Simultaneous mechanical ventilation of several patients with a single ventilator.

INTRODUCTION: Simultaneous mechanical ventilation of several patients with a single ventilator might reduce the deficit of these devices for the care of patients with acute respiratory failure due to Covid-19. OBJECTIVE: To communicate the results of a mechanical ventilation exercise with a ventilator in a lung simulator, and simultaneously in two and four. RESULTS: No statistically significant differences were observed between programmed, recorded and measured positive end-expiratory pressure, mean airway pressure and peak pressure, except when simultaneously ventilating four lung simulators. CONCLUSIONS: Simultaneous mechanical ventilation should be implemented by medical personnel with experience in the procedure, be restricted to two patients and carried out in the intensive care unit.

INTRODUCCIÓN: La ventilación mecánica simultánea a varios pacientes con un solo ventilador podría disminuir el déficit de esos dispositivos para atender a los enfermos con insuficiencia respiratoria aguda por Covid-19. OBJETIVO: Comunicar los resultados de un ejercicio de ventilación mecánica con un ventilador en un simulador de pulmón, y simultáneamente en dos y cuatro. RESULTADOS: No se observaron diferencias estadísticamente significativas entre la presión positiva al final de la espiración, presión media de la vía aérea y presión pico programadas, registradas y medidas, excepto al ventilar simultáneamente cuatro simuladores de pulmón. CONCLUSIONES: La ventilación mecánica simultánea debe ser instaurada por personal médico con experiencia en el procedimiento, restringirse a dos pacientes y ser realizada en la unidad de cuidados intensivos.

At 50 years of the description of acute respiratory distress syndrome. / A 50 años de la descripción del síndrome de insuficiencia respiratoria aguda.

In 1967, Ashbaugh et al. published in the Lancet the description of a new entity, for which they coined the name "adult respiratory distress syndrome". On that article, they thoroughly described 12 patients who had respiratory distress with bilateral pulmonary infiltrates and oxygen therapy-refractory hypoxemia. For its management, emphasis was made on the importance of intubation and mechanical ventilation with positive end-expiratory pressure. At 50 years of its first publication, great advances on the knowledge of this condition have been achieved, which has influenced on patient management and survival. To celebrate this 50th anniversary, the National Academy of Medicine of Mexico organized a symposium with the purpose to spread the knowledge about this condition, recognize the researchers who made the original description and those who over the course of 50 years of history have contributed to its better understanding. The symposium addressed the topics of lung-kidney interaction, molecular bases of the disease and therapeutic advances.

En 1967, Ashbaugh et al. publicaron en Lancet la descripción de una nueva entidad para la que acuñaron el nombre "síndrome de distress respiratorio del adulto". En ese artículo describieron minuciosamente a 12 enfermos que presentaban insuficiencia respiratoria, con infiltración pulmonar bilateral e hipoxemia resistente a oxigenoterapia. Para su manejo se hizo énfasis en la importancia de la intubación y la ventilación mecánica con presión positiva al final de la espiración. A 50 años de la publicación se han logrado grandes avances en el conocimiento de esta enfermedad, lo que ha influido en el manejo y supervivencia de los pacientes. Para celebrar este cincuentenario, la Academia Nacional de Medicina de México organizó un simposio que tuvo como objetivos difundir el conocimiento de esta enfermedad, reconocer a los personajes que hicieron la descripción original y a quienes en 50 años de historia han contribuido a su mejor entendimiento. El simposio abordó los temas de interacción pulmón-riñón, bases moleculares de la enfermedad y avances en el tratamiento.

Influenza infection in the intensive care unit: Four years after the 2009 pandemic.

