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1.
Best Pract Res Clin Anaesthesiol ; 34(3): 561-567, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33004167

RESUMO

Coronavirus disease 2019 (COVID-19) is a new disease with different phases that can be catastrophic for subpopulations of patients with cardiovascular and pulmonary disease states at baseline. Appreciation for these different phases and treatment modalities, including manipulation of ventilatory settings and therapeutics, has made it a less lethal disease than when it emerged earlier this year. Different aspects of the disease are still largely unknown. However, laboratory investigation and clinical course of the COVID-19 show that this new disease is not a typical acute respiratory distress syndrome process, especially during the first phase. For this reason, the best strategy to be applied is to treat differently the single phases and to support the single functions of the failing organs as they appear.


Assuntos
Betacoronavirus , Infecções por Coronavirus/fisiopatologia , Infecções por Coronavirus/terapia , Pulmão/fisiopatologia , Pneumonia Viral/fisiopatologia , Pneumonia Viral/terapia , Respiração com Pressão Positiva/métodos , Humanos , Pandemias , Volume de Ventilação Pulmonar/fisiologia
2.
BMJ Case Rep ; 13(9)2020 Sep 08.
Artigo em Inglês | MEDLINE | ID: mdl-32907873

RESUMO

A 71-year-old man presented to the emergency department (ED) with low oxygen saturations and symptoms consistent with COVID-19 infection. Apart from a small left-sided ischaemic stroke 10 years prior with very minor residual deficit, he had been well and in full-time employment until development of symptoms. Within minutes of commencing non-invasive ventilation (NIV) in the ED, he developed a complete left-sided paralysis and hemineglect. This case highlights the significance of the prothrombotic complications associated with COVID-19 infection. It also raises the question whether pressure changes upon commencing NIV could lead to clot migration.


Assuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Ventilação não Invasiva/métodos , Pneumonia Viral/complicações , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Doença Aguda , Idoso , Infecções por Coronavirus/terapia , Evolução Fatal , Fibrinolíticos/uso terapêutico , Humanos , Masculino , Pandemias , Pneumonia Viral/terapia , Respiração com Pressão Positiva/métodos , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/uso terapêutico , Tomografia Computadorizada por Raios X/métodos
3.
J Investig Med High Impact Case Rep ; 8: 2324709620957778, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32911986

RESUMO

Coronavirus disease 2019 (COVID-19) caused by a novel human coronavirus has led to a tsunami of viral illness across the globe, originating from Wuhan, China. Although the value and effectiveness of extracorporeal membrane oxygenation (ECMO) in severe respiratory illness from COVID-19 remains unclear at this time, there is emerging evidence suggesting that it could be utilized as an ultimate treatment in appropriately selected patients not responding to conventional care. We present a case of a 32-year-old COVID-19 positive male with a history of diabetes mellitus who was intubated for severe acute respiratory distress syndrome (ARDS). The patient's hypoxemia failed to improve despite positive pressure ventilation, prone positioning, and use of neuromuscular blockade for ventilator asynchrony. He was evaluated by a multidisciplinary team for considering ECMO for refractory ARDS. He was initiated on venovenous ECMO via dual-site cannulation performed at the bedside. Although his ECMO course was complicated by bleeding, he showed a remarkable improvement in his lung function. ECMO was successfully decannulated after 17 days of initiation. The patient was discharged home after 47 days of hospitalization without any supplemental oxygen and was able to undergo active physical rehabilitation. A multidisciplinary approach is imperative in the initiation and management of ECMO in COVID-19 patients with severe ARDS. While ECMO is labor-intensive, using it in the right phenotype and in specialized centers may lead to positive results. Patients who are young, with fewer comorbidities and single organ dysfunction portray a better prognosis for patients in which ECMO is utilized.


Assuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Oxigenação por Membrana Extracorpórea/métodos , Pneumonia Viral/complicações , Síndrome do Desconforto Respiratório do Adulto/terapia , Terapia de Salvação/métodos , Adulto , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Humanos , Masculino , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Respiração com Pressão Positiva/métodos , Radiografia Torácica , Síndrome do Desconforto Respiratório do Adulto/diagnóstico , Síndrome do Desconforto Respiratório do Adulto/etiologia , Tomografia Computadorizada por Raios X
4.
JAMA ; 324(9): 848-858, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32870298

RESUMO

Importance: In patients who undergo mechanical ventilation during surgery, the ideal tidal volume is unclear. Objective: To determine whether low-tidal-volume ventilation compared with conventional ventilation during major surgery decreases postoperative pulmonary complications. Design, Setting, and Participants: Single-center, assessor-blinded, randomized clinical trial of 1236 patients older than 40 years undergoing major noncardiothoracic, nonintracranial surgery under general anesthesia lasting more than 2 hours in a tertiary hospital in Melbourne, Australia, from February 2015 to February 2019. The last date of follow-up was February 17, 2019. Interventions: Patients were randomized to receive a tidal volume of 6 mL/kg predicted body weight (n = 614; low tidal volume group) or a tidal volume of 10 mL/kg predicted body weight (n = 592; conventional tidal volume group). All patients received positive end-expiratory pressure (PEEP) at 5 cm H2O. Main Outcomes and Measures: The primary outcome was a composite of postoperative pulmonary complications within the first 7 postoperative days, including pneumonia, bronchospasm, atelectasis, pulmonary congestion, respiratory failure, pleural effusion, pneumothorax, or unplanned requirement for postoperative invasive or noninvasive ventilation. Secondary outcomes were postoperative pulmonary complications including development of pulmonary embolism, acute respiratory distress syndrome, systemic inflammatory response syndrome, sepsis, acute kidney injury, wound infection (superficial and deep), rate of intraoperative need for vasopressor, incidence of unplanned intensive care unit admission, rate of need for rapid response team call, intensive care unit length of stay, hospital length of stay, and in-hospital mortality. Results: Among 1236 patients who were randomized, 1206 (98.9%) completed the trial (mean age, 63.5 years; 494 [40.9%] women; 681 [56.4%] undergoing abdominal surgery). The primary outcome occurred in 231 of 608 patients (38%) in the low tidal volume group compared with 232 of 590 patients (39%) in the conventional tidal volume group (difference, -1.3% [95% CI, -6.8% to 4.2%]; risk ratio, 0.97 [95% CI, 0.84-1.11]; P = .64). There were no significant differences in any of the secondary outcomes. Conclusions and Relevance: Among adult patients undergoing major surgery, intraoperative ventilation with low tidal volume compared with conventional tidal volume, with PEEP applied equally between groups, did not significantly reduce pulmonary complications within the first 7 postoperative days. Trial Registration: ANZCTR Identifier: ACTRN12614000790640.


Assuntos
Pneumopatias/prevenção & controle , Respiração com Pressão Positiva/métodos , Complicações Pós-Operatórias/prevenção & controle , Procedimentos Cirúrgicos Operatórios , Volume de Ventilação Pulmonar , Adulto , Feminino , Humanos , Incidência , Cuidados Intraoperatórios , Pneumopatias/epidemiologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Período Pós-Operatório , Método Simples-Cego , Procedimentos Cirúrgicos Operatórios/efeitos adversos
5.
Br J Anaesth ; 125(3): 373-382, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32665059

