Angela Cervera

Ventilación mecánica no invasiva en la Comunidad Valenciana: de la teoría a la práctica

OBJECTIVE To obtain representative data on the frequency of use and availability of resources for noninvasive mechanical ventilation (NIV) in hospitals (acute respiratory failure) and at home (chronic respiratory failure). METHOD We sent a purpose-designed questionnaire to all the hospitals in the Autonomous Community of Valencia, Spain and followed up with a telephone interview. RESULTS Seventy percent of the hospitals responded to the survey. NIV was used to treat patients with acute respiratory episodes in 100% of the intensive care units and in 88% of the respiratory medicine departments. The most common diseases were chronic obstructive pulmonary disease (COPD) (mean [SD] 60% [20%]), obesity hypoventilation syndrome (22% [12%]), neuromuscular diseases (6.5% [8%]), and kyphoscoliosis (6.5% [7%]). Other diseases accounted for 4% [11%] of cases. Emergency departments used NIV in 69% of patients, internal medicine departments in 37%, hospital-based home care units in 19%, and other departments in 12%. None of the hospitals that responded to the survey had an intermediate care unit and considerable differences were found in terms of NIV systems used. Home NIV was provided by 88% of hospitals. Patients using home NIV had COPD (31% [18%]), obesity hypoventilation syndrome (30% [18%]), neuromuscular diseases (16% [23%]), kyphoscoliosis (12% [10%]), and other diseases (11% [17%]). Patient numbers varied greatly from one hospital to the next. Home NIV was delivered using a nasal interface in 65% (32%) of cases, an oral-nasal interface in 33% (33%), a tracheostomy tube in 2% (3%), and a mouthpiece in 1% (32%). Only 31.3% of hospitals has a specialized home NIV unit. Home monitoring was performed mainly by service providers. We calculated that home NIV was used in 29 individuals per 100 000 population. Only 50% of the respiratory medicine departments surveyed had written hospitalization protocols; the corresponding percentages for other departments were 44% for home care units, 19% for emergency departments, and 12% for internal medicine departments. CONCLUSIONS We observed differences in the type of requirement used, and considerable deficiencies in the availability of human and material resources and support systems. Although NIV is mostly used in hospitals to treat patients with acute respiratory failure, home NIV is also very common and is characterized by greater variability in terms of the number and type of patients. We also observed deficiencies in terms of written protocols for patients with acute and chronic disease.

Hypoxemia Adds to the CURB-65 Pneumonia Severity Score in Hospitalized Patients With Mild Pneumonia

BACKGROUND: Hypoxemia may influence the prognosis of patients with mild pneumonia, regardless of the initial CURB-65 score (confusion, blood urea nitrogen > 20 mg/dL, respiratory rate > 30 breaths/min, blood pressure < 90/60 mm Hg, and age ≥ 65 y). OBJECTIVE: To determine the risk factors associated with hypoxemia and the influence of hypoxemia on clinical outcomes in hospitalized patients with mild pneumonia. METHODS: We performed a multicenter prospective cohort study of 585 consecutive hospitalized patients with mild pneumonia (CURB-65 groups 0 and 1). We stratified the patients according to the presence of hypoxemia, defined as a PaO2/FIO2 < 300 mm Hg on admission. We assessed the risk factors associated with hypoxemia, hypoxemias influence on the course of pneumonia, and clinical outcomes (mortality, hospital stay, and need for intensive care unit admission), with multivariable regression. RESULTS: Fifty percent of the patients (294 cases) had hypoxemia on admission. The risk factors independently associated with hypoxemia were: bilateral radiological involvement (odds ratio 2.8, 95% CI 1.1–7.5), history of COPD (odds ratio 2.5, 95% CI 1.4–4.3), and hypoalbuminemia (odds ratio 2.0, 95% CI 1.1–3.5). The hypoxemic patients had longer hospital stay, higher intensive care unit admission rate, higher rate of severe sepsis, and higher mortality than the non-hypoxemic patients. CONCLUSIONS: Hypoxemia in patients with mild pneumonia is independently associated with several adverse clinical and radiological variables, and the hypoxemic patients had worse clinical outcomes than the non-hypoxemic patients. Therefore, additional attention should be paid to the presence of hypoxemia, regardless of a low CURB-65 score.

Accuracy of PaO2/FiO2 calculated from SpO2 for severity assessment in ED patients with pneumonia

Assessment of oxygenation in patients with community‐acquired pneumonia is critical for treatment. The accuracy of percutaneous oxygen saturation (SpO2) determined by pulse oximetry is uncertain, and it has limited value in patients receiving supplemental oxygen. We hypothesized that calculation of partial arterial oxygen concentration/inspired oxygen faction (PaO2/FiO2) from SpO2 by the Ellis or Rice equations might adequately correlate with PaO2/FiO2 measured by arterial blood gases.

[Noninvasive mechanical ventilation in Valencia, Spain: from theory to practice].

