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Resumen Introduccion y objetivos La ventilacion no invasiva (VNI) es capaz de reducir la necesidad de intubacion endotraqueal y la mortalidad de los pacientes con insuficiencia cardiaca aguda (ICA). Sin embargo, de muchos de los ensayos clinicos se ha excluido a los pacientes con ICA secundaria a sindrome coronario agudo o infarto agudo de miocardio (SCA-IAM). El objetivo de este estudio es comparar la efectividad de la VNI entre pacientes con ICA desencadenada por SCA-IAM y por otras causas. Metodos Estudio prospectivo de cohortes, durante un periodo de 20 anos, de todos los pacientes con ICA tratados con VNI ingresados en una unidad de cuidados intensivos. Se agrupo a los pacientes por la presencia o ausencia de SCA-IAM como causante del evento de ICA. Se definio el fracaso de la VNI por la necesidad de intubacion endotraqueal o muerte. Resultados Se analizo a 1.009 pacientes, 403 (40%) con SCA-IAM y 606 (60%) con otras etiologias. La VNI fracaso en 61 casos (15,1%) del grupo de SCA-IAM y 64 (10,6%) del grupo sin SCA-IAM (p = 0,031), sin diferencias en la mortalidad hospitalaria (el 16,6 y el 14,9%; p = 0,478). Conclusiones El SCA-IAM como causa desencadenante de la ICA no influye en el pronostico de los pacientes con insuficiencia respiratoria aguda que precisan asistencia respiratoria no invasiva.

Introduction and objectives Noninvasive ventilation (NIV) has been shown to reduce the rate of endotracheal intubation and mortality in patients with acute heart failure (AHF). However, patients with AHF secondary to acute coronary syndrome/acute myocardial infarction (ACS-AMI) have been excluded from many clinical trials. The purpose of this study was to compare the effectiveness of NIV between patients with AHF triggered by ACS-AMI and by other etiologies. Methods Prospective cohort study of all patients with AHF treated with NIV admitted to the intensive care unit for a period of 20 years. Patients were divided according to whether they had ACS-AMI as the cause of the AHF episode. NIV failure was defined as the need for endotracheal intubation or death. Results A total of 1009 patients were analyzed, 403 (40%) showed ACS-AMI and 606 (60%) other etiologies. NIV failure occurred in 61 (15.1%) in the ACS-AMI group and in 64 (10.6%) in the other group (P = .031), without differences in in-hospital mortality (16.6% and 14.9%, respectively; P = .478). Conclusions The presence of ACS-AMI as the triggering cause of AHF did not influence patients with acute respiratory failure requiring noninvasive respiratory support .

The treatment of acute respiratory failure with non-invasive ventilation (NIV) as a first-line therapy is increasingly common in intensive care units. The reduced invasiveness of NIV leads to better outcomes than endotracheal intubation in carefully selected groups of patients. Furthermore, the use of NIV as a palliative treatment for respiratory failure and dyspnea has become increasingly common. NIV also has an impact on the use of "do not intubate" orders. In the present narrative review, we explore the use and outcome of NIV in elderly patients. To accomplish this, we reviewed the most recent available medical literature. Geriatr Gerontol Int 2017; 17: 689-696.

This study was designed to determine the results associated with the use of noninvasive mechanical ventilation (NIV) using the BiPAP S/T-AVAPS ventilation strategy in subjects with mild to moderate de novohypoxaemicrespiratory failure.This is a prospective study that includes subjects with de novohypoxaemic respiratory failure (not produced by acute exacerbations of COPD, chronic lung disease, or congestive heart failure) with mild to moderate PaO₂/FiO₂, who were admitted to the Intensive Care Unit (ICU) of Santa Maria Clinic in Guayaquil, Ecuador. Subjects were divided into two groups and compared according to their PaO₂/FiO₂: higher than 100 and up to 200 mm Hg (moderate ARDS) or between 200 and 300 mm Hg (mild ARDS) (both groups were ventilated with the BiPAP S/T-AVAPS strategy). A value of P0.05 was considered significant.A total of 38 subjects were analysed in this study. The total rate of intubation was 34.2% while the mortality rate was 28.9%. Significant differences were observed when comparing success versus failure in exhaled tidal volumes (P = 0.04), peak inspired pressure (P0.001), PaO₂ (P0.001), SaO₂ (P0.002), PaO₂/FiO₂ (P0.002), RR (P0.001), HR (P0.001), and inspiratory time (P = 0.029) measured at baseline and at 12-hour, 24-hour and 48-hour intervals.The BiPAP S/T-AVAPS ventilatory mode can be used in subjects with de novo hypoxaemic respiratory failure with special vigilance concerning exhaled tidal volumes and inspired pressure.