RESUMO

BACKGROUND: Robot-assisted laparoscopic radical prostatectomy requires general anaesthesia, extreme Trendelenburg positioning and capnoperitoneum. Together these promote impaired pulmonary gas exchange caused by atelectasis and may contribute to postoperative pulmonary complications. In morbidly obese patients, a recruitment manoeuvre (RM) followed by individualised PEEP improves intraoperative oxygenation and end-expiratory lung volume (EELV). We hypothesised that individualised PEEP with initial RM similarly improves intraoperative oxygenation and EELV in non-obese individuals undergoing robot-assisted prostatectomy. METHODS: Forty males (age, 49-76 yr; BMI <30 kg m-2) undergoing prostatectomy received volume-controlled ventilation (tidal volume 8 ml kg-1 predicted body weight). Participants were randomised to either (1) RM followed by individualised PEEP (RM/PEEPIND) optimised using electrical impedance tomography or (2) no RM with 5 cm H2O PEEP. The primary outcome was the ratio of arterial oxygen partial pressure to fractional inspired oxygen (Pao2/Fio2) before the last RM before extubation. Secondary outcomes included regional ventilation distribution and EELV which were measured before, during, and after anaesthesia. The cardiovascular effects of RM/PEEPIND were also assessed. RESULTS: In 20 males randomised to RM/PEEPIND, the median PEEPIND was 14 cm H2O [inter-quartile range, 8-20]. The Pao2/Fio2 was 10.0 kPa higher with RM/PEEPIND before extubation (95% confidence interval [CI], 2.6-17.3 kPa; P=0.001). RM/PEEPIND increased end-expiratory lung volume by 1.49 L (95% CI, 1.09-1.89 L; P<0.001). RM/PEEPIND also improved the regional ventilation of dependent lung regions. Vasopressor and fluid therapy was similar between groups, although 13 patients randomised to RM/PEEPIND required pharmacological therapy for bradycardia. CONCLUSION: In non-obese males, an individualised ventilation strategy improved intraoperative oxygenation, which was associated with higher end-expiratory lung volumes during robot-assisted laparoscopic prostatectomy. CLINICAL TRIAL REGISTRATION: DRKS00004199 (German clinical trials registry).


Assuntos
Impedância Elétrica , Respiração com Pressão Positiva/métodos , Prostatectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Idoso , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
6.
PLoS One ; 15(7): e0235363, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32628732

RESUMO

OBJECTIVE: There are differences in the adoption rates of less invasive surfactant administration (LISA) worldwide. We aimed to describe and analyze the process of LISA introduction at the country level. METHODS: A standardized training program (33 courses covering >500 neonatologists) was followed by a cohort study. Data regarding consecutive LISA procedures were acquired over 12 months in 31 tertiary neonatal centers, using a dedicated on-line platform. RESULTS: Of 500 LISA procedures, 75% were performed by specialists and 25% by residents. The mean percentage share of LISA in all surfactant therapies was 24%, which represents a 6-fold increase compared to previous years. After 12 months, 76% of the procedures were rated "easy/very easy" vs 59% at baseline (p<0.05). Surfactant re-treatment rate was 15%. Twenty-three percent of infants required mechanical ventilation within 72 hours of life. Oxygen desaturation and surfactant reflux were the most frequent complications. Unlike previous reports describing exclusive use of nasal continuous positive airway pressure (nCPAP) during LISA, majority of procedures (63%) were carried out using nasal intermittent positive pressure ventilation (NIPPV) or Bilevel Positive Airway Pressure (BiPAP). Efficacy of LISA with NIPPV or BiPAP was not significantly different from that with nCPAP (22.4% vs 24.5% of cases requiring intubation). Ventilation was provided with nasal cannulas or nasal masks (90%) and rarely with "RAM" cannulas or nasopharyngeal tubes. Rigid catheters were preferred (88.4%); tracheal insertion was successful at first attempt in 87% of cases. Majority of infants (79%) received no premedication prior to the procedure and almost all were given caffeine citrate. Median time of instillation was 1.5 minutes. CONCLUSIONS: The LISA procedure does not appear to be technically difficult to master. Training combining theory with practical exercises is an efficient implementation strategy. Variations in adoption rates indicate the need for additional, more personalized teachings in some centers.