UNLABELLED: The role of influenza viruses in severe acute respiratory infection (SARI) in Intensive Care Units (ICU) remains unknown. The post-pandemic influenza A(H1N1)pdm09 period, in particular, has been poorly studied. OBJECTIVE: To identify influenza SARI patients in ICU, to assess the usefulness of the symptoms of influenza-like illness (ILI), and to compare the features of pandemic vs. post-pandemic influenza A(H1N1) pdm09 infection. METHODS: A prospective observational study with SARI patients admitted to ICU during the first three post-pandemic seasons. Patient demographics, characteristics and outcomes were recorded. An influenza epidemic period (IEP) was defined as >100 cases/100,000 inhabitants per week. RESULTS: One hundred sixty-three patients were diagnosed with SARI. ILI was present in 65 (39.9%) patients. Influenza infection was documented in 41 patients, 27 (41.5%) ILI patients, and 14 (14.3%) non-ILI patients, 27 of them during an IEP. Influenza A viruses were mainly responsible. Only five patients had influenza B virus infection, which were non-ILI during an IEP. SARI overall mortality was 22.1%, and 15% in influenza infection patients. Pandemic and post-pandemic influenza infection patients shared similar clinical features. CONCLUSIONS: During influenza epidemic periods, influenza infection screening should be considered in all SARI patients. Influenza SARI was mainly caused by subtype A(H1N1)pdm09 and A(H3N2) in post-pandemic seasons, and no differences were observed in ILI and mortality rate compared with a pandemic season.

Effectiveness and predictors of failure of noninvasive mechanical ventilation in acute respiratory failure.

OBJECTIVE: To assess the effectiveness and identify predictors of failure of noninvasive ventilation. DESIGN: A retrospective, longitudinal descriptive study was made. SETTING: Adult patients with acute respiratory failure. PATIENTS: A total of 410 consecutive patients with noninvasive ventilation treated in an Intensive Care Unit of a tertiary university hospital from 2006 to 2011. PROCEDURES: Noninvasive ventilation. MAIN VARIABLES OF INTEREST: Demographic variables and clinical and laboratory test parameters at the start and two hours after the start of noninvasive ventilation. Evolution during admission to the Unit and until hospital discharge. RESULTS: The failure rate was 50%, with an overall mortality rate of 33%. A total of 156 patients had hypoxemic respiratory failure, 87 postextubation respiratory failure, 78 exacerbation of chronic obstructive pulmonary disease, 61 hypercapnic respiratory failure without chronic obstructive pulmonary disease, and 28 had acute pulmonary edema. The failure rates were 74%, 54%, 27%, 31% and 21%, respectively. The etiology of respiratory failure, serum bilirubin at the start, APACHEII score, radiological findings, the need for sedation to tolerate noninvasive ventilation, changes in level of consciousness, PaO2/FIO2 ratio, respiratory rate and heart rate from the start and two hours after the start of noninvasive ventilation were independently associated to failure. CONCLUSIONS: The effectiveness of noninvasive ventilation varies according to the etiology of respiratory failure. Its use in hypoxemic respiratory failure and postextubation respiratory failure should be assessed individually. Predictors of failure could be useful to prevent delayed intubation.

The role of high flow oxygen therapy in acute respiratory failure.

Acute respiratory failure represents one of the most common causes of intensive care unit admission and oxygen therapy remains the first-line therapy in the management of these patients. In recent years, high-flow oxygen via nasal cannula has been described as a useful alternative to conventional oxygen therapy in patients with acute respiratory failure. High-flow oxygen via nasal cannula rapidly alleviates symptoms of acute respiratory failure and improves oxygenation by several mechanisms, including dead space washout, reduction in oxygen dilution and inspiratory nasopharyngeal resistance, a moderate positive airway pressure effect that may generate alveolar recruitment and an overall greater tolerance and comfort with the interface and the heated and humidified inspired gases. However, the experience in adults is still limited and there are no clinical guidelines to establish recommendations for their use. This article aims to review the existing evidence on the use of high-flow oxygen via nasal cannula in adults with acute respiratory failure and its possible applications, advantages and limitations.

Switches in non-invasive respiratory support strategies during acute hypoxemic respiratory failure: Need to monitoring from a retrospective observational study.

