potential confounding. Of the 402 825 AMI-CS admissions, 16.8%, 22.5%, 39.3%, and 21.4% were admitted to the Northeast, Midwest, South, and West, respectively. Higher rates of ST-elevation AMI-CS were noted in the Midwest and West. Admissions to the Northeast were on average characterized by a higher frequency of whites, Medicare beneficiaries, and lower rates of cardiac arrest. Admissions to the Northeast were less likely to receive coronary angiography, percutaneous coronary intervention, and mechanical circulatory support, despite the highest rates of extracorporeal membrane oxygenation use. Compared with the Northeast, in-hospital mortality was lower in the Midwest (adjusted odds ratio [aOR], 0.96 [95% CI, 0.93-0.98]; P<0.001) and West (aOR, 0.96 [95% CI, 0.94-0.98]; P=0.001) but higher in the South (aOR, 1.04 [95% CI, 1.01-1.06]; P=0.002). The Midwest (aOR, 1.68 [95% CI, 1.62-1.74]; P<0.001), South (aOR, 1.86 [95% CI, 1.80-1.92]; P<0.001), and West (aOR, 1.93 [95% CI, 1.86-2.00]; P<0.001) had higher discharges to home. CONCLUSIONS: There remain significant regional disparities in the management and outcomes of AMI-CS.


Assuntos
Disparidades em Assistência à Saúde/tendências , Infarto do Miocárdio/terapia , Padrões de Prática Médica/tendências , Choque Cardiogênico/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco/tendências , Angiografia Coronária/tendências , Bases de Dados Factuais , Feminino , Coração Auxiliar/tendências , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/fisiopatologia , Intervenção Coronária Percutânea/tendências , Recuperação de Função Fisiológica , Diálise Renal/tendências , Respiração Artificial/tendências , Estudos Retrospectivos , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/mortalidade , Choque Cardiogênico/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto Jovem
16.
Int J Cardiol ; 299: 63-66, 2020 01 15.
Artigo em Inglês | MEDLINE | ID: mdl-31611084

RESUMO

BACKGROUND: Patients with myasthenia gravis (MG) remain at a higher risk of developing takotsubo syndrome (TS), particularly during a myasthenic crisis (MC) event. The prevalence of MC-associated TS and its impact on subsequent in-hospital outcomes have not been explored previously. METHODS: We queried the National Inpatient Sample (NIS) databases (2007-2014) using weighted data and ICD-9 CM codes to evaluate the prevalence of MC-associated TS, demographics, comorbidities and inpatient outcomes of TS secondary to MC vs. other triggers. RESULTS: The nationwide prevalence of MC-associated TS was 0.3% (175/56,472). Of all 156,506 TS encounters, MC was present in 0.11% (n = 175) of cases. The groups were comparable in terms of demographics (median age 68-73 years, Caucasian >70%, females >80%). In comparison to non-MC TS, MC-associated TS demonstrated a higher frequency of coexisting diabetes and a lower frequency of smoking. The MC-TS cohort experienced significantly higher rates of all-cause mortality [8.6% vs. 4.7%, p = 0.014, unadjusted (OR1.91, p = 0.017) and adjusted (OR1.82, p = 0.038)] and complications including respiratory failure, the need of intubation/mechanical ventilation, and arrhythmia. The MC-TS cohort had fewer routine discharges and frequent transfers. The median stay was 6 days longer (10 vs. 4 days) and median hospital charges per admission were nearly $100,000 higher ($133,999 vs. $38,367) with MC-associated TS. CONCLUSIONS: This population-based analysis revealed a 15 times greater prevalence of secondary TS following MC as compared to the general inpatient population, a nearly 2 times higher odds of all-cause mortality, and significantly higher resource utilization in MC-associated TS as compared to TS triggered by other etiologies.


Assuntos
Efeitos Psicossociais da Doença , Hospitalização/tendências , Miastenia Gravis/mortalidade , Cardiomiopatia de Takotsubo/mortalidade , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Bases de Dados Factuais/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Miastenia Gravis/diagnóstico , Miastenia Gravis/terapia , Respiração Artificial/tendências , Cardiomiopatia de Takotsubo/diagnóstico , Cardiomiopatia de Takotsubo/terapia
17.
Crit Care ; 23(1): 388, 2019 Dec 02.
Artigo em Inglês | MEDLINE | ID: mdl-31791375

