Documento de consenso de la Sociedad Española de Medicina Intensiva,Crítica,y Unidades Coronarias (SEMICYUC), la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) y la Sociedad Española de Anestesiología y Reanimación (SEDAR) sobre la traqueotomía en pacientes con COVID-19

The current COVID-19 pandemic has rendered up to 15% of patients under mechanical ventilation. Because the subsequent tracheotomy is a frequent procedure, the three societies mostly involved (SEMICYUC, SEDAR and SEORL-CCC) have setup a consensus paper that offers an overview about indications and contraindications of tracheotomy, be it by puncture or open, clarifying its respective advantages and enumerating the ideal conditions under which they should be performed, as well as the necessary steps. Regular and emergency situations are displayed together with the postoperative measures.     

SWIM技术治疗后循环大血管闭塞所致急性缺血性卒中的有效性和安全性观察

目的 观察SWIM技术治疗后循环大血管闭塞所致急性缺血性卒中的有效性及安全性。 方法 回顾性分析2017年2月-2018年11月于大连市中心医院采用SWIM技术治疗的后循环大血管闭 塞所致急性缺血性卒中患者的临床资料，评价该技术的疗效和安全性，并分析影响患者预后的因素。 观察指标为术后即刻成功再通（mTICI≥2b）、90 d良好预后（mRS评分≤2分），以及术后24 h任何颅内 出血、90 d全因死亡。 结果 共纳入35例患者，平均年龄66.1±12.1岁，男性26例（74.3%），基线NIHSS评分22（15～34）分。 术后即刻成功再通率为94.3%（33/35），90 d良好预后率为45.7%（16/35），24 h颅内出血率为17.1% （6/35），90 d全因死亡率为37.1%（13/35）。单因素分析显示，基线NIHSS评分较低（P =0.001）、基 线后循环ASPECTS评分较高（P =0.016）、发病至到院时间较短（P =0.039）、发病至再通时间较短 （P =0.047）、血管成功再通率较高（P =0.036）以及饮酒比例较低（P =0.042）与良好预后相关。 结论 使用SWIM技术治疗后循环急性缺血性卒中相对安全、有效。     

Impact of Using a Novel Gastric Feeding Tube Adaptor on Patient's Comfort and Air Leaks During Non-invasive Mechanical Ventilation

IntroductionThe presence of oral or naso-enteral probes during non-invasive mechanical ventilation (NIMV) increases the risk of leakage and patient discomfort. The objective of this study was to evaluate the effectiveness of a novel tube adapter for NIMV (TA-NIMV) in relation to leakage and comfort level.MethodsA non-randomized quasi-experimental design was performed in an adult intensive care unit of a highly complex hospital, in which patients were their own controls. We included adult patients who required NIV with oronasal mask and who simultaneously had oral or naso-enteric tubes. The interventions were as follows: every participant received two therapies, one with the TA-NIMV and one conventional therapy of NIMV (CT-NIMV). Comfort could be evaluated in 99 patients with a Glasgow Coma Scale of 15. The outcomes of interest was the average percentage of air leak and patient comfort during each intervention.Results196 patients were included in the study during a 16-month period. The mean air leak percentage was 9.2% [standard deviation (SD), 7.7] during TA-NIMV and 32.5% (SD, 12.5) during CT-NIMV (p < 0.001). 84.9% reported being comfortable or very comfortable during TA-VMNI. 66.7% Uncomfortable or Very uncomfortable during CT-NIMV (p < 0.001).ConclusionHigher comfort levels and lower air leakage volume percentages were achieved using the TA-NIMV than those achieved by CT-NIMV.     

Asthma and chronic obstructive pulmonary disease in the intensive care unit

The prevalence of asthma and chronic obstructive pulmonary disease is increasing worldwide. Patients who require intensive care management for acute exacerbations of these conditions represent a particular challenge. The requirement for invasive mechanical ventilation is associated with many pitfalls, as evidenced by the higher mortality rate of patients undergoing this intervention. This article describes the initial management, as well as escalating respiratory support and advanced pharmacological therapies, and the current evidence supporting these. In particular, the concept of dynamic hyperinflation is addressed as well as ventilation strategies that should be employed to prevent the development of complications.     

