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2.
Crit Care ; 25(1): 248, 2021 07 15.
Artigo em Inglês | MEDLINE | ID: mdl-34266454

RESUMO

BACKGROUND: Differences in physiology of ARDS have been described between COVID-19 and non-COVID-19 patients. This study aimed to compare initial values and longitudinal changes in respiratory system compliance (CRS), oxygenation parameters and ventilatory ratio (VR) in patients with COVID-19 and non-COVID-19 pulmonary ARDS matched on oxygenation. METHODS: 135 patients with COVID-19 ARDS from two centers were included in a physiological study; 767 non-COVID-19 ARDS from a clinical trial were used for the purpose of at least 1:2 matching. A propensity-matching was based on age, severity score, oxygenation, positive end-expiratory pressure (PEEP) and pulmonary cause of ARDS and allowed to include 112 COVID-19 and 198 non-COVID pulmonary ARDS. RESULTS: The two groups were similar on initial oxygenation. COVID-19 patients had a higher body mass index, higher CRS at day 1 (median [IQR], 35 [28-44] vs 32 [26-38] ml cmH2O-1, p = 0.037). At day 1, CRS was correlated with oxygenation only in non-COVID-19 patients; 61.6% and 68.2% of COVID-19 and non-COVID-19 pulmonary ARDS were still ventilated at day 7 (p = 0.241). Oxygenation became lower in COVID-19 than in non-COVID-19 patients at days 3 and 7, while CRS became similar. VR was lower at day 1 in COVID-19 than in non-COVID-19 patients but increased from day 1 to 7 only in COVID-19 patients. VR was higher at days 1, 3 and 7 in the COVID-19 patients ventilated using heat and moisture exchangers compared to heated humidifiers. After adjustment on PaO2/FiO2, PEEP and humidification device, CRS and VR were found not different between COVID-19 and non-COVID-19 patients at day 7. Day-28 mortality did not differ between COVID-19 and non-COVID-19 patients (25.9% and 23.7%, respectively, p = 0.666). CONCLUSIONS: For a similar initial oxygenation, COVID-19 ARDS initially differs from classical ARDS by a higher CRS, dissociated from oxygenation. CRS become similar for patients remaining on mechanical ventilation during the first week of evolution, but oxygenation becomes lower in COVID-19 patients. TRIAL REGISTRATION: clinicaltrials.gov NCT04385004.


Assuntos
COVID-19/terapia , Respiração com Pressão Positiva/métodos , Síndrome do Desconforto Respiratório/terapia , Idoso , Gasometria , Índice de Massa Corporal , COVID-19/fisiopatologia , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Troca Gasosa Pulmonar/fisiologia , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório/fisiopatologia , Testes de Função Respiratória , Mecânica Respiratória/fisiologia , SARS-CoV-2
3.
Medicine (Baltimore) ; 100(28): e26638, 2021 Jul 16.
Artigo em Inglês | MEDLINE | ID: mdl-34260559

RESUMO

BACKGROUND: Positive end-expiratory pressure (PEEP) is an important part of the lung protection strategies for one-lung ventilation (OLV). However, a fixed PEEP value is not suitable for all patients. Our objective was to determine the prevention of individualized PEEP on postoperative complications in patients undergoing one-lung ventilation. METHOD: We searched the PubMed, Embase, and Cochrane and performed a meta-analysis to compare the effect of individual PEEP vs fixed PEEP during single lung ventilation on postoperative pulmonary complications. Our primary outcome was the occurrence of postoperative pulmonary complications during follow-up. Secondary outcomes included the partial pressure of arterial oxygen and oxygenation index during one-lung ventilation. RESULT: Eight studies examining 849 patients were included in this review. The rate of postoperative pulmonary complications was reduced in the individualized PEEP group with a risk ratio of 0.52 (95% CI:0.37-0.73; P = .0001). The partial pressure of arterial oxygen during the OLV in the individualized PEEP group was higher with a mean difference 34.20 mm Hg (95% CI: 8.92-59.48; P = .0004). Similarly, the individualized PEEP group had a higher oxygenation index, MD: 49.07mmHg, (95% CI: 27.21-70.92; P < .0001). CONCLUSIONS: Individualized PEEP setting during one-lung ventilation in patients undergoing thoracic surgery was associated with fewer postoperative pulmonary complications and better perioperative oxygenation.


Assuntos
Ventilação Monopulmonar/métodos , Respiração com Pressão Positiva/métodos , Complicações Pós-Operatórias/prevenção & controle , Procedimentos Cirúrgicos Torácicos/métodos , Humanos , Ventilação Monopulmonar/efeitos adversos , Respiração com Pressão Positiva/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Procedimentos Cirúrgicos Torácicos/efeitos adversos
4.
Crit Care ; 25(1): 211, 2021 06 14.
Artigo em Inglês | MEDLINE | ID: mdl-34127027