OBJECTIVE: To explore combined non-invasive-respiratory-support (NIRS) patterns, reasons for NIRS switching, and their potential impact on clinical outcomes in acute-hypoxemic-respiratory-failure (AHRF) patients. DESIGN: Retrospective, single-center observational study. SETTING: Intensive Care Medicine. PATIENTS: AHRF patients (cardiac origin and respiratory acidosis excluded) underwent combined NIRS therapies such as non-invasive-ventilation (NIV) and High-Flow-Nasal-Cannula (HFNC). INTERVENTIONS: Patients were classified based on the first NIRS switch performed (HFNC-to-NIV or NIV-to-HFNC), and further specific NIRS switching strategies (NIV trial-like vs. Non-NIV trial-like and single vs. multiples switches) were independently evaluated. MAIN VARIABLES OF INTEREST: Reasons for switching, NIRS failure and mortality rates. RESULTS: A total of 63 patients with AHRF were included, receiving combined NIRS, 58.7% classified in the HFNC-to-NIV group and 41.3% in the NIV-to-HFNC group. Reason for switching from HFNC to NIV was AHRF worsening (100%), while from NIV to HFNC was respiratory improvement (76.9%). NIRS failure rates were higher in the HFNC-to-NIV than in NIV-to-HFNC group (81% vs. 35%, p < 0.001). Among HFNC-to-NIV patients, there was no difference in the failure rate between the NIV trial-like and non-NIV trial-like groups (86% vs. 78%, p = 0.575) but the mortality rate was significantly lower in NIV trial-like group (14% vs. 52%, p = 0.02). Among NIV to HFNC patients, NIV failure was lower in the single switch group compared to the multiple switches group (15% vs. 53%, p = 0.039), with a shorter length of stay (5 [2-8] vs. 12 [8-30] days, p = 0.001). CONCLUSIONS: NIRS combination is used in real life and both switches' strategies, HFNC to NIV and NIV to HFNC, are common in AHRF management. Transitioning from HFNC to NIV is suggested as a therapeutic escalation and in this context performance of a NIV-trial could be beneficial. Conversely, switching from NIV to HFNC is suggested as a de-escalation strategy that is deemed safe if there is no NIRS failure.

[Role of biomarkers in the differential diagnosis of acute respiratory failure in the immediate postoperative period of lung transplantation]. / Papel de los biomarcadores en el diagnóstico diferencial de la insuficiencia respiratoria aguda en el postoperatorio inmediato del trasplante pulmonar.

Lung transplant recipients are at high risk of suffering many complications during the immediate postoperative period, such as primary graft dysfunction, acute graft rejection or infection. The most common symptom is the presence of acute respiratory failure, and the use of biomarkers could be useful for establishing an early diagnosis of these conditions. Different biomarkers have been studied, but none have proven to be the gold standard in the differential diagnosis of acute respiratory failure. This paper offers a review of the different biomarkers that have been studied in this field.

[Ten-year evolution of mechanical ventilation in acute respiratory failure in the hematogical patient admitted to the intensive care unit]. / Evolución de 10 años de aplicación de la ventilación mecánica en la insuficiencia respiratoria aguda del paciente hematológico ingresado en la unidad de cuidados intensivos.

OBJECTIVE: A comparison was made between invasive mechanical ventilation (IMV) and noninvasive positive pressure ventilation (NPPV) in haematological patients with acute respiratory failure. DESIGN: A retrospective observational study was made from 2001 to December 2011. SETTING: A clinical-surgical intensive care unit (ICU) in a tertiary hospital. PATIENTS: Patients with hematological malignancies suffering acute respiratory failure (ARF) and requiring mechanical ventilation in the form of either IMV or NPPV. VARIABLES OF INTEREST: Analysis of infection and organ failure rates, duration of mechanical ventilation and ICU and hospital stays, as well as ICU, hospital and mortality after 90 days. The same variables were analyzed in the comparison between NPPV success and failure. RESULTS: Forty-one patients were included, of which 35 required IMV and 6 NPPV. ICU mortality was higher in the IMV group (100% vs 37% in NPPV, P=.006). The intubation rate in NPPV was 40%. Compared with successful NPPV, failure in the NPPV group involved more complications, a longer duration of mechanical ventilation and ICU stay, and greater ICU and hospital mortality. Multivariate analysis of mortality in the NPPV group identified NPPV failure (OR 13 [95%CI 1.33-77.96], P=.008) and progression to acute respiratory distress syndrome (OR 10 [95%CI 1.95-89.22], P=.03) as prognostic factors. CONCLUSION: The use of NPPV reduced mortality compared with IMV. NPPV failure was associated with more complications.

The role of corticosteroids in patients hospitalized for COVID-19 at Mexico general Hospital.

