Ricardo Coelho Reis

Influência das máscaras facial total, facial e nasal nos efeitos adversos agudos durante ventilação não-invasiva

OBJECTIVE Failure of noninvasive ventilation (NIV) has been associated with short-term adverse effects related to the use of masks. The aim of this study was to compare the incidence, type and intensity of adverse effects, as well as the comfort, of total face masks (TFMs), facial masks (FMs) and nasal masks (NMs) during NIV. METHODS This was a randomized crossover trial involving 24 healthy volunteers submitted to six sessions of NIV in bilevel positive airway pressure mode using the TFM, FM and NM masks at low and moderate-to-high pressure levels. A written questionnaire was applied in order to evaluate eleven specific adverse effects related to the use of the masks. Comfort was assessed using a visual analog scale. The CO2 exhaled into the ventilator circuit was measured between the mask and the exhalation port. RESULTS The performance of the TFM was similar to that of the NM and FM in terms of comfort scores. Higher pressure levels reduced comfort and increased adverse effects, regardless of the mask type. When the TFM was used, there were fewer air leaks and less pain at the nose bridge, although there was greater oronasal dryness and claustrophobia. Air leaks were most pronounced when the FM was used. The partial pressure of exhaled CO2 entering the ventilator circuit was zero for the TFM. CONCLUSIONS The short-term adverse effects caused by NIV interfaces are related to mask type and pressure settings. The TFM is a reliable alternative to the NM and FM. Rebreathing of CO2 from the circuit is less likely to occur when a TFM is used.

Continuous Positive Airway Pressure Effects on Regional Lung Aeration in Patients With COPD: A High-Resolution CT Scan Study

BACKGROUND The effects of nasal continuous positive airway pressure (CPAP) on the lung parenchyma of patients with COPD, to our knowledge, have never been assessed by high-resolution CT (HRCT) scanning. METHODS HRCT scans were obtained at the apex, hilum, and basis of the lungs at functional residual capacity while on spontaneous respiration and at the end of CPAP trials of 5 cm water (H(2)O), 10 cm H(2)O, and 15 cm H(2)O in 11 stable patients with COPD and eight healthy volunteers. Lung aeration was assessed by quantitative density parameters and by qualitative analysis of each CT image after processing by means of a density-based color-mask computational algorithm. The quantitative parameters were density histograms, the relative area of the lungs with attenuation values < -950 Hounsfield units (percentage of hyperaerated areas) and the 15th percentile (the density value separating the 15% voxels of least density). RESULTS A CPAP of 5 cm H(2)O caused little increase in lung aeration in both groups, but in some patients with COPD, CPAP deflated some regions of the lungs. CPAP levels of 10 cm H(2)O and 15 cm H(2)O increased the emphysematous zones in all sectors of the lungs, including dorsal and apical regions in patients with COPD compared to little hyperaeration predominantly in the ventral areas in healthy volunteers. CONCLUSIONS Nasal CPAP causes variable effects on regional lung aeration in relation to the applied pressure and the regional distribution of emphysema in patients with COPD. Low pressure levels may cause regional lung deflation in some patients. High levels increase the emphysematous areas wherever they are located inside the lungs.

Original ResearchCOPDContinuous Positive Airway Pressure Effects on Regional Lung Aeration in Patients With COPD: A High-Resolution CT Scan Study

BACKGROUND The effects of nasal continuous positive airway pressure (CPAP) on the lung parenchyma of patients with COPD, to our knowledge, have never been assessed by high-resolution CT (HRCT) scanning. METHODS HRCT scans were obtained at the apex, hilum, and basis of the lungs at functional residual capacity while on spontaneous respiration and at the end of CPAP trials of 5 cm water (H(2)O), 10 cm H(2)O, and 15 cm H(2)O in 11 stable patients with COPD and eight healthy volunteers. Lung aeration was assessed by quantitative density parameters and by qualitative analysis of each CT image after processing by means of a density-based color-mask computational algorithm. The quantitative parameters were density histograms, the relative area of the lungs with attenuation values < -950 Hounsfield units (percentage of hyperaerated areas) and the 15th percentile (the density value separating the 15% voxels of least density). RESULTS A CPAP of 5 cm H(2)O caused little increase in lung aeration in both groups, but in some patients with COPD, CPAP deflated some regions of the lungs. CPAP levels of 10 cm H(2)O and 15 cm H(2)O increased the emphysematous zones in all sectors of the lungs, including dorsal and apical regions in patients with COPD compared to little hyperaeration predominantly in the ventral areas in healthy volunteers. CONCLUSIONS Nasal CPAP causes variable effects on regional lung aeration in relation to the applied pressure and the regional distribution of emphysema in patients with COPD. Low pressure levels may cause regional lung deflation in some patients. High levels increase the emphysematous areas wherever they are located inside the lungs.