RESUMO

BACKGROUND: There are several reports of extracorporeal membrane oxygenation (ECMO) use in patients with coronavirus disease 2019 (COVID-19) who develop severe acute respiratory distress syndrome (ARDS). We conducted a systematic review and meta-analysis to guide clinical decision-making and future research. METHODS: We searched MEDLINE, Embase, Cochrane and Scopus databases from 1 December 2019 to 10 January 2021 for observational studies or randomised clinical trials examining ECMO in adults with COVID-19 ARDS. We performed random-effects meta-analyses and meta-regression, assessed risk of bias using the Joanna Briggs Institute checklist and rated the certainty of evidence using the GRADE approach. Survival outcomes were presented as pooled proportions while continuous outcomes were presented as pooled means, both with corresponding 95% confidence intervals [CIs]. The primary outcome was in-hospital mortality. Secondary outcomes were duration of ECMO therapy and mechanical ventilation, weaning rate from ECMO and complications during ECMO. RESULTS: We included twenty-two observational studies with 1896 patients in the meta-analysis. Venovenous ECMO was the predominant mode used (98.6%). The pooled in-hospital mortality in COVID-19 patients (22 studies, 1896 patients) supported with ECMO was 37.1% (95% CI 32.3-42.0%, high certainty). Pooled mortality in the venovenous ECMO group was 35.7% (95% CI 30.7-40.7%, high certainty). Meta-regression found that age and ECMO duration were associated with increased mortality. Duration of ECMO support (18 studies, 1844 patients) was 15.1 days (95% CI 13.4-18.7). Weaning from ECMO (17 studies, 1412 patients) was accomplished in 67.6% (95% CI 50.5-82.7%) of patients. There were a total of 1583 ECMO complications reported (18 studies, 1721 patients) and renal complications were the most common. CONCLUSION: The majority of patients received venovenous ECMO support for COVID-19-related ARDS. In-hospital mortality in patients receiving ECMO support for COVID-19 was 37.1% during the first year of the pandemic, similar to those with non-COVID-19-related ARDS. Increasing age was a risk factor for death. Venovenous ECMO appears to be an effective intervention in selected patients with COVID-19-related ARDS. PROSPERO CRD42020192627.


Assuntos
COVID-19/terapia , Estado Terminal/terapia , Oxigenação por Membrana Extracorpórea/métodos , Síndrome do Desconforto Respiratório/terapia , Adulto , Fatores Etários , Idoso , COVID-19/complicações , COVID-19/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Respiração com Pressão Positiva/métodos , Síndrome do Desconforto Respiratório/etiologia , Medição de Risco
5.
Am J Med Sci ; 362(1): 13-23, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34090669

RESUMO

Acute respiratory distress syndrome (ARDS) is a clinically and biologically heterogeneous disorder associated with a variety of disease processes that lead to acute lung injury with increased non-hydrostatic extravascular lung water, reduced compliance, and severe hypoxemia. Despite significant advances, mortality associated with this syndrome remains high. Mechanical ventilation remains the most important aspect of managing patients with ARDS. An in-depth knowledge of lung protective ventilation, optimal PEEP strategies, modes of ventilation and recruitment maneuvers are essential for ventilatory management of ARDS. Although, the management of ARDS is constantly evolving as new studies are published and guidelines being updated; we present a detailed review of the literature including the most up-to-date studies and guidelines in the management of ARDS. We believe this review is particularly helpful in the current times where more than half of the acute care hospitals lack in-house intensivists and the burden of ARDS is at large.


Assuntos
Gerenciamento Clínico , Oxigenação por Membrana Extracorpórea/normas , Guias de Prática Clínica como Assunto/normas , Respiração Artificial/normas , Síndrome do Desconforto Respiratório/terapia , Oxigenação por Membrana Extracorpórea/métodos , Humanos , Respiração com Pressão Positiva/métodos , Respiração com Pressão Positiva/normas , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório/diagnóstico , Síndrome do Desconforto Respiratório/fisiopatologia
7.
Undersea Hyperb Med ; 48(2): 157-168, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33975406

RESUMO

Introduction: Safe administration of critical care hyperbaric medicine requires specialized equipment and advanced training. Equipment must be tested in order to evaluate function in the hyperbaric environment. High-frequency percussive ventilation (HFPV) has been used in intensive care settings effectively, but it has never been tested in a hyperbaric chamber. Methods: Following a modified U.S. Navy testing protocol used to evaluate hyperbaric ventilators, we evaluated an HFPV transport ventilator in a multiplace hyperbaric chamber at 1.0, 1.9, and 2.8 atmospheres absolute (ATA). We used a test lung with analytical software for data collection. The ventilator uses simultaneous cyclic pressure-controlled ventilation at a pulsatile flow rate (PFR)/oscillatory continuous positive airway pressure (oCPAP) ratio of 30/10 with a high-frequency oscillation percussive rate of 500 beats per minute. Inspiratory and expiratory times were maintained at two seconds throughout each breathing cycle. Results: During manned studies, the PFR/oCPAP ratios were 26/6, 22/7, and 22.5/8 at an airway resistance of 20cm H2O/L/second and 18/9, 15.2/8.5, and 13.6/7 at an airway resistance of 50 cm/H2O/L/second at 1, 1.9, and 2.8 ATA. The resulting release volumes were 800, 547, and 513 mL at airway resistance of 20 cm H2O/L/sec and 400, 253, and 180 mL at airway resistance of 50 cm/H2O/L/sec at 1, 1.9, and 2.8 ATA. Unmanned testing showed similar changes. The mean airway pressure (MAP) remained stable throughout all test conditions; theoretically, supporting adequate lung recruitment and gas exchange. A case where HFPV was used to treat a patient for CO poisoning was presented to illustrate that HFPV worked well under HBO2 conditions and no complications occurred during HBO2 treatment. Conclusion: The HFPV transport ventilator performed adequately under hyperbaric conditions and should be considered a viable option for hyperbaric critical care. This ventilator has atypical terminology and produces unique pulmonary physiology, thus requiring specialized training prior to use.