OBJECTIVE: To compare the evolution of hospitalized patients infected with SARS-CoV-2 who received corticosteroid-based treatment versus patients who received standard therapy. METHOD: Retrospective, observational, and analytical study. Clinical records were collected from the different intensive care units, and data were obtained from confirmed COVID-19 patients over 18 years of age who were hospitalized. The population was divided into two groups: patients who received corticosteroid treatment, and those who received standard therapy. RESULTS: A total of 1603 patients were admitted to hospital, and of these 984 (62.9%) were discharged due to death. The main result was the identification by odds ratio (OR: 4.68; 95% confidence interval [95% CI]: 3.75-5.83; p = 0.001) as risk for death to the use of systemic steroids, as well as the use of invasive mechanical ventilation (OR: 2.26; 95% CI: 1.80-2.82; p < 0.001). The male gender was the most affected with 1051 (65.6%) patients. Mean age was 56 years (± 14). CONCLUSIONS: Corticosteroid use was associated with poor prognosis in patients hospitalized for COVID-19 compared to those receiving standard therapy.

OBJETIVO: Comparar la evolución de los pacientes hospitalizados infectados por SARS-CoV-2 que recibieron tratamiento a base de corticoesteroides frente a los pacientes que recibieron la terapia estándar. MÉTODO: Estudio de tipo retrospectivo, observacional y analítico. Se recolectaron los expedientes clínicos de las diferentes unidades de terapia intensiva y se obtuvieron datos de los pacientes confirmados de COVID-19, mayores de 18 años, que estuvieron hospitalizados. Se dividió la población en dos grupos: pacientes que recibieron tratamiento con corticoesteroides y pacientes que recibieron terapia estándar. RESULTADOS: De un total de 1603 pacientes ingresados a hospitalización, 984 (62.9%) fallecieron. El resultado principal fue la identificación mediante razón de momios (odds ratio [OR]: 4.68; intervalo de confianza del 95% [IC95%]: 3.75-5.83; p = 0.001) como riesgo para defunción con uso de esteroides sistémicos, así como con uso de ventilación mecánica invasiva (OR: 2.26; IC95%: 1.80-2.82; p < 0.001). El sexo masculino fue el más afectado, con 1051 (65.6%) pacientes. La media de edad fue de 56 años (± 14). CONCLUSIONES: El uso de corticoesteroides se asoció con mal pronóstico en los pacientes hospitalizados por COVID-19, en comparación con los que recibieron la terapia estándar.

Role of ultrasound in acute respiratory failure and in the weaning of mechanical ventilation.

Comprehensive ultrasound assessment has become an essential tool to facilitate the diagnosis and therapeutic management of critically ill patients with acute respiratory failure (ARF). There is evidence supporting the use of ultrasound for the diagnosis of pneumothorax, acute respiratory distress syndrome, cardiogenic pulmonary edema, pneumonia and acute pulmonary thromboembolism, and in patients with COVID-19. In addition, in recent years, the use of ultrasound to evaluate responses to treatment in critically ill patients with ARF has been developed, providing a noninvasive tool for titrating positive end-expiratory pressure, monitoring recruitment maneuvers and response to prone position, as well as for facilitating weaning from mechanical ventilation. The objective of this review is to summarize the basic concepts on the utility of ultrasound in the diagnosis and monitoring of critically ill patients with ARF.

Clinical outcomes according to timing to invasive ventilation due to noninvasive ventilation failure in children.

OBJECTIVE: Noninvasive ventilation (NIV) failure it has been associated to worst clinical outcomes due to a delay in intubation and initiation of invasive mechanical ventilation (IMV). There is a lack of evidence in pediatric patients regarding this topic. The objective was to deter-mine the association between duration of IMV and length of stay, with duration of NIV prior tointubation/IMV in pediatric patients. DESIGN: A prospective cohort study since January 2015 to October 2019. SETTING: A pediatric intensive care unit. PATIENTS: Children under 15 years with acute respiratory failure who failed to noninvasive ventilation. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Demographic variables, pediatric index of mortality (PIM2), pediatric acute respiratory distress syndrome (PARDS) diagnosis, IMV and NIV duration, PICU LOS were registered and intrahospital mortality. RESULTS: A total of 109 patients with a median (IQR) age of 7 (3-14) months were included. The main diagnosis was pneumonia (89.9%). PARDS was diagnosed in 37.6% of the sample. No association was found between NIV duration and duration of IMV after Kaplan-Meier analysis (Log rank P = .479). There was no significant difference between PICU LOS (P = .253) or hospital LOS (P = 0.669), when categorized by NIV duration before intubation. PARDS diagnosis was associated to an increased length of invasive ventilation (HR: 0.64 [95% IC: 0.42-0.99]). CONCLUSIONS: No association was found between NIV duration prior to intubation and duration of invasive ventilation in critical pediatric patients with acute respiratory failure.

