Raquel da Silva Townsend

Diagnostic accuracy of the Bedside Lung Ultrasound in Emergency protocol for the diagnosis of acute respiratory failure in spontaneously breathing patients

Objetivo: O ultrassom pulmonar (USP) a beira do leito e uma tecnica de imagem nao invasiva e prontamente disponivel que pode complementar a avaliacao clinica. O protocolo Bedside Lung Ultrasound in Emergency (BLUE, ultrassom pulmonar a beira do leito em situacoes de emergencia) demonstrou elevado rendimento diagnostico em pacientes com insuficiencia respiratoria aguda (IRpA). Recentemente, um programa de treinamento em USP a beira do leito foi implementado na nossa UTI. O objetivo deste estudo foi avaliar a acuracia do USP baseado no protocolo BLUE, quando realizado por medicos com habilidades basicas em ultrassonografia, para orientar o diagnostico de IRpA. Metodos: Ao longo de um ano, todos os pacientes adultos consecutivos respirando espontaneamente admitidos na UTI por IRpA foram prospectivamente inclusos. Apos treinamento, 4 operadores com habilidades basicas em ultrassonografia realizaram o USP em ate 20 minutos apos a admissao na UTI, cegados para a historia do paciente. Os diagnosticos do USP foram comparados aos diagnosticos da equipe assistente ao final da internacao na UTI (padrao-ouro). Resultados: Foram inclusos na analise 37 pacientes (media etaria: 73,2 ± 14,7 anos; APACHE II: 19,2 ± 7,3). O diagnostico do USP demonstrou concordância com o diagnostico final em 84% dos casos (kappa total: 0,81). As causas mais comuns de IRpA foram pneumonia (n = 17) e edema pulmonar cardiogenico (n = 15). A sensibilidade e a especificidade do USP comparado ao diagnostico final foram de 88% e 90% para pneumonia e de 86% e 87% para edema pulmonar cardiogenico, respectivamente. Conclusoes: O USP baseado no protocolo BLUE foi reproduzivel por medicos com habilidades basicas em ultrassonografia e acurado para o diagnostico de pneumonia e de edema pulmonar cardiogenico.Objective: Bedside lung ultrasound (LUS) is a noninvasive, readily available imaging modality that can complement clinical evaluation. The Bedside Lung Ultrasound in Emergency (BLUE) protocol has demonstrated a high diagnostic accuracy in patients with acute respiratory failure (ARF). Recently, bedside LUS has been added to the medical training program of our ICU. The aim of this study was to investigate the accuracy of LUS based on the BLUE protocol, when performed by physicians who are not ultrasound experts, to guide the diagnosis of ARF. Methods: Over a one-year period, all spontaneously breathing adult patients consecutively admitted to the ICU for ARF were prospectively included. After training, 4 non-ultrasound experts performed LUS within 20 minutes of patient admission. They were blinded to patient medical history. LUS diagnosis was compared with the final clinical diagnosis made by the ICU team before patients were discharged from the ICU (gold standard). Results: Thirty-seven patients were included in the analysis (mean age, 73.2 ± 14.7 years; APACHE II, 19.2 ± 7.3). LUS diagnosis had a good agreement with the final diagnosis in 84% of patients (overall kappa, 0.81). The most common etiologies for ARF were pneumonia (n = 17) and hemodynamic lung edema (n = 15). The sensitivity and specificity of LUS as measured against the final diagnosis were, respectively, 88% and 90% for pneumonia and 86% and 87% for hemodynamic lung edema. Conclusions: LUS based on the BLUE protocol was reproducible by physicians who are not ultrasound experts and accurate for the diagnosis of pneumonia and hemodynamic lung edema.