Assuntos
Ventilação de Alta Frequência/instrumentação , Oxigenação Hiperbárica/instrumentação , Lesão por Inalação de Fumaça/terapia , Ventiladores Mecânicos , Acidose/etiologia , Idoso , Resistência das Vias Respiratórias , Pressão Atmosférica , Intoxicação por Monóxido de Carbono/complicações , Feminino , Ventilação de Alta Frequência/métodos , Humanos , Oxigenação Hiperbárica/métodos , Pulmão/fisiologia , Respiração com Pressão Positiva/instrumentação , Respiração com Pressão Positiva/métodos , Troca Gasosa Pulmonar/fisiologia , Fluxo Pulsátil , Valores de Referência , Respiração
8.
Minerva Med ; 112(3): 346-353, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34015910

RESUMO

BACKGROUND: Obstructive sleep apnea (OSA) is often associated with clinical, psychological and neuropsychological comorbidities such as Mild Cognitive Impairment (MCI). This study evaluated changes in clinical, psychosocial, Health Related Quality of Life (HRQoL) and neuropsychological profile in OSA subjects after ventilatory therapy, making comparison with normative data. The aim of the study was to verify the suitability of the HRQoL and neuropsychological screening tests in detecting variations in OSA subjects. METHODS: At baseline, 32 OSA subjects underwent the following assessment: EuroQol (EQ-5D-3L) and EQ VAS, Hospital Anxiety and Depression Scale (HADS), Montreal Cognitive Assessment (MoCA) and Frontal Assessment Battery (FAB). After the ventilatory titration, 31 OSA subjects repeated the EQ VAS, MoCA and FAB assessment. RESULTS: The analyzed subjects (77% male, 58.97±10.06 years old and 47.34±26.67 AHI [ev*hr-1]) showed low emotive distress, a lower perception of HRQoL than normative data and 35.48% of them exhibited executive deficits, too. MCI was detected in 3.2% and 48.4% of subjects after normative Italian and international correction, respectively. Subsequently the ventilatory therapy and the rehabilitative interdisciplinary treatment, subjects improved in EQ VAS (68.23±18.73 vs. 87.13±10.80, P=0.0001), FAB scores (15,30±2.03 vs. 16,65±1,40, P=0.007) and MoCA memory subtest scores (2.16±1.34 vs. 3.06±1.63, P=0.008). CONCLUSIONS: Ventilatory therapy provided during a rehabilitative and interdisciplinary program increased subjects' HRQoL, executive functions and verbal memory.


Assuntos
Disfunção Cognitiva/reabilitação , Respiração com Pressão Positiva/métodos , Qualidade de Vida , Apneia Obstrutiva do Sono/reabilitação , Idoso , Disfunção Cognitiva/etiologia , Disfunção Cognitiva/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Intervenção Psicossocial , Apneia Obstrutiva do Sono/complicações , Apneia Obstrutiva do Sono/psicologia
9.
Br J Anaesth ; 127(1): 143-152, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33892948

RESUMO

BACKGROUND: Bilateral lung transplantation results in pulmonary vagal denervation, which potentially alters respiratory drive, volume-feedback, and ventilatory pattern. We hypothesised that Neurally Adjusted Ventilatory Assist (NAVA) ventilation, which is driven by diaphragm electrical activity (EAdi), would reveal whether vagally mediated pulmonary-volume feedback is preserved in the early phases after bilateral lung transplantation. METHODS: We prospectively studied bilateral lung transplant recipients within 48 h of surgery. Subjects were ventilated with NAVA and randomised to receive 3 ventilatory modes (baseline NAVA, 50%, and 150% of baseline NAVA values) and 2 PEEP levels (6 and 12 cm H2O). We recorded airway pressure, flow, and EAdi. RESULTS: We studied 30 subjects (37% female; age: 37 (27-56) yr), of whom 19 (63%) had stable EAdi. The baseline NAVA level was 0.6 (0.2-1.0) cm H2O µV-1. Tripling NAVA level increased the ventilatory peak pressure over PEEP by 6.3 (1.8), 7.6 (2.4), and 8.7 (3.2) cm H2O, at 50%, 100%, and 150% of baseline NAVA level, respectively (P<0.001). EAdi peak decreased by 10.1 (9.0), 9.5 (9.4) and 8.8 µV (8.7) (P<0.001), accompanied by small increases in tidal volume, 8.3 (3.0), 8.7 (3.6), and 8.9 (3.3) ml kg-1 donor's predicted body weight at 50%, 100%, and 150% of baseline NAVA levels, respectively (P<0.001). Doubling PEEP did not affect tidal volume. CONCLUSIONS: NAVA ventilation was feasible in the majority of patients during the early postoperative period after bilateral lung transplantation. Despite surgical vagotomy distal to the bronchial anastomoses, bilateral lung transplant recipients maintained an unmodified respiratory pattern in response to variations in ventilatory assistance and PEEP. CLINICAL TRIAL REGISTRATION: NCT03367221.