Assuntos
Implementação de Plano de Saúde/estatística & dados numéricos , Respiração com Pressão Positiva/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Surfactantes Pulmonares/administração & dosagem , Síndrome do Desconforto Respiratório do Recém-Nascido/terapia , Feminino , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Internato e Residência/organização & administração , Internato e Residência/estatística & dados numéricos , Masculino , Neonatologistas/educação , Neonatologistas/estatística & dados numéricos , Polônia , Respiração com Pressão Positiva/efeitos adversos , Respiração com Pressão Positiva/métodos , Padrões de Prática Médica/organização & administração , Estudos Prospectivos
7.
Br J Anaesth ; 125(3): 383-392, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32682559

RESUMO

BACKGROUND: Higher intraoperative driving pressures (ΔP) are associated with increased postoperative pulmonary complications (PPC). We hypothesised that dynamic adjustment of PEEP throughout abdominal surgery reduces ΔP, maintains positive end-expiratory transpulmonary pressures (Ptp_ee) and increases respiratory system static compliance (Crs) with PEEP levels that are variable between and within patients. METHODS: In a prospective multicentre pilot study, adults at moderate/high risk for PPC undergoing elective abdominal surgery were randomised to one of three ventilation protocols: (1) PEEP≤2 cm H2O, compared with periodic recruitment manoeuvres followed by individualised PEEP to either optimise respiratory system compliance (PEEPmaxCrs) or maintain positive end-expiratory transpulmonary pressure (PEEPPtp_ee). The composite primary outcome included intraoperative ΔP, Ptp_ee, Crs, and PEEP values (median (interquartile range) and coefficients of variation [CVPEEP]). RESULTS: Thirty-seven patients (48.6% female; age range: 47-73 yr) were assigned to control (PEEP≤2 cm H2O; n=13), PEEPmaxCrs (n=16), or PEEPPtp_ee (n=8) groups. The PEEPPtp_ee intervention could not be delivered in two patients. Subjects assigned to PEEPmaxCrs had lower ΔP (median8 cm H2O [7-10]), compared with the control group (12 cm H2O [10-15]; P=0.006). PEEPmaxCrs was also associated with higher Ptp_ee (2.0 cm H2O [-0.7 to 4.5] vs controls: -8.3 cm H2O [-13.0 to -4.0]; P≤0.001) and higher Crs (47.7 ml cm H2O [43.2-68.8] vs controls: 39.0 ml cm H2O [32.9-43.4]; P=0.009). Individualised PEEP (PEEPmaxCrs and PEEPPtp_ee combined) varied widely (median: 10 cm H2O [8-15]; CVPEEP=0.24 [0.14-0.35]), both between, and within, subjects throughout surgery. CONCLUSIONS: This pilot study suggests that individualised PEEP management strategies applied during abdominal surgery reduce driving pressure, maintain positive Ptp_ee and increase static compliance. The wide range of PEEP observed suggests that an individualised approach is required to optimise respiratory mechanics during abdominal surgery. CLINICAL TRIAL REGISTRATION: NCT02671721.


Assuntos
Abdome/cirurgia , Cuidados Intraoperatórios/métodos , Respiração com Pressão Positiva/métodos , Complicações Pós-Operatórias/prevenção & controle , Mecânica Respiratória/fisiologia , Idoso , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos
8.
Crit Care Med ; 48(8): 1129-1134, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32697482

