Interacción paciente-ventilador en ventilación mecánica no invasiva

Noninvasive mechanical ventilation is one more step in the treatment of patients with acute respiratory failure. In addition to gas exchange disorders, its primary indication to initiate it is the presence of signs of respiratory muscles fatigue. To assure successful mechanical ventilation, the ventilator and patient must be synchronized, that is, the effort the patient makes to start inspiration is recognized by the ventilator and it quickly delivers gas flow, that the flow provided by the ventilator adapts to the flow need of the patient during delivery of gas phase and that the ventilator recognizes the cessation of inspiratory activity by the patient, ends the delivery of gas and opens the expiratory valve to allow the patient expiration. This sequence of events, which seem so logical, is almost never achieved in the clinical practice, commonly observing some asynchrony in ventilated patients. The presence of patient-ventilator asynchrony leads to increased breathing work, which would lead to the failure of the main objective of ventilatory support, that is none other than decline in the patient's respiratory work.     

Factores asociados a mortalidad intrahospitalaria en pacientes adultos mayores con asistencia ventilatoria mecánica invasiva en el servicio de urgencias

AimsTo identify factors associated with in-hospital mortality, to estimate the intubation rate and to describe in-hospital mortality in patients over 65 years old with invasive mechanical ventilation (IMV) in the emergency department (ED).MethodsRetrospective cohort study of patients over 65 years old, who were intubated in an ED of a high complexity hospital between 2016 and 2018. Demographic data, comorbidities, and severity scores on admission were described. Bivariate and multivariate analyses were performed with logistic regression according to mortality and possible confounders.ResultsA total of 285 patients with a mean age of 80 years required IMV in the emergency department, for a median of 3 days, and with a mean APACHE II score of 20 points of severity. The IMV rate was .48% (95% CI .43-.54), and 55.44% (158) died. Mortality-associated factors after age and sex adjustment were stroke (OR 2.13; 95%CI 1.21-3.76), chronic kidney failure, (OR 4.,38; 95%CI 1.91-10.04), Charlson index (OR 1.19; 95%CI 1.02-1.38), APACHE II score (OR 1.07; 95%CI 1.02-1.12), and SOFA score (OR 1.14; 95%CI 1.03-1.27).DiscussionOur IMV rate was lower than that stated by Johnson et al. in the United States in 2018 (.59%). In-hospital mortality in our study exceeded that predicted by the APACHE II score (40%) and SOFA (33%). However it was consistent with that reported by Lieberman et al. in Israel and Esteban et al. in the United States.ConclusionsAlthough the IMV rate was low in the ED, more than half the patients died during hospitalization. Pre-existing cerebrovascular and renal diseases and high results in the comorbidities index and severity scores on admission were independent factors associated with in-hospital mortality.     

Evolución de la fuerza muscular en paciente críticos con ventilación mecánica invasiva

ObjectiveTo assess the evolution of muscle strength in critically ill patients with mechanical ventilation (MV) from withdrawal of sedatives to hospital discharge.Material and methodA cohort study was conducted in two intensive care units in the Hospital Universitari de Bellvitge from November 2011 to March 2012. Inclusion criteria: Consecutive patients with MV > 72 h. Dependent outcome: Muscle strength measured with the Medical Research Council (MRC) scale beginning on the first day the patient was able to answer 3 out of 5 simple orders (day 1), every week, at ICU discharge and at hospital discharge or at day 60 Independent outcomes: factors associated with muscle strength loss, ventilator-free days, ICU length of stay and hospital length of stay. The patients were distributed into two groups (MRC< 48, MRC ≥ 48) after the first measurement.ResultsThirty-four patients were assessed. Independent outcomes associated with muscle strength weakness were: days with cardiovascular SOFA >2 (P<.001) and days with costicosteroids (P<.001). Initial MRC in MRC<48 group was 38 (27-43), and 52 (50-54) in MRC ≥ 48. The largest muscle strength gain was obtained the first week (31% versus 52%). A MRC < 48 value was associated with more MV days (P<.007) and a longer ICU stay. (P<.003).ConclusionThe greatest muscle strength gain after withdrawing of the sedatives was achieved in the first week. Muscle strength loss was associated with a cardiovascular SOFA > 2 and costicosteroids. Patients with a MRC < 48 required more days with MV and a longer ICU stay.     