Coccidioidomicose pulmonar em caçador de tatus

Coccidioidomycosis is a disease caused by inhalation of arthrospores of the fungus Coccidioides immitis. It has been recognized as a clinical entity since 1892. It is related to activities that involves dust exposure. It is found in many regions of the western hemisphere with dry and alkaline soil. In Brazil it has been described almost exclusively in the Northeast region where drought periods may favor its growth in its soil. We report a case of fatal coccidioidomycosis, in an immunocompetent host, associated to the activity of armadillo hunting (Dasypus novemcynctus) in a rural area of Ceara state.

Patients with severe accidental tetanus admitted to an intensive care unit in Northeastern Brazil: clinical–epidemiological profile and risk factors for mortality

INTRODUCTION Tetanus, an acute infectious disease, is highly prevalent worldwide, especially in developing countries. Due to respiratory failure and hemodynamic instability associated with dysautonomia, severe cases require intensive care, but little has been published regarding the management in the Intensive Care Unit. OBJECTIVE To draw a 10-year clinical-epidemiological profile of Intensive Care Unit patients with severe tetanus, observe their evolution in the Intensive Care Unit and identify risk factors for mortality. METHODS In this retrospective study, we used a standardized questionnaire to collect information from the records of patients with severe tetanus admitted to the intensive care unit of a referral hospital for infectious and contagious diseases in Northeastern Brazil. RESULTS The initial sample included 144 patients, of whom 29 were excluded due to incomplete information, leaving a cohort of 115 subjects. The average age was 49.6±15.3 years, most patients had no (or incomplete) vaccination against tetanus, and most were male. The main intensive care-related complications were pneumonia (84.8%) and dysautonomia (69.7%). Mortality (44.5%) was higher than expected from the mean APACHE II score (11.8), with shock/multiple organ failure as the main cause of death (72.9%). The independent factors most predictive of mortality were APACHE II score, dysautonomia, continuous neuromuscular blockade and age. CONCLUSION A high mortality rate was observed in our cohort of Intensive Care Unit patients with severe tetanus and a number of risk factors for mortality were identified. Our results provide important insights for the development of intervention protocols capable of reducing complications and mortality in this patient population.

Liver transplantation in a patient with Niemann-Pick disease and pulmonary involvement

Do ponto de vista respiratorio, os varios tipos de DNP, incluindo o tipo B, podem apresentar acometimento pulmonar com progressiva perda da funcao pulmonar e achado radiologico sugestivo. Relatamos o caso de uma paciente do sexo feminino, 27 anos, com DNP tipo B. Foi inicialmente encaminhada para acompanhamento ambulatorial em 2003, com historia de hepatoesplenomegalia e retardo no desenvolvimento neuropsicomotor desde a infância. A DNP foi confirmada por dosagem de esfingomielinase em leucocitos perifericos, a qual estava diminuida (0,009 −1nmol

Síndrome de Jó ou hiperimunoglobulinemia E

Jobs syndrome, or hyperimmunoglobulinemia E, is a rare immunodeficiency condition with no established etiology, characterized by recurrent lower and upper respiratory tract and skin infections associated with high levels of immunoglobulin E, eosinophilia, and a characteristic facial alteration. The authors report on a 22-year-old man who carried this disease complicated by pleural empyema and lung cysts, showing a good evolution.

Non-invasive ventilation for treatment of acute and chronic exacerbated respiratory failure: What to expect outside the critical care units?

Background: Non-Invasive Ventilation (NIV) brings unquestionable benefits in the management of patients with respiratory failure and is increasingly being used outside the ICU. Objective: To describe our experience with ward-based NIV for treatment of acute and chronic exacerbated respiratory failure. Methods: We retrospectively analyzed demographic and clinical data of all patients that underwent a NIV trial in our Respiratory ward during two years. Multivariate analysis was performed on age, sex, pH and paCO2 before NIV, FEV1 and number of exacerbations in the last year, to identify predictors of prolonged ventilation time or adverse outcome (need for mechanical invasive ventilation or death). Results: Altogether, 75 admissions were included (54,7% male; mean age 72 ± 11,3 years). The main indications to NIV were acute exacerbations of COPD (56%) or Overlap Syndrome (16%), pneumonia (6,7%), Obesity-Hypoventilation decompensation (5,3%), Cardiogenic Pulmonary Edema (4%), Neuromuscular Disease (4%) and other conditions (7,9%). Hypercapnic respiratory failure was predominant (90,7%). Eight patients (10,7%) had an adverse outcome, four of which (50%) initiated NIV for COPD exacerbation. Patients who failed NIV had significantly lower pH before NIV trial compared to those who succeeded (7,21 vs 7,31, p=0,034). Conclusions: In our ward-based study, 89,3% of the patients who underwent a NIV-trial did not required ICU transfer or had increased mortality. These results suggest that NIV can be safely implemented in Respiratory wards with well-trained clinicians. Severe acidosis appears to be an important predictor of NIV failure.