| Extubación de pacientes con debilidad neuromuscular. Un manejo nuevo de manejo |
Extubation of Patients With Neuromuscular Weakness A New Management Paradigm John Robert Bach, MD, Miguel R. Gonçalves, PT, Irram Hamdani, MD and Joao Carlos Winck, MD, PhD Chest 2010;137;1033-1039;Abstract Background: Successful extubation conventionally necessitates the passing of spontaneous breathing trials (SBTs) and ventilator weaning parameters. We report successful extubation of patients with neuromuscular disease (NMD) and weakness who could not pass them. Methods: NMD-specific extubation criteria and a new extubation protocol were developed. Data were collected on 157 consecutive "unweanable" patients, including 83 transferred from other hospitals who refused tracheostomies. They could not pass the SBTs before or after extubation. Once the pulse oxyhemoglobin saturation (SpO 2) was maintained at ≥ 95% in ambient air, patients were extubated to full noninvasive mechanical ventilation (NIV) support and aggressive mechanically assisted coughing (MAC). Rather than oxygen, NIV and MAC were used to maintain or return the SpO 2 to ≥ 95%. Extubation success was defined as not requiring reintubation during the hospitalization and was considered as a function of diagnosis, preintubation NIV experience, and vital capacity and assisted cough peak flows (CPF) at extubation. Results: Before hospitalization 96 (61%) patients had no experience with NIV, 41 (26%) used it < 24 h per day, and 20 (13%) were continuously NIV dependent. The first-attempt protocol extubation success rate was 95% (149 patients). All 98 extubation attempts on patients with assisted CPF ≥ 160 L/m were successful. The dependence on continuous NIV and the duration of dependence prior to intubation correlated with extubation success (P < .005). Six of eight patients who initially failed extubation succeeded on subsequent attempts, so only two with no measurable assisted CPF underwent tracheotomy. Conclusions: Continuous volume-cycled NIV via oral interfaces and masks and MAC with oximetry feedback in ambient air can permit safe extubation of unweanable patients with NMD. http://chestjournal.chestpubs.org/content/137/5/1033.full.pdf+html |
| Falla respiratoria hipoxémica severa: parte 2- estrategias no ventilatorias |
Severe hypoxemic respiratory failure: part 2--nonventilatory strategies. Raoof S, Goulet K, Esan A, Hess DR, Sessler CN. Division of Pulmonary and Critical Care Medicine, New York Methodist Hospital, 506 Sixth St, Brooklyn, NY 11215, USA. sur9016@nyp.orgChest. 2010 Jun;137(6):1437-48.Abstract ARDS is characterized by hypoxemic respiratory failure, which can be refractory and life-threatening. Modifications to traditional mechanical ventilation and nontraditional modes of ventilation are discussed in Part 1 of this two-part series. In this second article, we examine nonventilatory strategies that can influence oxygenation, with particular emphasis on their role in rescue from severe hypoxemia. A literature search was conducted and a narrative review written to summarize the use of adjunctive, nonventilatory interventions intended to improve oxygenation in ARDS. Several adjunctive interventions have been demonstrated to rapidly ameliorate severe hypoxemia in many patients with severe ARDS and therefore may be suitable as rescue therapy for hypoxemia that is refractory to prior optimization of mechanical ventilation. These include neuromuscular blockade, inhaled vasoactive agents, prone positioning, and extracorporeal life support. Although these interventions have been linked to physiologic improvement, including relief from severe hypoxemia, and some are associated with outcome benefits, such as shorter duration of mechanical ventilation, demonstration of survival benefit has been rare in clinical trials. Furthermore, some of these nonventilatory interventions carry additional risks and/or high cost; thus, when used as rescue therapy for hypoxemia, it is important that they be demonstrated to yield clinically significant improvement in gas exchange, which should be periodically reassessed. Additionally, various management strategies can produce a more gradual improvement in oxygenation in ARDS, such as conservative fluid management, intravenous corticosteroids, and nutritional modification. Although improvement in oxygenation has been reported with such strategies, demonstration of additional beneficial outcomes, such as reduced duration of mechanical ventilation or ICU length of stay, or improved survival in randomized controlled trials, as well as consideration of potential adverse effects should guide decisions on their use. Various nonventilatory interventions can positively impact oxygenation as well as outcomes of ARDS. These interventions may be considered for use, particularly for cases of refractory severe hypoxemia, with proper appreciation of potential costs and adverse effects. http://chestjournal.chestpubs.org/content/137/6/1437.full.pdf+html |
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