RESUMO

OBJECTIVES: Severe cases of coronavirus disease 2019 develop the acute respiratory distress syndrome, requiring admission to the ICU. This study aimed to describe specific pathophysiological characteristics of acute respiratory distress syndrome from coronavirus disease 2019. DESIGN: Prospective crossover physiologic study. SETTING: ICU of a university-affiliated hospital from northern Italy dedicated to care of patients with confirmed diagnosis of coronavirus disease 2019. PATIENTS: Ten intubated patients with acute respiratory distress syndrome and confirmed diagnosis of coronavirus disease 2019. INTERVENTIONS: We performed a two-step positive end-expiratory pressure trial with change of 10 cm H2O in random order. MEASUREMENTS AND MAIN RESULTS: At each positive end-expiratory pressure level, we assessed arterial blood gases, respiratory mechanics, ventilation inhomogeneity, and potential for lung recruitment by electrical impedance tomography. Potential for lung recruitment was assessed by the recently described recruitment to inflation ratio. In a subgroup of seven paralyzed patients, we also measured ventilation-perfusion mismatch at lower positive end-expiratory pressure by electrical impedance tomography. At higher positive end-expiratory pressure, respiratory mechanics did not change significantly: compliance remained relatively high with low driving pressure. Oxygenation and ventilation inhomogeneity improved but arterial CO2 increased despite unchanged respiratory rate and tidal volume. The recruitment to inflation ratio presented median value higher than previously reported in acute respiratory distress syndrome patients but with large variability (median, 0.79 [0.53-1.08]; range, 0.16-1.40). The FIO2 needed to obtain viable oxygenation at lower positive end-expiratory pressure was significantly correlated with the recruitment to inflation ratio (r = 0.603; p = 0.05). The ventilation-perfusion mismatch was elevated (median, 34% [32-45%] of lung units) and, in six out of seven patients, ventilated nonperfused units represented a much larger proportion than perfused nonventilated ones. CONCLUSIONS: In patients with acute respiratory distress syndrome from coronavirus disease 2019, potential for lung recruitment presents large variability, while elevated dead space fraction may be a specific pathophysiological trait. These findings may guide selection of personalized mechanical ventilation settings.


Assuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Respiração com Pressão Positiva/métodos , Síndrome do Desconforto Respiratório do Adulto/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Gasometria , Estudos Cross-Over , Feminino , Hospitais Universitários , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Oxigênio/sangue , Pandemias , Estudos Prospectivos , Síndrome do Desconforto Respiratório do Adulto/etiologia , Síndrome do Desconforto Respiratório do Adulto/fisiopatologia , Mecânica Respiratória
11.
Heart Fail Clin ; 16(3): 271-282, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32503751

RESUMO

Noninvasive positive pressure ventilation (NIPPV), which can be applied without endotracheal airway or tracheostomy, has been used as the first-line device for patients with acute decompensated heart failure (ADHF) and cardiogenic pulmonary edema. Positive airway pressure (PAP) devices include continuous PAP, bilevel PAP, and adaptive servoventilation. NIPPV can provide favorable physiologic benefits, including improving oxygenation, respiratory mechanics, and pulmonary and systemic hemodynamics. It can also reduce the intubation rate and improve clinical symptoms, resulting in good quality of life and mortality.


Assuntos
Insuficiência Cardíaca , Respiração com Pressão Positiva/métodos , Edema Pulmonar , Doença Aguda , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/terapia , Humanos , Ventilação não Invasiva/métodos , Edema Pulmonar/etiologia , Edema Pulmonar/terapia , Resultado do Tratamento
12.
Medicine (Baltimore) ; 99(26): e20891, 2020 Jun 26.
Artigo em Inglês | MEDLINE | ID: mdl-32590795

RESUMO

RATIONALE: The use of extra-positive end-expiratory pressure (PEEP) at a level of 80% intrinsic-PEEP (iPEEP) to improve ventilation in severe asthma patients with control ventilation remains controversial. Electrical impedance tomography (EIT) may provide regional information for determining the optimal extra-PEEP to overcome gas trapping and distribution. Moreover, the experience of using EIT to determine extra-PEEP in severe asthma patients with controlled ventilation is limited. PATIENTS CONCERNS: A severe asthma patient had 12-cmH2O iPEEP using the end-expiratory airway occlusion method at Zero positive end-expiratory pressures (ZEEP). How to titrate the extra-PEEP to against iPEEP at bedside? DIAGNOSES AND INTERVENTIONS: An incremental PEEP titration was performed in the severe asthma patient with mechanical ventilation. An occult pendelluft phenomenon of the ventral and dorsal regions was found during the early and late expiration periods when the extra-PEEP was set to <6 cmH2O. If the extra-PEEP was elevated from 4 to 6 cmH2O, a decrease in the end-expiratory lung impedance (EELI) and a disappearance of the pendelluft phenomenon were observed during the PEEP titration. Moreover, there was broad disagreement as to the "best" extra-PEEP settings according to the various EIT parameters. The regional ventilation delay had the lowest extra-PEEP value (10 cmH2O), whereas the value was 12 cmH2O for the lung collapse/overdistension index and 14 cmH2O for global inhomogeneity. OUTCOMES: The extra-PEEP was set at 6 cmH2O, and the severe whistling sound was improved. The patient's condition further became better under the integrated therapy. LESSONS: A broad literature review shows that this was the 3rd case of using EIT to titrate an extra-PEEP to against PEEPi. Importantly, the visualization of occult pendelluft and possible air release during incremental PEEP titration was documented for the first time during incremental PEEP titration in patients with severe asthma. Examining the presence of the occult pendelluft phenomenon and changes in the EELI by EIT might be an alternative means for determining an individual's extra-PEEP.