Custom-made 3D printed masks for children using non-invasive ventilation: a feasibility study of production method and testing of outcomes in adult volunteers

Abstract

Non-invasive ventilation (NIV) is assisted mechanical ventilation delivered via a facemask for people with chronic conditions that affect breathing. NIV is most commonly delivered via an interface (mask) covering the nose (nasal mask) or the nose and mouth (oronasal mask). The number of children in the UK requiring NIV is currently estimated to be around 5000. Mass-produced masks are available for both the adult and paediatric markets but masks that fit well are difficult to find for children who are small or have asymmetrical facial features. A good conforming fit between the mask and the patient’s face to minimise unintentional air leakage is essential to deliver the treatment effectively; most ventilators will trigger an alarm requiring action if such leakage is detected. We present an innovative use of 3D scanning and manufacturing technologies to deliver novel mask-face interfaces to optimise mask fit to the needs of individual patients. Ahead of planned user trials with paediatric patients, the project team trialled the feasibility of the process of creating and printing bespoke masks from 3D scan data and carried out testing of the masks in adult volunteers to select the strongest design concept for the paediatric trial. The evaluation of the process of designing a bespoke mask from scan data, arranging for its manufacture and carrying out user testing has been invaluable in gaining knowledge and discovering the pitfalls and timing bottlenecks in the processes. This allowed the team to iteratively refine the techniques and methods involved, informing user trials later on in the project. It has also provided indicative cost estimates for 3D printed mask prototype components which are useful in project decision making and trial planning. The value of the process extends to considerations for future implementation of the process within a clinical pathway.     

Application of a photoelectric magnifier to nasal injury in preterm infants receiving non-invasive ventilation: A prospective observational study

PurposeThis study was to explore a photoelectric magnifier assessing nasal injury in preterm infants receiving non-invasive ventilation (NIV) treatment, and to describe the occurrence status and risk factors of nasal injuries.DesignA prospective observational study.Subjectsand setting: Preterm infants admitted from the Second Affiliated Hospital of Wenzhou Medical University between October 2018 and October 2019.MethodsA continuously convenient sample of 127 preterm infants was included. When the infants were receiving NIV treatment, nursing staff checked nasal skin and mucosa daily with a photoelectric magnifier to confirm whether nasal injuries occurred. Meanwhile, a self-designed questionnaire was used to collect data. The Chi-square test, t-test, univariate and multiple logistic regression model were applied.ResultsA total of 127 preterm infants received 175 times NIV therapy, showing that the incidence of nasal injuries (infants number) was 27.6% (35/127) and the incidence of nasal injuries (ventilation cases) was 21.1% (37/175). Of the 37 cases of nasal injuries, 27 cases were I stage, while Ⅱ stage, Ⅲ stage and mucosa injuries appeared 2 cases, 2 cases and 6 cases. In the multivariate logistic analysis, nasal mask interface and NIV treatment more than seven days were independent risk factors affecting the occurrence of nasal injuries.ConclusionsThe premature infants who received nasal NIV treatment were susceptible to nasal injuries, and clinical nurse capable of identifying risk factors and inintervening should be strengthened to prevent the occurrence and progression.     

乌司他丁联合机械通气对社区获得性肺炎重症患儿动脉血气指标和炎症因子的影响

目的研究乌司他丁联合机械通气对社区获得性肺炎(CAP)重症患儿动脉血气指标和炎症因子的影响。方法选取社区获得性肺炎重症患儿100例,将其均分为对照组和观察组,对照组采用常规治疗加机械通气,观察组在对照组基础上使用乌司他丁治疗。比较两组临床有效率、并发症、临床症状消退时间、治疗前后动脉血二氧化碳分压(PaCO₂)、呼气末二氧化碳分压(PetCO₂)、C反应蛋白(CRP)、肿瘤坏死因子-α(TNF-α)水平,并对CAP严重程度评估。结果与对照组比较,观察组总有效率明显升高,咳嗽、发热、呼吸困难、肺部湿性啰音消退时间缩短(P＜0.05)。与治疗前比较,治疗后两组动脉血气指标及炎症因子水平明显下降,且观察组下降幅度明显大于对照组(P＜0.05)。与治疗前比较,治疗后两组CAP严重程度均有所改善,且观察组改善情况明显优于对照组(P＜0.05)。结论乌司他丁联合机械通气治疗CAP重症患儿能提高临床治疗有效率,改善血气指标,降低炎症因子水平,并发症发生率低,具有较高的临床应用价值。     