Awake pronation with helmet continuous positive airway pressure for COVID-19 acute respiratory distress syndrome patients outside the ICU: A case series.

OBJECTIVE: Continuous positive airway pressure (CPAP) is an important therapeutic tool in COVID-19 acute respiratory distress syndrome (ARDS) since it improves oxygenation, reduces respiratory rate and can prevent intubation and intensive care unit (ICU) admission. CPAP during pronation has seldom been described and never during sedation. DESIGN: Case series. SETTING: High dependency unit of San Carlo University Hospital (Potenza, Italy). PATIENTS: Eleven consecutive patients with COVID-19 ARDS. INTERVENTION: Helmet CPAP in prone position after failing a CPAP trial in the supine position. MAIN VARIABLE OF INTEREST: Data collection at baseline and then after 24, 48 and 72h of pronation. We measured PaO2/FIO2, pH, lactate, PaCO2, SpO2, respiratory rate and the status of the patients at 28-day follow up. RESULTS: Patients were treated with helmet CPAP for a mean±SD of 7±2.7 days. Prone positioning was feasible in all patients, but in 7 of them dexmedetomidine improved comfort. PaO2/FIO2 improved from 107.5±20.8 before starting pronation to 244.4±106.2 after 72h (p<.001). We also observed a significantly increase in Sp02 from 90.6±2.3 to 96±3.1 (p<.001) and a decrease in respiratory rate from 27.6±4.3 to 20.1±4.7 (p=.004). No difference was observed in PaCO2 or pH. At 28 days two patients died after ICU admission, one was discharged in the main ward after ICU admission and eight were discharged home after being successfully managed outside the ICU. CONCLUSIONS: Helmet CPAP during pronation was feasible and safe in COVID-19 ARDS managed outside the ICU and sedation with dexmedetomidine safely improved comfort. We recorded an increase in PaO2/FIO2, SpO2 and a reduction in respiratory rate.

Impact of a modification of the clinical practice guide of the American Academy of Pediatrics in the management of severe acute bronchiolitis in a pediatric intensive care unit.

OBJECTIVE: To describe the characteristics and evolution of patients with bronchiolitis admitted to a pediatric intensive care unit, and compare treatment pre- and post-publication of the American Academy of Pediatrics clinical practice guide. DESIGN: A descriptive and observational study was carried out between September 2010 and September 2017. SETTING: Pediatric intensive care unit. PATIENTS: Infants under one year of age with severe bronchiolitis. INTERVENTIONS: Two periods were compared (2010-14 and 2015-17), corresponding to before and after modification of the American Academy of Pediatrics guidelines for the management of bronchiolitis in hospital. MAIN VARIABLES: Patient sex, age, comorbidities, severity, etiology, administered treatment, bacterial infections, respiratory and inotropic support, length of stay and mortality. RESULTS: A total of 706 patients were enrolled, of which 414 (58.6%) males, with a median age of 47 days (IQR 25-100.25). Median bronchiolitis severity score (BROSJOD) upon admission: 9 points (IQR 7-11). Respiratory syncytial virus appeared in 460 (65.16%) patients. The first period (2010-14) included 340 patients and the second period (2015-17) 366 patients. More adrenalin and hypertonic saline nebulizations and more corticosteroid treatment were administered in the second period. More noninvasive ventilation and less conventional mechanical ventilation were used, and less inotropic support was needed, with no significant differences. The antibiotherapy rate decreased significantly (p=0.003). CONCLUSIONS: Despite the decrease in antibiotherapy, the use of nebulizations and glucocorticoids in these patients should be limited, as recommended by the guide.

Impact of a modification of the clinical practice guide of the American Academy of Pediatrics in the management of severe acute bronchiolitis in a pediatric intensive care unit. / Impacto de una modificación de la guía de práctica clínica de la Academia Americana de Pediatría en el manejo de la bronquiolitis aguda grave en una unidad de cuidados intensivos pediátricos.