RESUMO

Most patients with ischaemic stroke are managed on the ward or in specialty stroke units, but a significant number requires higher-acuity care and, consequently, admission to the intensive care unit. Mechanical ventilation is frequently performed in these patients due to swallowing dysfunction and airway or respiratory system compromise. Experimental studies have focused on stroke-induced immunosuppression and brain-lung crosstalk, leading to increased pulmonary damage and inflammation, as well as reduced alveolar macrophage phagocytic capability, which may increase the risk of infection. Pulmonary complications, such as respiratory failure, pneumonia, pleural effusions, acute respiratory distress syndrome, lung oedema, and pulmonary embolism from venous thromboembolism, are common and found to be among the major causes of death in this group of patients. Furthermore, over the past two decades, tracheostomy use has increased among stroke patients, who can have unique indications for this procedure-depending on the location and type of stroke-when compared to the general population. However, the optimal mechanical ventilator strategy remains unclear in this population. Although a high tidal volume (VT) strategy has been used for many years, the latest evidence suggests that a protective ventilatory strategy (VT = 6-8 mL/kg predicted body weight, positive end-expiratory pressure and rescue recruitment manoeuvres) may also have a role in brain-damaged patients, including those with stroke. The aim of this narrative review is to explore the pathophysiology of brain-lung interactions after acute ischaemic stroke and the management of mechanical ventilation in these patients.


Assuntos
Isquemia Encefálica/fisiopatologia , Respiração Artificial/métodos , Acidente Vascular Cerebral/fisiopatologia , Isquemia Encefálica/terapia , Humanos , Unidades de Terapia Intensiva/organização & administração , Pneumonia Associada à Ventilação Mecânica/etiologia , Pneumonia Associada à Ventilação Mecânica/fisiopatologia , Respiração Artificial/efeitos adversos , Respiração Artificial/tendências , Mecânica Respiratória , Acidente Vascular Cerebral/terapia
18.
Crit Care ; 23(1): 338, 2019 10 30.
Artigo em Inglês | MEDLINE | ID: mdl-31666136

RESUMO

BACKGROUND: Adaptive mechanical ventilation automatically adjusts respiratory rate (RR) and tidal volume (VT) to deliver the clinically desired minute ventilation, selecting RR and VT based on Otis' equation on least work of breathing. However, the resulting VT may be relatively high, especially in patients with more compliant lungs. Therefore, a new mode of adaptive ventilation (adaptive ventilation mode 2, AVM2) was developed which automatically minimizes inspiratory power with the aim of ensuring lung-protective combinations of VT and RR. The aim of this study was to investigate whether AVM2 reduces VT, mechanical power, and driving pressure (ΔPstat) and provides similar gas exchange when compared to adaptive mechanical ventilation based on Otis' equation. METHODS: A prospective randomized cross-over study was performed in 20 critically ill patients on controlled mechanical ventilation, including 10 patients with acute respiratory distress syndrome (ARDS). Each patient underwent 1 h of mechanical ventilation with AVM2 and 1 h of adaptive mechanical ventilation according to Otis' equation (adaptive ventilation mode, AVM). At the end of each phase, we collected data on VT, mechanical power, ΔP, PaO2/FiO2 ratio, PaCO2, pH, and hemodynamics. RESULTS: Comparing adaptive mechanical ventilation with AVM2 to the approach based on Otis' equation (AVM), we found a significant reduction in VT both in the whole study population (7.2 ± 0.9 vs. 8.2 ± 0.6 ml/kg, p <  0.0001) and in the subgroup of patients with ARDS (6.6 ± 0.8 ml/kg with AVM2 vs. 7.9 ± 0.5 ml/kg with AVM, p <  0.0001). Similar reductions were observed for ΔPstat (whole study population: 11.5 ± 1.6 cmH2O with AVM2 vs. 12.6 ± 2.5 cmH2O with AVM, p <  0.0001; patients with ARDS: 11.8 ± 1.7 cmH2O with AVM2 and 13.3 ± 2.7 cmH2O with AVM, p = 0.0044) and total mechanical power (16.8 ± 3.9 J/min with AVM2 vs. 18.6 ± 4.6 J/min with AVM, p = 0.0024; ARDS: 15.6 ± 3.2 J/min with AVM2 vs. 17.5 ± 4.1 J/min with AVM, p = 0.0023). There was a small decrease in PaO2/FiO2 (270 ± 98 vs. 291 ± 102 mmHg with AVM, p = 0.03; ARDS: 194 ± 55 vs. 218 ± 61 with AVM, p = 0.008) and no differences in PaCO2, pH, and hemodynamics. CONCLUSIONS: Adaptive mechanical ventilation with automated minimization of inspiratory power may lead to more lung-protective ventilator settings when compared with adaptive mechanical ventilation according to Otis' equation. TRIAL REGISTRATION: The study was registered at the German Clinical Trials Register ( DRKS00013540 ) on December 1, 2017, before including the first patient.