The respiratory failure is a common cause of admission to intensive and respiratory care units in patients with hemato-oncological malignancies. Non-invasive Mechanical Ventilation (NIV) is expanding with promising results. It is essential to identify patients which initially benefit from invasive mechanical ventilation (IMV), in order not to delay its indication. Considering the success and failure determinants, it is important for the selection of patients and to start a proper ventilatory therapy. Success in NIV is determined by different factors like PaO2/FiO2, comorbidities, use of vasopressors, renal failure, respiratory rate, some scoring systems, the delay of its indication, environmental factors, ventilator settings, and patient adaptation. NIV has shown to be effective improving dyspnea and sometimes reversing the acute deterioration despite the high overall mortality rate.

Patients with acute respiratory failure and decreased respiratory system compliance due to ARDS frequently present a formidable challenge. These patients are often subjected to high inspiratory pressure, and in severe cases in order to improve oxygenation and preserve life, we may need to resort to unconventional measures. The currently accepted ARDSNet guidelines are characterized by a generalized approach in which an algorithm for PEEP application and limited plateau pressure are applied to all mechanically ventilated patients. These guidelines do not make any distinction between patients, who may have different chest wall mechanics with diverse pathologies and different mechanical properties of their respiratory system. The ability of assessing pleural pressure by measuring esophageal pressure allows us to partition the respiratory system into its main components of lungs and chest wall. Thus, identifying the dominant factor affecting respiratory system may better direct and optimize mechanical ventilation. Instead of limiting inspiratory pressure by plateau pressure, PEEP and inspiratory pressure adjustment would be individualized specifically for each patient's lung compliance as indicated by transpulmonary pressure. The main goal of this approach is to specifically target transpulmonary pressure instead of plateau pressure, and therefore achieve the best lung compliance with the least transpulmonary pressure possible.

OBJECTIVES The objective of this study was to assess the effectiveness of noninvasive motion ventilation (NIMV) in patients with chronic obstructive pulmonary disease (COPD), having infectious exacerbation and severe hypercapnic neurological dysfunction in the emergency room. DESIGN This is a prospective interventional study. SETTING The study setting was the emergency room at the Military Hospital in Guayaquil, Ecuador. PATIENTS A total of 24 patients were studied. Twelve patients had acute exacerbation of their chronic obstructive pulmonary disease: they presented at the emergency room with severe neurological dysfunction, with a Glasgow Coma Scale (GCS) score of less than 8 and a pH of less than 7.25. These patients were compared with 12 controls who were being treated with invasive mechanical ventilation (IMV), who were then matched according to their GCS scores, pH status, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, and age. INTERVENTIONS We evaluated the effectiveness and safety of applying a ventilatory strategy based on a biphasic positive airway pressure protocol in the emergency room. MEASUREMENTS AND RESULTS The pH, PCO2, and GCS scores, measured during the first 3 h, were predictors of success for the application of NIMV treatment (P

Tracheostomy is one of the most frequently performed procedures in the intensive care unit (ICU) [1], especially after the introduction of percutaneous techniques [2]. It is performed in critically ill patients to protect the airway, remove secretions, or provide ventilatory support [3].The indications for placement of a tracheostomy tube include failure to wean from invasive mechanical ventilation, impaired neurologic status, an inability to handle excessive secretions, and the need to bypass an upper-airway obstruction [4]. In addition, the placement of a tracheostomy tube facilitates the transfer of the patient from the ICU to a weaning facility such as a step-down unit or a long-term care hospital [5].

Aim: To identify nursing interventions aimed at persons with venous, arterial or mixed leg ulcers. Methodology: Carried out research in the EBSCO search engine: CINAHL Plus with Full Text, MEDLINE with Full Text, MedicLatina, Academic Search Complete, sought full text articles, published between 2008/01/01 and 2015/01/31, with the following keywords [(MM "leg ulcer") OR (wound care) OR (wound healing)] AND [(nursing) OR (nursing assessment) OR (nursing intervention)], filtered through initial question in PI[C]O format. Results: The different etiologies of leg ulcer require a specific therapeutic and prophylactic approach. Factors that promote healing were identified: individualization of care, interpersonal relationship, pain control, control of the exudate, education for health self-management, self-care, therapeutic adherence, implementation of guidelines of good practice and auditing and feedback of the practices. Conclusion: Person-centred care and practices based on evidence improves health results in prevention and treatment of leg ulcers.