OBJECTIVE: To describe the characteristics and evolution of patients with bronchiolitis admitted to a pediatric intensive care unit, and compare treatment pre- and post-publication of the American Academy of Pediatrics clinical practice guide. DESIGN: A descriptive and observational study was carried out between September 2010 and September 2017. SETTING: Pediatric intensive care unit. PATIENTS: Infants under one year of age with severe bronchiolitis. INTERVENTIONS: Two periods were compared (2010-14 and 2015-17), corresponding to before and after modification of the American Academy of Pediatrics guidelines for the management of bronchiolitis in hospital. MAIN VARIABLES: Patient sex, age, comorbidities, severity, etiology, administered treatment, bacterial infections, respiratory and inotropic support, length of stay and mortality. RESULTS: A total of 706 patients were enrolled, of which 414 (58.6%) males, with a median age of 47 days (IQR 25-100.25). Median bronchiolitis severity score (BROSJOD) upon admission: 9 points (IQR 7-11). Respiratory syncytial virus appeared in 460 (65.16%) patients. The first period (2010-14) included 340 patients and the second period (2015-17) 366 patients. More adrenalin and hypertonic saline nebulizations and more corticosteroid treatment were administered in the second period. More noninvasive ventilation and less conventional mechanical ventilation were used, and less inotropic support was needed, with no significant differences. The antibiotherapy rate decreased significantly (P=.003). CONCLUSIONS: Despite the decrease in antibiotherapy, the use of nebulizations and glucocorticoids in these patients should be limited, as recommended by the guide.

Summary of Recommendations and Key Points of the Consensus of Spanish Scientific Societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the Use of Non-Invasive Ventilation and High-Flow Oxygen Therapy with Nasal Cannulas in Adult, Pediatric, and Neonatal Patients With Severe Acute Respiratory Failure.

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analog classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

Summary of recommendations and key points of the consensus of Spanish scientific societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the use of non-invasive ventilation and high-flow oxygen therapy with nasal cannulas in adult, pediatric, and neonatal patients with severe acute respiratory failure.

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analogue classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

Summary of recommendations and key points of the consensus of Spanish scientific societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the use of non-invasive ventilation and high-flow oxygen therapy with nasal cannulas in adult, pediatric, and neonatal patients with severe acute respiratory failure. / Sumario de las recomendaciones y puntos clave del Consenso de las Sociedades Científicas Españolas (SEPAR, SEMICYUC, SEMES; SECIP, SENeo, SEDAR, SENP) para la utilización de la ventilación no invasiva y terapia de alto flujo con cánulas nasales en el paciente adulto, pediátrico y neonatal con insuficiencia respiratoria aguda grave.

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analogue classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

Awake pronation with helmet continuous positive airway pressure for COVID-19 acute respiratory distress syndrome patients outside the ICU: A case series.

OBJECTIVE: Continuous positive airway pressure (CPAP) is an important therapeutic tool in COVID-19 acute respiratory distress syndrome (ARDS) since it improves oxygenation, reduces respiratory rate and can prevent intubation and intensive care unit (ICU) admission. CPAP during pronation has seldom been described and never during sedation. DESIGN: Case series. SETTING: High dependency unit of San Carlo University Hospital (Potenza, Italy). PATIENTS: Eleven consecutive patients with COVID-19 ARDS. INTERVENTION: Helmet CPAP in prone position after failing a CPAP trial in the supine position. MAIN VARIABLE OF INTEREST: Data collection at baseline and then after 24, 48 and 72h of pronation. We measured PaO2/FIO2, pH, lactate, PaCO2, SpO2, respiratory rate and the status of the patients at 28-day follow up. RESULTS: Patients were treated with helmet CPAP for a mean±SD of 7±2.7 days. Prone positioning was feasible in all patients, but in 7 of them dexmedetomidine improved comfort. PaO2/FIO2 improved from 107.5±20.8 before starting pronation to 244.4±106.2 after 72h (p<.001). We also observed a significantly increase in Sp02 from 90.6±2.3 to 96±3.1 (p<.001) and a decrease in respiratory rate from 27.6±4.3 to 20.1±4.7 (p=.004). No difference was observed in PaCO2 or pH. At 28 days two patients died after ICU admission, one was discharged in the main ward after ICU admission and eight were discharged home after being successfully managed outside the ICU. CONCLUSIONS: Helmet CPAP during pronation was feasible and safe in COVID-19 ARDS managed outside the ICU and sedation with dexmedetomidine safely improved comfort. We recorded an increase in PaO2/FIO2, SpO2 and a reduction in respiratory rate.