Assuntos
Retroalimentação , Suporte Ventilatório Interativo/métodos , Transplante de Pulmão/métodos , Respiração com Pressão Positiva/métodos , Cuidados Pós-Operatórios/métodos , Volume de Ventilação Pulmonar/fisiologia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Ventilação Pulmonar/fisiologia , Desmame do Respirador/métodos
10.
J Crit Care ; 64: 141-143, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33906102

RESUMO

Airway closure is a physiological phenomenon in which the distal airways are obstructed when the airway pressure drops below the airway opening pressure. We assessed this phenomenon in 27 patients with coronavirus disease 2019-related acute respiratory distress syndrome. Twelve (44%) patients had an airway opening pressure above 5 cmH2O. The median airway opening pressure was 8 cmH2O (interquartile range, 7-10), with a maximum value of 17 cmH2O. Three patients had a baseline positive end-expiratory pressure lower than the airway opening pressure.


Assuntos
COVID-19/fisiopatologia , COVID-19/terapia , Respiração com Pressão Positiva/métodos , Síndrome do Desconforto Respiratório/fisiopatologia , Síndrome do Desconforto Respiratório/terapia , SARS-CoV-2 , Adulto , Idoso , Obstrução das Vias Respiratórias/prevenção & controle , Cuidados Críticos , Feminino , França/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Mecânica Respiratória
11.
Pediatr Pulmonol ; 56(7): 2057-2066, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33826802

RESUMO

BACKGROUND: Aerosol generating medical procedures (AGMPs) are common during newborn resuscitation. Neonates with respiratory viruses such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may pose a risk to healthcare workers. International guidelines differ on methods to minimize the risk due to limited data. OBJECTIVE: We examined the expiratory airflow dispersion during common neonatal resuscitation AGMPs using infant simulators. METHODS: Expiratory airflow dispersion in term and preterm manikins was simulated (n = 288) using fine particle smoke at tidal volumes of 5 ml/kg. Using ImageJ, we quantified dispersion during common airway procedures including endotracheal tube (ETT) and T-piece ventilation. RESULTS: Maximal expiratory dispersion distances for the unsupported airway and disconnected uncuffed ETT scenarios were 30.2 and 22.7 cm (term); 22.1 and 17.2 cm (preterm), respectively. Applying T-piece positive end expiratory pressure (PEEP) via an ETT (ETTPEEP ) generated no expiratory dispersion but increased tube leak during term simulation, while ventilation breaths (ETTVENT ) caused significant expiratory dispersion and leak. There was no measurable dispersion during face mask ventilation. For term uncuffed ETT ventilation, the particle filter eliminated expiratory dispersion but increased leak. No expiratory dispersion and negligible leak were observed when combining a cuffed ETT and filter. Angulated T-pieces generated the greatest median dispersion distances of 35.8 cm (ETTPEEP ) and 23.3 cm (ETTVENT ). CONCLUSIONS: Airflow dispersion during neonatal AGMPs is greater than previously postulated and potentially could contaminate healthcare providers during resuscitation of infants infected with contagious viruses such as SARS-CoV-2. It is possible to mitigate this risk using particle filters and cuffed ETTs. Applicability in the clinical setting requires further evaluation.


Assuntos
Microbiologia do Ar , Expiração , Vírus Sinciciais Respiratórios/isolamento & purificação , Ressuscitação/métodos , SARS-CoV-2/isolamento & purificação , Simulação por Computador , Humanos , Recém-Nascido , Intubação Intratraqueal , Manequins , Respiração com Pressão Positiva/métodos , Pressão , Volume de Ventilação Pulmonar
12.
BMC Pulm Med ; 21(1): 133, 2021 Apr 24.
Artigo em Inglês | MEDLINE | ID: mdl-33894747

RESUMO

BACKGROUND: Among the challenges for personalizing the management of mechanically ventilated patients with coronavirus disease (COVID-19)-associated acute respiratory distress syndrome (ARDS) are the effects of different positive end-expiratory pressure (PEEP) levels and body positions in regional lung mechanics. Right-left lung aeration asymmetry and poorly recruitable lungs with increased recruitability with alternating body position between supine and prone have been reported. However, real-time effects of changing body position and PEEP on regional overdistension and collapse, in individual patients, remain largely unknown and not timely monitored. The aim of this study was to individualize PEEP and body positioning in order to reduce the mechanisms of ventilator-induced lung injury: collapse and overdistension. METHODS: We here report a series of five consecutive mechanically ventilated patients with COVID-19-associated ARDS in which sixteen decremental PEEP titrations were performed in the first days of mechanical ventilation (8 titration pairs: supine position immediately followed by 30° targeted lateral position). The choice of lateral tilt was based on X-Ray. This targeted lateral position strategy was defined by selecting the less aerated lung to be positioned up and the more aerated lung to be positioned down. For each PEEP level, global and regional collapse and overdistension maps and percentages were measured by electrical impedance tomography. Additionally, we present the incidence of lateral asymmetry in a cohort of forty-four patients. RESULTS: The targeted lateral position strategy resulted in significantly smaller amounts of overdistension and collapse when compared with the supine one: less collapse along the PEEP titration was found within the left lung in targeted lateral (P = 0.014); and less overdistension along the PEEP titration was found within the right lung in targeted lateral (P = 0.005). Regarding collapse within the right lung and overdistension within the left lung: no differences were found for position. In the cohort of forty-four patients, ventilation inequality of > 65/35% was observed in 15% of cases. CONCLUSIONS: Targeted lateral positioning with bedside personalized PEEP provided a selective attenuation of overdistension and collapse in mechanically ventilated patients with COVID-19-associated ARDS and right-left lung aeration/ventilation asymmetry. TRIAL REGISTRATION: Trial registration number: NCT04460859.