Assuntos
Asma/terapia , Impedância Elétrica/uso terapêutico , Respiração com Pressão Positiva/instrumentação , Radiologia Intervencionista/instrumentação , Idoso de 80 Anos ou mais , Asma/fisiopatologia , Feminino , Humanos , Respiração com Pressão Positiva/métodos , Radiologia Intervencionista/métodos , Respiração Artificial/métodos , Tomografia Computadorizada por Raios X/métodos
14.
Eur Heart J Acute Cardiovasc Care ; 9(3): 229-238, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: covidwho-197859

RESUMO

The severe acute respiratory syndrome coronavirus 2 pandemic is to date affecting more than a million of patients and is challenging healthcare professionals around the world. Coronavirus disease 2019 may present with a wide range of clinical spectrum and severity, including severe interstitial pneumonia with high prevalence of hypoxic respiratory failure requiring intensive care admission. There has been increasing sharing experience regarding the patient's clinical features over the last weeks which has underlined the need for general guidance on treatment strategies. We summarise the evidence existing in the literature of oxygen and positive pressure treatments in patients at different stages of respiratory failure and over the course of the disease, including environment and ethical issues related to the ongoing coronavirus disease 2019 infection.


Assuntos
Betacoronavirus/isolamento & purificação , Infecções por Coronavirus/complicações , Hipóxia/terapia , Equipamento de Proteção Individual/normas , Pneumonia Viral/complicações , Insuficiência Respiratória/terapia , Defesa Civil , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/virologia , Cuidados Críticos/métodos , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/prevenção & controle , Gerenciamento Clínico , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Humanos , Hipóxia/etiologia , Peso Corporal Ideal/fisiologia , Intubação Intratraqueal/ética , Intubação Intratraqueal/métodos , Masculino , Oxigênio/administração & dosagem , Oxigênio/uso terapêutico , Pandemias , Equipamento de Proteção Individual/provisão & distribução , Pneumonia Viral/epidemiologia , Pneumonia Viral/mortalidade , Pneumonia Viral/virologia , Respiração com Pressão Positiva/métodos , Respiração Artificial/métodos , Insuficiência Respiratória/etiologia
15.
Eur Heart J Acute Cardiovasc Care ; 9(3): 229-238, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32375488

RESUMO

The severe acute respiratory syndrome coronavirus 2 pandemic is to date affecting more than a million of patients and is challenging healthcare professionals around the world. Coronavirus disease 2019 may present with a wide range of clinical spectrum and severity, including severe interstitial pneumonia with high prevalence of hypoxic respiratory failure requiring intensive care admission. There has been increasing sharing experience regarding the patient's clinical features over the last weeks which has underlined the need for general guidance on treatment strategies. We summarise the evidence existing in the literature of oxygen and positive pressure treatments in patients at different stages of respiratory failure and over the course of the disease, including environment and ethical issues related to the ongoing coronavirus disease 2019 infection.