Reliability and validity of a scale for measurement of trunk mobility in Parkinson's disease: Trunk Mobility Scale

Axial rigidity is an important motor manifestation in Parkinsons disease (PD). Trunk mobility impairment can cause gait, balance and postural problems. However, only few instruments analyze the trunk mobility in PD patients. The aim of this study is to present a new Trunk Mobility Scale (TMS) and its validation in PD. The TMS constituted of dynamic tests involving trunk movements in sagittal, transversal and coronal planes. Ninety eight PD patients and 31 normal controls were analyzed. A strong correlation was found between the TMS scores and the Hoehn & Yahr staging scale (r: 0.72; p<0.01), motor Unified Parkinsons Disease Rating Scale (r: 0.84; p<0.01) and Schwab and England Activities of Daily Living (r: -0.72; p<0.01). The scale showed a satisfactory reliability rate (αCronbach: 0.85, ICC: 099). TMS is a simple and reliable instrument to evaluate trunk mobility impairment in patients with PD.

Out-of-bed extubation: a feasibility study

Objective In clinical intensive care practice, weaning from mechanical ventilation is accompanied by concurrent early patient mobilization. The aim of this study was to compare the success of extubation performed with patients seated in an armchair compared to extubation with patients in a supine position. Methods A retrospective study, observational and non-randomized was conducted in a mixed-gender, 23-bed intensive care unit. The primary study outcome was success of extubation, which was defined as the patient tolerating the removal of the endotracheal tube for at least 48 hours. The differences between the study groups were assessed using Students t-test and chi-squared analysis. Results Ninety-one patients were included from December 2010 and June 2011. The study population had a mean age of 71 years ± 12 months, a mean APACHE II score of 21±7.6, and a mean length of mechanical ventilation of 2.6±2 days. Extubation was performed in 33 patients who were seated in an armchair (36%) and in 58 patients in a supine position (64%). There were no significant differences in age, mean APACHE II score or length of mechanical ventilation between the two groups, and a similar extubation success rate was observed (82%, seated group versus 85%, supine group, p>0.05). Furthermore, no significant differences were found between the two groups in terms of post-extubation distress, need for tracheostomy, duration of mechanical ventilation weaning, or intensive care unit stay. Conclusion Our results suggest that the clinical outcomes of patients extubated in a seated position are similar to those of patients extubated in a supine position. This new practice of seated extubation was not associated with adverse events and allowed extubation to occur simultaneously with early mobilization.

Platypnea-orthodeoxia syndrome in patients presenting enlarged aortic root: case report and literature review

We describe herein a case of a patient who, when in orthostatic positions, had severe hypoxemia and ventilatory dysfunction. Although the severity of symptoms required hospitalization in an intensive care setting, the initial tests only identified the presence of enlarged aortic root, which did not explain the condition. The association of these events with an unusual etiology, namely intracardiac shunt, characterized the diagnosis of platypnea-orthodeoxia syndrome. The literature review shows that, with advancing research methods, there was a progressive increase in the identification of this condition, and this association should be part of the differential diagnosis of dyspnea in patients with enlarged aortic root.

Emprego de guia introdutor (bougie) artesanal para intubação em situação de emergência em pacientes que se apresentam com via aérea de difícil intubação: série de casos

BACKGROUND AND OBJECTIVES The incidence of difficult airway reaches 10% of emergency intubations. Although few studies address the use of handmade introducer guides in emergency and intensive care environment, there are descriptions of handmade guides available on the Internet. We describe a case series on the use of a handmade introducer guide (bougie) for emergency intubation in patients with difficult airway. CASE REPORT The handmade introducer guide was used in five consecutive patients with difficult airways, and clinical instability and in the absence of another immediate method to obtain an airway. This technique provided successful intubation and there were no complications. CONCLUSIONS The use of the handmade introducer guide can be a useful option for the management of difficult airways.

Use of a homemade introducer guide (bougie) for intubation in emergency situation in patients who present with difficult airway: a case series

BACKGROUND AND OBJECTIVES The incidence of difficult airway reaches 10% of emergency intubations. Although few studies address the use of handmade introducer guides in emergency and intensive care environment, there are descriptions of handmade guides available on the Internet. We describe a case series on the use of a handmade introducer guide (bougie) for emergency intubation in patients with difficult airway. CASE REPORT The handmade introducer guide was used in five consecutive patients with difficult airways, and clinical instability and in the absence of another immediate method to obtain an airway. This technique provided successful intubation and there were no complications. CONCLUSIONS The use of the handmade introducer guide can be a useful option for the management of difficult airways.