Assuntos
COVID-19/terapia , Posicionamento do Paciente/métodos , Atelectasia Pulmonar/prevenção & controle , Síndrome do Desconforto Respiratório/terapia , Lesão Pulmonar Induzida por Ventilação Mecânica/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Impedância Elétrica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Respiração com Pressão Positiva/métodos , Estudos Prospectivos , Atelectasia Pulmonar/terapia , Respiração Artificial/métodos , SARS-CoV-2
13.
J Med Internet Res ; 23(4): e23446, 2021 04 28.
Artigo em Inglês | MEDLINE | ID: mdl-33819166

RESUMO

BACKGROUND: With the growing stress on hospitals caused by the COVID-19 pandemic, the need for home-based solutions has become a necessity to support these overwhelmed hospitals. OBJECTIVE: The goal of this study was to compare two nonpharmacological respiratory treatment methods for home-isolated COVID-19 patients using a newly developed telemanagement health care system. METHODS: In this single-blinded randomized clinical trial, 60 patients with stage 1 pneumonia caused by SARS-CoV-2 infection were treated. Group A (n=30) received oxygen therapy with bilevel positive airway pressure (BiPAP) ventilation, and Group B (n=30) received osteopathic manipulative respiratory and physical therapy techniques. Arterial blood gases of PaO2 and PaCO2, pH, vital signs (ie, temperature, respiratory rate, oxygen saturation, heart rate, and blood pressure), and chest computed tomography scans were used for follow-up and for assessment of the course and duration of recovery. RESULTS: Analysis of the results showed a significant difference between the two groups (P<.05), with Group A showing shorter recovery periods than Group B (mean 14.9, SD 1.7 days, and mean 23.9, SD 2.3 days, respectively). Significant differences were also observed between baseline and final readings in all of the outcome measures in both groups (P<.05). Regarding posttreatment satisfaction with our proposed telemanagement health care system, positive responses were given by most of the patients in both groups. CONCLUSIONS: It was found that home-based oxygen therapy with BiPAP can be a more effective prophylactic treatment approach than osteopathic manipulative respiratory and physical therapy techniques, as it can impede exacerbation of early-stage COVID-19 pneumonia. Telemanagement health care systems are promising methods to help in the pandemic-related shortage of hospital beds, as they showed reasonable effectiveness and reliability in the monitoring and management of patients with early-stage COVID-19 pneumonia. TRIAL REGISTRATION: ClinicalTrials.gov NCT04368923; https://clinicaltrials.gov/ct2/show/NCT04368923.


Assuntos
COVID-19/terapia , Oxigenoterapia/métodos , Modalidades de Fisioterapia , Respiração com Pressão Positiva/métodos , Telemedicina/métodos , Adulto , COVID-19/epidemiologia , Feminino , Humanos , Masculino , Pandemias , SARS-CoV-2/isolamento & purificação , Resultado do Tratamento , Adulto Jovem
14.
PLoS One ; 16(3): e0247360, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33647041

RESUMO

BACKGROUND: It is important to evaluate the size of respiratory effort to prevent patient self-inflicted lung injury and ventilator-induced diaphragmatic dysfunction. Esophageal pressure (Pes) measurement is the gold standard for estimating respiratory effort, but it is complicated by technical issues. We previously reported that a change in pleural pressure (ΔPpl) could be estimated without measuring Pes using change in CVP (ΔCVP) that has been adjusted with a simple correction among mechanically ventilated, paralyzed pediatric patients. This study aimed to determine whether our method can be used to estimate ΔPpl in assisted and unassisted spontaneous breathing patients during mechanical ventilation. METHODS: The study included hemodynamically stable children (aged <18 years) who were mechanically ventilated, had spontaneous breathing, and had a central venous catheter and esophageal balloon catheter in place. We measured the change in Pes (ΔPes), ΔCVP, and ΔPpl that was calculated using a corrected ΔCVP (cΔCVP-derived ΔPpl) under three pressure support levels (10, 5, and 0 cmH2O). The cΔCVP-derived ΔPpl value was calculated as follows: cΔCVP-derived ΔPpl = k × ΔCVP, where k was the ratio of the change in airway pressure (ΔPaw) to the ΔCVP during airway occlusion test. RESULTS: Of the 14 patients enrolled in the study, 6 were excluded because correct positioning of the esophageal balloon could not be confirmed, leaving eight patients for analysis (mean age, 4.8 months). Three variables that reflected ΔPpl (ΔPes, ΔCVP, and cΔCVP-derived ΔPpl) were measured and yielded the following results: -6.7 ± 4.8, - -2.6 ± 1.4, and - -7.3 ± 4.5 cmH2O, respectively. The repeated measures correlation between cΔCVP-derived ΔPpl and ΔPes showed that cΔCVP-derived ΔPpl had good correlation with ΔPes (r = 0.84, p< 0.0001). CONCLUSIONS: ΔPpl can be estimated reasonably accurately by ΔCVP using our method in assisted and unassisted spontaneous breathing children during mechanical ventilation.