Assuntos
Betacoronavirus/isolamento & purificação , Infecções por Coronavirus/complicações , Hipóxia/terapia , Equipamento de Proteção Individual/normas , Pneumonia Viral/complicações , Insuficiência Respiratória/terapia , Defesa Civil , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/virologia , Cuidados Críticos/métodos , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/prevenção & controle , Gerenciamento Clínico , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Humanos , Hipóxia/etiologia , Peso Corporal Ideal/fisiologia , Intubação Intratraqueal/ética , Intubação Intratraqueal/métodos , Masculino , Oxigênio/administração & dosagem , Oxigênio/uso terapêutico , Pandemias , Equipamento de Proteção Individual/provisão & distribução , Pneumonia Viral/epidemiologia , Pneumonia Viral/mortalidade , Pneumonia Viral/virologia , Respiração com Pressão Positiva/métodos , Respiração Artificial/métodos , Insuficiência Respiratória/etiologia
16.
Br J Anaesth ; 125(1): e148-e157, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32386831

RESUMO

BACKGROUND: Bedside measures of patient effort are essential to properly titrate the level of pressure support ventilation. We investigated whether the tidal swing in oesophageal (ΔPes) and transdiaphragmatic pressure (ΔPdi), and ultrasonographic changes in diaphragm (TFdi) and parasternal intercostal (TFic) thickening are reliable estimates of respiratory effort. The effect of diaphragm dysfunction was also considered. METHODS: Twenty-one critically ill patients were enrolled: age 73 (14) yr, BMI 27 (7) kg m-2, and Pao2/Fio2 33.3 (9.2) kPa. A three-level pressure support trial was performed: baseline, 25% (PS-medium), and 50% reduction (PS-low). We recorded the oesophageal and transdiaphragmatic pressure-time products (PTPs), work of breathing (WOB), and diaphragm and intercostal ultrasonography. Diaphragm dysfunction was defined by the Gilbert index. RESULTS: Pressure support was 9.0 (1.6) cm H2O at baseline, 6.7 (1.3) (PS-medium), and 4.4 (1.0) (PS-low). ΔPes was significantly associated with the oesophageal PTP (R2=0.868; P<0.001) and the WOB (R2=0.683; P<0.001). ΔPdi was significantly associated with the transdiaphragmatic PTP (R2=0.820; P<0.001). TFdi was only weakly correlated with the oesophageal PTP (R2=0.326; P<0.001), and the correlation improved after excluding patients with diaphragm dysfunction (R2=0.887; P<0.001). TFdi was higher and TFic lower in patients without diaphragm dysfunction: 33.6 (18.2)% vs 13.2 (9.2)% and 2.1 (1.7)% vs 12.7 (9.1)%; P<0.0001. CONCLUSIONS: ΔPes and ΔPdi are adequate estimates of inspiratory effort. Diaphragm ultrasonography is a reliable indicator of inspiratory effort in the absence of diaphragm dysfunction. Additional measurement of parasternal intercostal thickening may discriminate a low inspiratory effort or a high effort in the presence of a dysfunctional diaphragm.


Assuntos
Esôfago/fisiologia , Respiração com Pressão Positiva/métodos , Músculos Respiratórios/fisiologia , Ultrassonografia/métodos , Trabalho Respiratório/fisiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Cuidados Críticos/métodos , Estado Terminal , Diafragma/fisiologia , Esôfago/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Músculos Respiratórios/diagnóstico por imagem
17.
Clinics (Sao Paulo) ; 75: e1894, 2020.
Artigo em Inglês | MEDLINE | ID: covidwho-114337

RESUMO

This review aims to verify the main epidemiologic, clinical, laboratory-related, and therapeutic aspects of coronavirus disease 2019 (COVID-19) in critically ill pediatric patients. An extensive review of the medical literature on COVID-19 was performed, mainly focusing on the critical care of pediatric patients, considering expert opinions and recent reports related to this new disease. Experts from a large Brazilian public university analyzed all recently published material to produce a report aiming to standardize the care of critically ill children and adolescents. The report emphasizes on the clinical presentations of the disease and ventilatory support in pediatric patients with COVID-19. It establishes a flowchart to guide health practitioners on triaging critical cases. COVID-19 is essentially an unknown clinical condition for the majority of pediatric intensive care professionals. Guidelines developed by experts can help all practitioners standardize their attitudes and improve the treatment of COVID-19.