乙酰唑胺对慢性阻塞性肺疾病无创通气酸碱平衡的影响

目的探讨乙酰唑胺对慢性阻塞性肺疾病(COPD)无创通气患者酸碱平衡的影响。方法选择2010-2014年急性加重期COPD患者70例,分为乙酰唑胺治疗组(研究组,38例)和非乙酰唑胺治疗组(对照组,32例),测定患者服用乙酰唑胺0、24、48 h后的PaCO_2、HCO_3~-,以及血清、尿液的pH值。结果研究组患者治疗后24、48 h的PaCO_2、HCO_3~-、血清pH值均降低(P<0.05),尿pH值升高(P<0.05),但治疗24 h与48 h比较差异无统计学意义(P>0.05),对照组仅在治疗48 h时HCO_3~-降低,尿pH升高(P<0.05)。研究组无创通气治疗时间较对照组缩短[(5.53±1.72)d vs.(18.81±4.08)d,P<0.001],但两组住院时间比较差异无统计学意义(t=0.418,P=0.877)。结论乙酰唑胺能有效改善COPD患者的PaCO_2、HCO_3~-及血清和尿液的pH值,连续2d服用可缩短无创通气治疗时间。     

Efficacy and safety of tirofiban therapy in patients receiving endovascular treatment after large vessel ischaemic stroke: A systematic review and meta-analysis

BackgroundAlthough tirofiban therapy is considered a potentially effective treatment to reduce the incidence of thrombotic complications in patients receiving endovascular treatment (EVT), the safety and efficacy of tirofiban remain controversial. Our objective was to investigate the efficacy and safety of EVT plus tirofiban therapy in patients with emergent large artery occlusion.MethodsRelevant articles from randomized controlled trials (RCTs) or observational studies that compared treatment with tirofiban to treatment without tirofiban in patients undergoing EVT were retrieved from the PubMed and Embase databases. We calculated odds ratios (ORs) with corresponding 95% confidence intervals (CIs) for the safety and efficacy outcomes based on a random effects model.ResultsTwelve studies including 2533 patients were identified for the analysis. Overall, the risk of fatal intracranial haemorrhage (ICH) was higher for the treatment with tirofiban group than for the treatment without tirofiban group in patients with large artery occlusion who underwent EVT (p = 0.002), whereas the risk of any ICH, symptomatic ICH, parenchymal haematoma type 2, in-hospital mortality and 3-month mortality did not differ significantly (p > 0.05). No significant differences in reocclusion rate, recanalization rate or excellent functional outcome were found between the patients treated with or without tirofiban, but significantly favourable functional outcome at 3 months occurred in the tirofiban group (p = 0.017).ConclusionsTirofiban administration in patients receiving EVT significantly improved 3-month favourable functional outcomes, whereas an increased risk of fatal ICH was also observed. Further rigorous trials are needed to verify the safety of tirofiban.     

Are dental patients able to perceive erosive tooth wear on anterior teeth?: An internet-based survey assessing awareness and related action

BackgroundErosive tooth wear (ETW) is irreversible loss of dental hard tissue. The authors examined patients’ ability to recognize ETW relative to sound teeth and teeth with caries.MethodsUsing Amazon’s crowdsourcing service, the authors recruited participants (N = 623) to view standardized images of buccal surfaces of teeth (sound, ETW, or caries). Participants reported whether a dental condition existed (yes or no), likelihood to seek care, and esthetic attractiveness for teeth with no, initial, moderate, or severe signs of ETW or caries.ResultsDental patients showed poor recognition of cases of ETW, especially compared with sound and caries-affected teeth at each level of severity. Patients were less likely to schedule a dental appointment for care or treatment of teeth with ETW than for teeth with caries at each level of severity. Patients also found ETW more esthetically attractive than caries at each level of severity and found initial ETW more attractive than sound teeth.ConclusionsDental patients struggle to recognize ETW, in general and compared with caries, at each level of severity and particularly for early stages of ETW. These recognition difficulties likely arise, in part, from tooth esthetic attractiveness standards (smooth and shiny teeth look more esthetic), possibly leading to lack of appropriate care-seeking behavior.Practical ImplicationsThis internet-based tool may be used to assess dental patients’ awareness and ability to recognize cases of ETW. Improved patient awareness might lead to seeking professional care to prevent or delay ETW progression.