Assuntos
Pressão Venosa Central/fisiologia , Respiração com Pressão Positiva/métodos , Respiração Artificial/métodos , Cateterismo/métodos , Diafragma/patologia , Esôfago/patologia , Feminino , Frequência Cardíaca , Humanos , Lactente , Pulmão/patologia , Masculino , Projetos Piloto , Cavidade Pleural/fisiologia , Pressão , Estudos Prospectivos , Respiração , Respiração Artificial/efeitos adversos , Mecânica Respiratória , Sinais Vitais
15.
Surgery ; 170(1): 277-283, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33771357

RESUMO

BACKGROUND: As respiratory system compliances are heterogenous, we hypothesized that individualized intraoperative positive end-expiratory pressure titration on the basis of lowest driving pressure can reduce postoperative atelectasis and improve intraoperative oxygenation and postoperative lung functions. METHODS: Eighty-two adult patients undergoing major abdominal surgery were recruited in this randomized trial. In the titrated positive end-expiratory pressure group, positive end-expiratory pressure was titrated incrementally until lowest driving pressure was achieved, and the same procedure was repeated in every 2 hours. In the fixed positive end-expiratory pressure group, a positive end-expiratory pressure of 5 cmH2O was used throughout the surgery. The primary objective of this study was lung ultrasound score noted at the completion of surgery and 5 minutes after extubation at 12 lung areas bilaterally. RESULTS: Mean (standard deviation) age of the recruited patients were 43.8 (17.3) years, and 50% of all patients (41 of 82) were women. Lung ultrasound aeration scores were significantly higher in the fixed positive end-expiratory pressure group both before and after extubation (median [interquartile range] 7 [5-8] vs 4 [2-6] before extubation and 8 [6-9] vs 5 [3-7] after extubation; P = .0004 and P = .0011, respectively). Incidence of postoperative pulmonary complications was significantly lower in the titrated positive end-expiratory pressure group (absolute risk difference [95% CI] 17.1% [32.5%-1.7%]; P = .034). The number of patients requiring postoperative supplemental oxygen therapy to maintain SpO2 >95%, the requirement of intraoperative rescue therapy, and the duration of hospital stay were similar in both of the groups. CONCLUSION: Intraoperative titrated positive end-expiratory pressure reduced postoperative lung atelectasis in adult patients undergoing major abdominal surgery. Further large clinical trials are required to know its effect on postoperative pulmonary complications.


Assuntos
Abdome/cirurgia , Procedimentos Cirúrgicos Eletivos , Respiração com Pressão Positiva/métodos , Atelectasia Pulmonar/prevenção & controle , Adulto , Idoso , Feminino , Humanos , Cuidados Intraoperatórios , Tempo de Internação , Pulmão/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Ultrassonografia
16.
Cochrane Database Syst Rev ; 3: CD009969, 2021 03 30.
Artigo em Inglês | MEDLINE | ID: mdl-33781001

RESUMO

BACKGROUND: Preterm infants and neonates with respiratory conditions commonly require intubation and conventional mechanical ventilation (CMV) to maintain airway patency and support their respiration. Whilst this therapy is often lifesaving, it simultaneously carries the risk of lung injury. The use of lung recruitment manoeuvres (LRMs) has been found to reduce the incidence of lung injury, and improve oxygenation and lung compliance in ventilated adults. However, evidence pertaining to their use in neonates is limited, and there is no consensus of opinion as to whether LRMs are appropriate or effective in this population. OBJECTIVES: To determine the effects of LRMs on mortality and respiratory outcomes in mechanically ventilated neonates, when compared to no recruitment (routine care).  SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2020, Issue 4) in the Cochrane Library, MEDLINE via Ovid (1946 to 13 April 2020), and CINAHL via EBSCOhost (1989 to 13 April 2020). We also handsearched the reference lists of retrieved studies to source additional articles.  SELECTION CRITERIA: We included randomised controlled trials (RCTs), quasi-RCTs and randomised cross-over studies that compared the effect of LRMs to no recruitment (routine care) in mechanically ventilated neonates. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial eligibility, extracted data and evaluated risk of bias in the included studies. When studies were sufficiently similar, we performed a meta-analysis using mean difference (MD) for continuous data and risk ratio (RR) for dichotomous data, with their respective 95% confidence intervals (CIs). We used the GRADE approach to assess the certainty of the evidence for key (clinically important) outcomes. MAIN RESULTS: We included four studies (152 participants in total) in this review. Three of these studies, enrolling 56 participants, contributed data to our prespecified outcomes. Two studies enrolling 44 participants on CMV for respiratory distress syndrome compared a stepwise LRM with positive end-expiratory pressure (PEEP) to routine care. Meta-analysis demonstrated no evidence of a difference between the LRM and routine care on mortality by hospital discharge (RR 1.00, 95% CI 0.17 to 5.77; low-certainty evidence), incidence of bronchopulmonary dysplasia (RR 0.25, 95% CI 0.03 to 2.07; low-certainty evidence), duration of supplemental oxygen (MD -7.52 days, 95% CI -20.83 to 5.78; very low-certainty evidence), and duration of ventilatory support (MD -3.59 days, 95% CI -12.97 to 5.79; very low-certainty evidence). The certainty of the evidence for these outcomes was downgraded due to risk of bias, imprecision, and inconsistency. Whilst these studies contributed data to four of our primary outcomes, we were unable to identify any studies that reported our other primary outcomes: duration of continuous positive airway pressure therapy, duration of neonatal intensive care unit stay, and duration of hospital stay.  The third study that contributed data to the review enrolled 12 participants on CMV for respiratory and non-respiratory causes, and compared two different LRMs applied after endotracheal tube suctioning to routine care. It was determined that both LRMs may slightly improve end-expiratory lung volume at 120 minutes' post-suctioning, when compared to routine care (incremental PEEP LRM versus routine care: MD -0.21, 95% CI -0.37 to -0.06; double PEEP LRM versus routine care: MD -0.18, 95% CI -0.35 to -0.02). It was also demonstrated that a double PEEP LRM may slightly reduce mean arterial pressure at 30 minutes' post-suctioning, when compared with routine care (MD -16.00, 95% CI -29.35 to -2.65).  AUTHORS' CONCLUSIONS: There is insufficient evidence to guide the use of LRMs in mechanically ventilated neonates. Well-designed randomised trials with larger sample sizes are needed to further evaluate the potential benefits and risks of LRM application in this population.