Efecto de la música sobre la ansiedad y el dolor en pacientes con ventilación mecánica

The power of music to relieve anxiety or pain has been widely used throughout history.ObjectiveTo evaluate effects of music on anxiety and pain in patients on invasive mechanical ventilation.DesignA randomized controlled trial with repeated measures.Material and methodThis was a randomized, experimental prospective study in a tertiary hospital conducted from January 2009 to June 2010. The sample was made up of 44 participants. Intervention consisted in a 30-minute musical session in which the subject used a headset and was in an individual room. For the control group, the usual setting of an intensive care unit was maintained unchanged. Each patient underwent a minimum of 3 and maximum of 5 sessions. The patient per se selected the music from among a selection prepared by the investigator team. Anxiety and pain and hemodynamic variables of heart rate, respiratory rate systolic and diastolic blood pressure were measured at baseline, after the music session and then one-hour later.ResultsMusic therapy significantly decreased anxiety score (P = .000) when measured with the State-Trait Anxiety Inventory (STAI) scale. There were no differences in pain in the experimental group (P = .157) when measured with the visual analogue scale. No summative effects were demonstrated during multiple sessions.ConclusionMusic reduces anxiety in patients with invasive mechanical ventilation. Invasive mechanical ventilation can be established as a non-pharmacologic tool added to the available therapeutic options.     

Decúbito prono en pacientes COVID-19 con síndrome de distrés respiratorio agudo y ventilación mecánica invasiva

ObjectiveTo identify adverse events related to prone positioning in COVID-19 patients with severe disease and acute respiratory distress syndrome, to analyze the risk factors associated with the development of anterior pressure ulcers, to determine whether the recommendation of prone positioning is associated with improved clinical outcomes.MethodsRetrospective study performed in 63 consecutive patients with COVID-19 pneumonia admitted to intensive care unit on invasive mechanical ventilation and treated with prone positioning between March and April 2020. Association between prone-related pressure ulcers and selected variables was explored by the means of logistic regression.ResultsA total of 139 proning cycles were performed. The mean number of cycles were 2 [1-3] and the mean duration per cycle was of 22 hours [15-24]. The prevalence of adverse events this population was 84.9%, being the physiologic ones (i.e., hypo/hypertension) the most prevalent. 29 out of 63 patients (46%) developed prone-related pressure ulcers. The risk factors for prone-related pressure ulcers were older age, hypertension, levels of pre-albumin < 21 mg/dL, the number of proning cycles and severe disease. We observed a significant increase in the PaO2/FiO2 at different time points during the prone positioning, and a significant decrease after it.ConclusionsThere is a high incidence of adverse events due to PD, with the physiological type being the most frequent. The identification of the main risk factors for the development of prone-related pressure ulcers will help to prevent the occurrence of these lesions during the prone positioning. Prone positioning offered an improvement in the oxygenation in these patients.     

Efectividad de un programa de rehabilitación respiratoria en pacientes con enfermedad pulmonar obstructiva crónica

Objective

To evaluate the effectiveness of the multidisciplinary respiratory rehabilitation (RR) programme in patients with severe or very severe chronic obstructive pulmonary disease pre the RR programme, at the end of the programme and one year after the RR, measuring changes in ability to exercise (walking test), effort tolerance(forced expiratory volume (FEV1)) and health-related quality of life.