Assuntos
Respiração Artificial/métodos , Idoso , Estudos Cross-Over , Feminino , Alemanha , Hemodinâmica/fisiologia , Humanos , Complacência Pulmonar/fisiologia , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Medicina de Precisão/métodos , Medicina de Precisão/tendências , Estudos Prospectivos , Respiração Artificial/tendências , Mecânica Respiratória/fisiologia , Volume de Ventilação Pulmonar/fisiologia
19.
Crit Care ; 23(1): 370, 2019 11 21.
Artigo em Inglês | MEDLINE | ID: mdl-31752937

RESUMO

BACKGROUND: Intensive care unit (ICU)-acquired weakness (ICU-AW) and ICU-acquired diaphragm dysfunction (ICU-DD) occur frequently in mechanically ventilated (MV) patients. It is unknown whether they have different risk factors and different impacts on outcome. This study was designed to (1) describe the respective risk factors associated with ICU-AW and severe ICU-DD and (2) evaluate the respective impact of ICU-AW and severe ICU-DD on outcome. METHODS: Post hoc analysis of two prospective cohort studies conducted in two ICUs. In patients mechanically ventilated for at least 24 h undergoing a first spontaneous breathing trial, severe ICU-DD was defined as diaphragm twitch pressure < 7 cmH2O and ICU-AW was defined as Medical Research Council Score < 48. RESULTS: One hundred sixteen patients were assessed. Factors independently associated with severe ICU-DD were age, longer duration of MV, and exposure to sufentanil, and those factors associated with ICU-AW were longer duration of MV and exposure to norepinephrine. Severe ICU-DD (OR 3.56, p = 0.008), but not ICU-AW, was independently associated with weaning failure (59%). ICU-AW (OR 4.30, p = 0.033), but not severe ICU-DD, was associated with ICU mortality. Weaning failure and mortality rate were higher in patients with both severe ICU-DD and ICU-AW (86% and 39%, respectively) than in patients with either severe ICU-DD (64% and 0%) or ICU-AW (63% and 13%). CONCLUSION: Severe ICU-DD and ICU-AW have different risk factors and different impacts on weaning failure and mortality. The impact of the combination of ICU-DD and ICU-AW is more pronounced than their individual impact.


Assuntos
Diafragma/fisiopatologia , Unidades de Terapia Intensiva , Debilidade Muscular/mortalidade , Respiração Artificial/mortalidade , Índice de Gravidade de Doença , Desmame do Respirador/mortalidade , Adulto , Idoso , Estudos de Coortes , Estado Terminal , Feminino , Humanos , Unidades de Terapia Intensiva/tendências , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Debilidade Muscular/diagnóstico , Debilidade Muscular/terapia , Estudos Prospectivos , Respiração Artificial/tendências , Desmame do Respirador/tendências
20.
Crit Care ; 23(1): 367, 2019 11 21.
Artigo em Inglês | MEDLINE | ID: mdl-31752980

RESUMO

BACKGROUND: Higher inspiratory airway pressures are associated with worse outcomes in mechanically ventilated patients with the acute respiratory distress syndrome (ARDS). This relationship, however, has not been well investigated in patients without ARDS. We hypothesized that higher driving pressures (ΔP) and plateau pressures (Pplat) are associated with worse patient-centered outcomes in mechanically ventilated patients without ARDS as well as those with ARDS. METHODS: Using data collected during a prospective, observational cohort study of 6179 critically ill participants enrolled in 59 ICUs across the USA, we used multivariable logistic regression to determine whether ΔP and Pplat at enrollment were associated with hospital mortality among 1132 mechanically ventilated participants. We stratified analyses by ARDS status. RESULTS: Participants without ARDS (n = 822) had lower average severity of illness scores and lower hospital mortality (27.3% vs. 38.7%; p <  0.001) than those with ARDS (n = 310). Average Pplat (20.6 vs. 23.9 cm H2O; p <  0.001), ΔP (14.3 vs. 16.0 cm H2O; p <  0.001), and positive end-expiratory pressure (6.3 vs. 7.9 cm H2O; p <  0.001) were lower in participants without ARDS, whereas average tidal volumes (7.2 vs. 6.8 mL/kg PBW; p <  0.001) were higher. Among those without ARDS, higher ΔP (adjusted OR = 1.36 per 7 cm H2O, 95% CI 1.14-1.62) and Pplat (adjusted OR = 1.42 per 8 cm H2O, 95% CI 1.17-1.73) were associated with higher mortality. We found similar relationships with mortality among those participants with ARDS. CONCLUSIONS: Higher ΔP and Pplat are associated with increased mortality for participants without ARDS. ΔP may be a viable target for lung-protective ventilation in all mechanically ventilated patients.


Assuntos
Mortalidade Hospitalar/tendências , Inalação/fisiologia , Respiração com Pressão Positiva/mortalidade , Respiração com Pressão Positiva/tendências , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Respiração Artificial/mortalidade , Respiração Artificial/tendências
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