Assuntos
Displasia Broncopulmonar/epidemiologia , Respiração Artificial/efeitos adversos , Síndrome do Desconforto Respiratório do Recém-Nascido/terapia , Lesão Pulmonar Induzida por Ventilação Mecânica/mortalidade , Viés , Intervalos de Confiança , Humanos , Incidência , Recém-Nascido , Recém-Nascido Prematuro , Oxigênio/administração & dosagem , Respiração com Pressão Positiva/efeitos adversos , Respiração com Pressão Positiva/métodos , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos , Lesão Pulmonar Induzida por Ventilação Mecânica/prevenção & controle
17.
Cochrane Database Syst Rev ; 3: CD009098, 2021 03 30.
Artigo em Inglês | MEDLINE | ID: mdl-33784416

RESUMO

BACKGROUND: In patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), mortality remains high. These patients require mechanical ventilation, which has been associated with ventilator-induced lung injury. High levels of positive end-expiratory pressure (PEEP) could reduce this condition and improve patient survival. This is an updated version of the review first published in 2013. OBJECTIVES: To assess the benefits and harms of high versus low levels of PEEP in adults with ALI and ARDS. SEARCH METHODS: For our previous review, we searched databases from inception until 2013. For this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, and the Web of Science from inception until May 2020. We also searched for ongoing trials (www.trialscentral.org; www.clinicaltrial.gov; www.controlled-trials.com), and we screened the reference lists of included studies. SELECTION CRITERIA: We included randomised controlled trials that compared high versus low levels of PEEP in ALI and ARDS participants who were intubated and mechanically ventilated in intensive care for at least 24 hours. DATA COLLECTION AND ANALYSIS: Two review authors assessed risk of bias and extracted data independently. We contacted investigators to identify additional published and unpublished studies. We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We included four new studies (1343 participants) in this review update. In total, we included 10 studies (3851 participants). We found evidence of risk of bias in six studies, and the remaining studies fulfilled all criteria for low risk of bias. In eight studies (3703 participants), a comparison was made between high and low levels of PEEP, with the same tidal volume in both groups. In the remaining two studies (148 participants), the tidal volume was different between high- and low-level groups. In the main analysis, we assessed mortality occurring before hospital discharge only in studies that compared high versus low PEEP, with the same tidal volume in both groups. Evidence suggests that high PEEP may result in little to no difference in mortality compared to low PEEP (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.90 to 1.04; I² = 15%; 7 studies, 3640 participants; moderate-certainty evidence). In addition, high PEEP may result in little to no difference in barotrauma (RR 1.00, 95% CI 0.64 to 1.57; I² = 63%; 9 studies, 3791 participants; low-certainty evidence). High PEEP may improve oxygenation in patients up to the first and third days of mechanical ventilation (first day: mean difference (MD) 51.03, 95% CI 35.86 to 66.20; I² = 85%; 6 studies, 2594 participants; low-certainty evidence; third day: MD 50.32, 95% CI 34.92 to 65.72; I² = 83%; 6 studies, 2309 participants; low-certainty evidence) and probably improves oxygenation up to the seventh day (MD 28.52, 95% CI 20.82 to 36.21; I² = 0%; 5 studies, 1611 participants; moderate-certainty evidence). Evidence suggests that high PEEP results in little to no difference in the number of ventilator-free days (MD 0.45, 95% CI -2.02 to 2.92; I² = 81%; 3 studies, 1654 participants; low-certainty evidence). Available data were insufficient to pool the evidence for length of stay in the intensive care unit. AUTHORS' CONCLUSIONS: Moderate-certainty evidence shows that high levels compared to low levels of PEEP do not reduce mortality before hospital discharge. Low-certainty evidence suggests that high levels of PEEP result in little to no difference in the risk of barotrauma. Low-certainty evidence also suggests that high levels of PEEP improve oxygenation up to the first and third days of mechanical ventilation, and moderate-certainty evidence indicates that high levels of PEEP improve oxygenation up to the seventh day of mechanical ventilation. As in our previous review, we found clinical heterogeneity - mainly within participant characteristics and methods of titrating PEEP - that does not allow us to draw definitive conclusions regarding the use of high levels of PEEP in patients with ALI and ARDS. Further studies should aim to determine the appropriate method of using high levels of PEEP and the advantages and disadvantages associated with high levels of PEEP in different ARDS and ALI patient populations.