Abstract Objective To obtain representative data on the type, frequency of use, and availability of resources for noninvasive mechanical ventilation (NIV) in hospitals (acute respiratory failure) and at home (chronic respiratory failure). Method We sent a purpose-designed questionnaire to all the hospitals in the Autonomous Community of Valencia, Spain and followed up with a telephone interview. Results Seventy percent of the hospitals responded to the survey. NIV was used to treat patients with acute respiratory episodes in 100% of the intensive care units and in 88% of the respiratory medicine departments. The most common diseases were chronic obstructive pulmonary disease (COPD) (mean [SD] 60% [20%]), obesity hypoventilation syndrome (22% [12%]), neuromuscular diseases (6.5% [8%]), and kyphoscoliosis (6.5% [7%]). Other diseases accounted for 4% [11%] of cases. Emergency departments used NIV in 69% of patients, internal medicine departments in 37%, hospital-based home care units in 19%, and other departments in 12%. None of the hospitals that responded to the survey had an intermediate care unit and considerable differences were found in terms of NIV systems used. Home NIV was provided by 88% of hospitals. Patients using home NIV had COPD (31% [18%]), obesity hypoventilation syndrome (30% [18%]), neuromuscular diseases (16% [23%]), kyphoscoliosis (12% [10%]), and other diseases (11% [17%]). Patient numbers varied greatly from one hospital to the next. Home NIV was delivered using a nasal interface in 65% (32%) of cases, an oral-nasal interface in 33% (33%), a tracheostomy tube in 2% (3%), and a mouthpiece in 1% (3%). Only 31.3% of hospitals has a specialized home NIV unit. Home monitoring was performed mainly by service providers. We calculated that home NIV was used in 29 individuals per 100 000 population. Only 50% of the respiratory medicine departments surveyed had written NIV protocols; the corresponding percentages for other departments were 44% for home care units, 19% for emergency departments, and 12% for internal medicine departments. Conclusions We observed differences in the type of equipment used, and considerable deficiencies in the availability of human and material resources and support systems. Although NIV is mostly used in hospitals to treat patients with acute respiratory failure, home NIV is also very common and is characterized by greater variability in terms of the number and type of patients. We also observed deficiencies in terms of written protocols for patients with acute and chronic disease.

Does prolonged onset of symptoms have a prognostic significance in community-acquired pneumonia?

Severity assessment is made at the time of the initial clinical presentation in patients with community‐acquired pneumonia (CAP). It is unclear how the gap between time of presentation and duration of symptoms onset may impact clinical outcomes. Here we evaluate the association of prolonged onset of symptoms (POS) and the impact on clinical outcomes among hospitalized patients with CAP.

Survival benefit of beta-lactam plus macrolide combined therapy versus beta-lactam plus quinolones in hospitalized community-acquired pneumonia

Background: Guidelines do not state a specific advantage regarding the addition of macrolides or quinolones to beta-lactams in empirical combined antibiotic therapy. But little is known if there exists a survival benefit of the different regimes. We aim to evaluate the impact in mortality of two different guidelines-recommended combined antibiotic therapies. Methods: We stratified patients from a prospective multicenter cohort according to the use of combined antibiotic treatment [beta-lactam plus macrolide (B+M) or beta-lactam plus quinolones (B+Q)]. Demographic, clinical, radiographic, microbiologic and complication characteristics were analyzed. Outcomes were analyzed performing a multivariate analysis using the different antibiotic combinations as the dependent variable. Results: From an initial population of 2,013 patients, 758 (37.6%) were treated with combination therapy: B+M, 575 (75.9%); B+Q 183 (24.1%). Comorbities were more frequent in patients treated with B+Q but this was not confirmed by multivariate analysis. B+M showed a protective effect regarding the development of acute kidney injury (OR 0.51, 95%CI 0.28-0.93) and ICU admission (OR 0.43, 95%CI 0.22-0.85). Mortality was significantly higher in B+Q group (11.6 vs 4.6, p Conclusions: Empiric combination antibiotic therapy with beta-lactams plus macrolides is associated with better survival than beta-lactam plus quinolones in CAP. Randomized control trials are needed to confirm this finding.

Differential Characteristics of Patients With Mild Acute Respiratory Distress Syndrome Due to Community-Acquired Pneumonia Admitted to ICU

Aims: To determine the characteristics of patients with community-acquired pneumonia and mild acute respiratory distress syndrome (CAP-mild ARDS) who require ICU admission. Methods: Analysis of demographic characteristics, comorbidities, etiology and outcomes of patients with CAP-mild ARDS admitted to ICU comparing to those who did not. X2, t student and logistic regression were used to compare both groups. Results: In a series of 1314 CAP patients, 164 (12.5%) showed mild ARDS at admission, of whom 25% (41 cases) were admitted to ICU. ICU patients were younger [57.5 (16) vs. 68.7 (15.4) years, p<0.01], and had a lower duration of symptoms [3.4 (1.9) vs. 6.5 (6) days, p<0.01] than no ICU patients. Pneumonia severity was higher in ICU group (PSI V: 39% vs. 17.1%; p=0.004). Multivariate analysis showed that age <65 years (OR 9.79, 95%CI 3.13-30.68), septic shock (OR 7.76, 95%CI 2.36-25.50), and PSI V (OR 7.28, 95%CI 2.16-24.56) were associated with ICU admission in CAP-mild ARDS patients; they showed a longer length of stay (LOS) [27 (28.6) vs. 10.6 (6) days, p<0.01] and more complications compared to those that were treated in a general ward (100% vs. 4.9%, p<0.01). Mortality was higher in ICU CAP mild-ARDS group but not statistically significant (17.1% vs. 7.3%, p= 0.068). Conclusions: 1-In our series, 25% of patients with CAP-mild ARDS required ICU admission. 2- Age <65 years, the presence of septic shock, and pneumonia severity were factors that determine ICU admission of CAP-mild ARDS patients in our series. 3-Patients with CAP-mild ARDS and ICU admission showed more complications and longer LOS without differences in mortality.