Efecto del entrenamiento de resistencia en centros o domiciliario en la fuerza muscular y pico de VO2 en pacientes con insuficiencia cardíaca: revisión sistemática y metaanálisis

ObjectiveTo analyze the components of resistance training (RT) exercises and evaluate the effects of RT on improving muscle strength and oxygen consumption (VO₂) peak based on either center-based rehabilitation or home-based rehabilitation in patients with heart failure with reduced ejection fraction (HFrEF).MethodsAccording to the PRISMA guidelines, articles were searched through five databases, including Embase, MEDLINE, CINAHL, PEDro and Cochrane. RevMan 5.3 software was used to perform the meta-analysis.ResultsNine randomized controlled trial studies met the study criteria, including a total of 299 respondents. In the center-based respondents (n = 81 for intervention group vs. n = 81 for control group), RT resulted in significant effects on both muscle strength of lower extremity (SDM = 1.46, 95% CI = 0.41–2.50, n = 151) and upper extremity (SDM = 0.46, 95% CI = 0.05–0.87, n = 97) and VO₂ peak (MD = 1.45 ml/kg/min, 95% CI = 0.01–2.89, n = 114). In the home-based respondents (n = 71 for intervention group vs. n = 66 for control group), RT resulted in significant effects on muscle strength of both lower extremity (SDM = 0.58, 95% CI: 0.20–0.97, n = 113) and upper extremity (SDM = 0.84, 95% CI: 0.24–1.44, n = 47) and VO₂ peak (MD = 5.43 ml/kg/min, 95% CI: 0.23–10.62, n = 89).ConclusionThe RT exercise could increase muscle strength and VO₂ peak at either center-based or home-based rehabilitation and should be considered as a part of the care of patients with HFrEF.     

Evaluación de un programa de prevención de neumonía asociada a ventilación mecánica (NAVM): resultados al año

IntroductionWith the aim of improving healthcare quality and safety of the patient, a multidisciplinary program was introduced and directed at the prevention of Mechanical Ventilation Associated Pneumonia (MVAP), following a continuous improvement cycle of PDCA (Plan, Do, Check, Adjust). An analysis of the measures applied is presented.AimsEvaluation of the MVAP prevention program: theoretical knowledge, and fulfilment of the measures proposed.Analysis of the annual MVAP variation.Material and methodsAcquired knowledge was evaluated through questionnaires. The results of the fulfilment of the measures proposed (elevation of the bed headboard, optimal pressure of the cuff, and oral hygiene) were analysed through monthly audits. Calculation of annual rate of MVAP and respiratory infections.ResultsThe knowledge of MVAP and its prevention had improved (P<.05). Preventive measures: Significant difference in the maintenance of headboard at >30° (P<.05) and in the performing of oral hygiene (P<.05). Improvement in the maintenance of cuff pressure between 20 and 30 cm H2O (P=.13).Decline and stabilization of yearly rate of MVAP (0.7%).ConclusionsThe introduction of a training program and of a set of preventive non-pharmacological measures decreased the incidence of MVAP.     

Evaluación del efecto de la terapia de relajación en pacientes con hipertensión arterial

ObjectivesTo evaluate whether the application of a relaxation therapy reduces the blood pressure in hypertensive patients and whether there is improvement in several parameters which can influence blood pressure such as anxiety, quality of life and sleep.MethodsA quasi-experimental study (measures before-after) was performed in 25 Primary Care patients with hypertension poorly controlled by pharmacological treatment. The intervention consisted of relaxation therapy composed of 3 techniques: passive relaxation of Schwartz-Haynes, diaphragmatic breathing and imaginary visualization. A total of 14 group sessions of 30 min each (2/week) were conducted. Systolic and diastolic blood pressure were taken at the beginning and end of the relaxation programme implemented and after each of the programme sessions. The Pittsburgh Sleep Quality, Quality of Life Hypertension, State-Trait Anxiety and Perceived Stress questionnaires were used to measure psychosocial parameters.ResultsAfter intervention, a reduction in systolic blood pressure of 20 mmHg (p < .001) and of 8 mmHg (p < .001) in diastolic blood pressure was observed. Regarding other factors, sleep quality (p < .001), quality of life (p< .001) and state anxiety (p = .004) were significantly improved.ConclusionsRelaxation therapy had positive effects in improving blood pressure parameters, as well as the other factors evaluated. In our opinion, such strategies should be evaluated more thoroughly to consider their inclusion in Primary Care.