Assuntos
Respiração com Pressão Positiva/métodos , Síndrome do Desconforto Respiratório/terapia , Lesão Pulmonar Induzida por Ventilação Mecânica/terapia , Doença Aguda , Adulto , Viés , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Consumo de Oxigênio , Respiração com Pressão Positiva/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto , Síndrome do Desconforto Respiratório/mortalidade , Volume de Ventilação Pulmonar , Lesão Pulmonar Induzida por Ventilação Mecânica/mortalidade
18.
J Crit Care ; 63: 106-112, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33676795

RESUMO

PURPOSE: Acute Respiratory Distress Syndrome (ARDS) secondary to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has demonstrated variable oxygenation and respiratory-system mechanics without investigation of transpulmonary and chest-wall mechanics. This study describes lung, chest wall and respiratory-system mechanics in patients with SARS-CoV-2 and ARDS. METHODS: Data was collected from forty patients with confirmed SARS-CoV-2 and ARDS at Beth Israel Deaconess Medical Center in Boston, Massachusetts. Esophageal balloons were placed to estimate pleural and transpulmonary pressures. Clinical characteristics, respiratory-system, transpulmonary, and chest-wall mechanics were measured over the first week. RESULTS: Patients had moderate-severe ARDS (PaO2/FiO2 123[98-149]) and were critically ill (APACHE IV 108 [94-128] and SOFA 12 [11-13]). PaO2/FiO2 improved over the first week (150 mmHg [122.9-182] to 185 mmHg [138-228] (p = 0.035)). Respiratory system (30-35 ml/cm H2O), lung (40-50 ml/cm H2O) and chest wall (120-150 ml/cm H2O) compliance remained similar over the first week. Elevated basal pleural pressures correlated with BMI. Patients required prolonged mechanical ventilation (14.5 days [9.5-19.0]), with a mortality of 32.5%. CONCLUSIONS: Patients displayed normal chest-wall mechanics, with increased basal pleural pressure. Respiratory system and lung mechanics were similar to known existing ARDS cohorts. The wide range of respiratory system mechanics illustrates the inherent heterogeneity that is consistent with typical ARDS.


Assuntos
COVID-19/complicações , Pulmão/fisiopatologia , Síndrome do Desconforto Respiratório/etiologia , Mecânica Respiratória , SARS-CoV-2/genética , APACHE , Idoso , Boston/epidemiologia , COVID-19/epidemiologia , COVID-19/terapia , COVID-19/virologia , Estudos de Coortes , Estado Terminal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Respiração com Pressão Positiva/métodos , Síndrome do Desconforto Respiratório/epidemiologia , Síndrome do Desconforto Respiratório/terapia , Síndrome do Desconforto Respiratório/virologia
19.
BMC Pregnancy Childbirth ; 21(Suppl 1): 235, 2021 Mar 26.
Artigo em Inglês | MEDLINE | ID: mdl-33765958

RESUMO

BACKGROUND: Annually, 14 million newborns require stimulation to initiate breathing at birth and 6 million require bag-mask-ventilation (BMV). Many countries have invested in facility-based neonatal resuscitation equipment and training. However, there is no consistent tracking for neonatal resuscitation coverage. METHODS: The EN-BIRTH study, in five hospitals in Bangladesh, Nepal, and Tanzania (2017-2018), collected time-stamped data for care around birth, including neonatal resuscitation. Researchers surveyed women and extracted data from routine labour ward registers. To assess accuracy, we compared gold standard observed coverage to survey-reported and register-recorded coverage, using absolute difference, validity ratios, and individual-level validation metrics (sensitivity, specificity, percent agreement). We analysed two resuscitation numerators (stimulation, BMV) and three denominators (live births and fresh stillbirths, non-crying, non-breathing). We also examined timeliness of BMV. Qualitative data were collected from health workers and data collectors regarding barriers and enablers to routine recording of resuscitation. RESULTS: Among 22,752 observed births, 5330 (23.4%) babies did not cry and 3860 (17.0%) did not breathe in the first minute after birth. 16.2% (n = 3688) of babies were stimulated and 4.4% (n = 998) received BMV. Survey-report underestimated coverage of stimulation and BMV. Four of five labour ward registers captured resuscitation numerators. Stimulation had variable accuracy (sensitivity 7.5-40.8%, specificity 66.8-99.5%), BMV accuracy was higher (sensitivity 12.4-48.4%, specificity > 93%), with small absolute differences between observed and recorded BMV. Accuracy did not vary by denominator option. < 1% of BMV was initiated within 1 min of birth. Enablers to register recording included training and data use while barriers included register design, documentation burden, and time pressure. CONCLUSIONS: Population-based surveys are unlikely to be useful for measuring resuscitation coverage given low validity of exit-survey report. Routine labour ward registers have potential to accurately capture BMV as the numerator. Measuring the true denominator for clinical need is complex; newborns may require BMV if breathing ineffectively or experiencing apnoea after initial drying/stimulation or subsequently at any time. Further denominator research is required to evaluate non-crying as a potential alternative in the context of respectful care. Measuring quality gaps, notably timely provision of resuscitation, is crucial for programme improvement and impact, but unlikely to be feasible in routine systems, requiring audits and special studies.


Assuntos
Confiabilidade dos Dados , Morte Perinatal/prevenção & controle , Respiração com Pressão Positiva/estatística & dados numéricos , Ressuscitação/estatística & dados numéricos , Adolescente , Adulto , Bangladesh/epidemiologia , Feminino , Humanos , Recém-Nascido , Nascido Vivo , Masculino , Máscaras/estatística & dados numéricos , Nepal/epidemiologia , Respiração com Pressão Positiva/instrumentação , Respiração com Pressão Positiva/métodos , Gravidez , Sistema de Registros/estatística & dados numéricos , Ressuscitação/instrumentação , Ressuscitação/métodos , Natimorto , Inquéritos e Questionários/estatística & dados numéricos , Tanzânia/epidemiologia , Adulto Jovem
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