Assuntos
Betacoronavirus , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/terapia , Pneumonia Viral/diagnóstico , Pneumonia Viral/terapia , Criança , Técnicas de Laboratório Clínico , Infecções por Coronavirus/metabolismo , Estado Terminal , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Pandemias , Respiração com Pressão Positiva/métodos , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Síndrome Respiratória Aguda Grave/diagnóstico , Síndrome Respiratória Aguda Grave/terapia , Índice de Gravidade de Doença , Fatores de Tempo
18.
Clinics (Sao Paulo) ; 75: e1894, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32321116

RESUMO

This review aims to verify the main epidemiologic, clinical, laboratory-related, and therapeutic aspects of coronavirus disease 2019 (COVID-19) in critically ill pediatric patients. An extensive review of the medical literature on COVID-19 was performed, mainly focusing on the critical care of pediatric patients, considering expert opinions and recent reports related to this new disease. Experts from a large Brazilian public university analyzed all recently published material to produce a report aiming to standardize the care of critically ill children and adolescents. The report emphasizes on the clinical presentations of the disease and ventilatory support in pediatric patients with COVID-19. It establishes a flowchart to guide health practitioners on triaging critical cases. COVID-19 is essentially an unknown clinical condition for the majority of pediatric intensive care professionals. Guidelines developed by experts can help all practitioners standardize their attitudes and improve the treatment of COVID-19.


Assuntos
Betacoronavirus , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/terapia , Pneumonia Viral/diagnóstico , Pneumonia Viral/terapia , Criança , Técnicas de Laboratório Clínico , Infecções por Coronavirus/metabolismo , Estado Terminal , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Pandemias , Respiração com Pressão Positiva/métodos , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Síndrome Respiratória Aguda Grave/diagnóstico , Síndrome Respiratória Aguda Grave/terapia , Índice de Gravidade de Doença , Fatores de Tempo
19.
Pneumologie ; 74(4): 217-221, 2020 Apr.
Artigo em Alemão | MEDLINE | ID: mdl-32274780

RESUMO

CPAP is the most common treatment for obstructive sleep apnea.Serious complications from this treatment are very rare. Pneumothorax following lung barotrauma under CPAP therapy has been described in case reports only in patients with pre-existing lung and thoracic diseases.A 68-year-old sleep apnea patient without pre-existing lung or thoracic diseases and with established CPAP therapy since many years was admitted to the hospital after a severe thoracic pain event with persistent shortness of breath. Chest radiograph and computed tomography showed an extensive right-sided pneumothorax with basal bullous emphysema. After surgical treatment of the secondary spontaneous pneumothorax, on the third postoperative day CPAP with reduced pressure was re-introduced with satisfactory sleep apnea findings and without pneumothorax recurrence.As possible cause of pneumothorax in the patient, alveolar inflammatory changes due to over-distention and increased pressure in the alveoli was assumed, which can occur after years of CPAP treatment with gradual pressure increase.In summary, in sleep apnea patients treated with CPAP for years, after sudden onset of thoracic pain and shortness of breath possible spontaneous pneumothorax should be considered.


Assuntos
Pneumotórax/etiologia , Respiração com Pressão Positiva/métodos , Enfisema Pulmonar/complicações , Enfisema Pulmonar/cirurgia , Síndromes da Apneia do Sono/terapia , Idoso , Pressão Positiva Contínua nas Vias Aéreas , Humanos , Masculino , Oxigênio/sangue , Pneumotórax/cirurgia , Respiração com Pressão Positiva/efeitos adversos , Apneia Obstrutiva do Sono , Toracoscopia
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