[Breve reseña histórica de la primera publicación del síndrome de insuficiencia respiratoria aguda]. / Brief historical review of the first publication of the acute respiratory insufficiency syndrome.

Acute respiratory distress syndrome was first described by Ashbaugh, Petty, Levine y Bigellow in 1967 writing in The Lancet. Their study was based on a case series of 12 patients with acute respiratory distress, cyanosis refractory to oxygen therapy, decreased lung compliance and diffuse infiltrates evident on the chest radiograph. Mortality was 58% with greater survival in five patients managed with mechanical ventilation and positive end expiratory pressure. Histopathology revealed heavy lungs, atelectasis, interstitial and alveolar edema, as well as hyaline membranes. 50 years after the publication of this article, advances in knowledge and management of this disease have been considerable, which is reflected in decreased mortality. The aim of this paper is to describe the original publication, recognize its importance and genious of its authors, to celebrate the 50th anniversary of this landmark and fundamental paper in intensive care medicine and honor their authors.

El síndrome de insuficiencia respiratoria aguda fue descrito por primera vez en la revista The Lancet en el año 1967 por Ashbaugh, Petty, Levine y Bigellow. Su estudio se fundamenta en la descripción de una serie de 12 enfermos que presentaban insuficiencia respiratoria aguda, cianosis refractaria a tratamiento con oxígeno, disminución de la distensibilidad pulmonar e infiltrados difusos en la radiografía de tórax. La mortalidad fue del 58%, con más oportunidad de sobrevida en aquellos enfermos manejados con ventilación mecánica y presión positiva al final de la espiración. El estudio histopatológico mostró pulmones de mayor peso, atelectasias, edema intersticial y alveolar, y membranas hialinas. A 50 años de su publicación, se han logrado importantes avances en el conocimiento y el tratamiento de esta enfermedad, lo que se ha reflejado en una disminución de la mortalidad. El objetivo de este trabajo es describir la publicación original y reconocer su importancia y la genialidad de los autores, para de esta manera celebrar el cincuentenario de este artículo clave y fundamental en la medicina intensiva y hacer un justo homenaje a los que participaron en su publicación.

Risk factors and outcomes of severe acute respiratory failure requiring invasive mechanical ventilation in cancer patients: A retrospective cohort study.

OBJECTIVES: To determine the risk factors for severe acute respiratory failure requiring invasive mechanical ventilation (SARF-MV) and its effect upon clinical outcomes in critically ill cancer patients. DESIGN: A retrospective cohort study was carried out. SETTING: A 12-bed oncological intensive care unit (ICU) from January 2014 to December 2015. PATIENTS: A total of 878 consecutive cancer patients were included. Patients with an ICU stay of ≤1 day were excluded. The final sample size was 691 patients. INTERVENTIONS: None. VARIABLES: Clinical variables at ICU admission were extracted from the medical records. The primary outcome was SARF-MV. We also measured ICU and hospital mortality, as well as length of stay. RESULTS: The SARF-MV rate was 15.8%. The multivariate analysis identified brain tumour (OR 14.54; 95%CI 3.86-54.77; p<0.0001), stage IV cancer (OR 3.47; 95%CI 1.26-9.54; p=0.016), sepsis upon admission (OR 2.28; 95%CI 1.14-4.56; p=0.020) and an APACHE II score≥20 points (OR 5.38; 95%CI 1.92-15.05; p=0.001) as being independently associated to SARF-MV. Compared with the patients without SARF-MV, those with SARF-MV had a prolonged length of ICU stay (p<0.0001), a lower ICU survival rate (p<0.0001) and a lower hospital survival rate (p<0.0001). CONCLUSIONS: A number of clinical factors are related to SARF-MV. In this regard, SARF-MV is a powerful factor independently correlated to poor outcomes. Future studies should investigate means for preventing SARF-MV in critically ill cancer patients, which may have an impact upon outcomes.