Objective: To conduct a multinational survey of intensive care unit professionals to determine the practices on delirium assessment and management, in addition to their perceptions and attitudes toward the evaluation and impact of delirium in patients requiring noninvasive ventilation. Methods: An electronic questionnaire was created to evaluate the profiles of the respondents and their related intensive care units, the systematic delirium assessment and management and the respondents' perceptions and attitudes regarding delirium in patients requiring noninvasive ventilation. The questionnaire was distributed to the cooperative network for research of the Associacao de Medicina Intensiva Brasileira (AMIB-Net) mailing list and to researchers in different centers in Latin America and Europe. Results: Four hundred thirty-six questionnaires were available for analysis; the majority of the questionnaires were from Brazil (61.9%), followed by Turkey (8.7%) and Italy (4.8%). Approximately 61% of the respondents reported no delirium assessment in the intensive care unit, and 31% evaluated delirium in patients under noninvasive ventilation. The Confusion Assessment Method for the intensive care unit was the most reported validated diagnostic tool (66.9%). Concerning the indication of noninvasive ventilation in patients already presenting with delirium, 16.3% of respondents never allow the use of noninvasive ventilation in this clinical context. Conclusion: This survey provides data that strongly reemphasizes poor efforts toward delirium assessment and management in the intensive care unit setting, especially regarding patients requiring noninvasive ventilation.

Patients with acute asthma exacerbation (AAE) represent agrowing health problem in the Emergency Departments (ED)[1–5]. The assessment of AAE severity is of great importancebecause it will determine the level and place of care [6].In this sense, tools to assess acute asthma severity are helpful[9]. Dankner et al. [7] retrospectively tested a simplifiedseverity score (SSS) on more than 500 adult patients thatvisited an ED for AAE. The following variables wereincluded in the SSS upon arrival: pulse rate, respiratorywheezes, rales, prolonged expiration, oxygen saturation andthe use of accessory muscles. The severity of the AAE wasgraded as mild, moderate or severe.We have read with interest this interesting originalcontribution. There are, however, a few issues we think arenoteworthy to review. In regard to patient selection anddiagnosis, the authors recruited adult patients younger than35 years so the results may not be applicable to other agegroups. It is also unknown if the diagnosis of asthma wasmade prior to the ED visit [8].The measurement of bedside clinical signs is limited fordifferent reasons: (A) interpretation of clinical signs dependon the subjectivity and experience of the treating physician.Obviously, patients with most severe AAE will present theworst physical findings. (B) Although PF is the gold standard,most EDs do not have the capacity or expertise to obtain thismeasurement in a meaningful way. The authors stated thatbaseline PF values were available in close to 50% of patients.In this case, they should analyze their data and compare it tothe SSS, since this is a good way to suggest validity. (C) Anadditional patient’s factor not included in the score isalertness [9]. Even though somehow subjective, it may helpthe clinician in the patient’s assessment.There are also aspects relevant to effectiveness of therapythat, although not practical for a simplified score, ought to betaken into account in everyday practice: poor asthma control,noncompliance with medications, intake of high dosemedication, psychiatric issues, socioeconomic status, accessto heath care and exposure to cigarette smoke. Some of thesemight be determinant in deciding to hospitalise someone witha ‘‘mild’’ AAE.Regarding the treatment used, it is surprising that fewerthan 60% of patients with moderate AAE and fewer than 80%of patients with severe AAE received systemic steroids.In regard to the use of ipratropium, fewer than 40% of patientsreceived this drug because of unavailability. Nowadays, manypatients with AAE may receive ipratropium together withalbuterol, specially, if symptoms persist. If ipratropium isadministered, it might lead to fewer hospitalisations across thewhole group of patients. Finally, the use of xanthines acrossthe severity range of AAE was quite high. The availablecurrent evidence suggests that they should only be consideredfor those with AAE severe enough to not respond to first linetherapy [8]. Therefore, we can say that treatment of patients inthe original study did not follow standard of care. If thepatients were under-treated or inappropriately treated, theresults can hardly be deemed valid.The authors conclude that the SSS has a good potentialdiscriminatory capacity to help select patients for discharge oradmission. However, they ignore that a dynamic evaluation inthe ED of AAE patients is preferred. We know that the timingof response to treatment varies among patients with AAE andalso depends on the type – type 1 or type 2 – of exacerbation.In this sense, we think that a repeated SSS value just beforeclinical decision takes place – e.g. 2–3h after the firstassessment – would test the score’s performance in a morereliable manner. So, the lack of a follow-up score limits thevalidity of results [10].Workloads and cost implications: the authors argue thatuse of SSS does not require additional costs in the ED [11].However, it would be interesting to know about thephysician’s and nurse’s workload, since it could affectadherence with filling up the score. Educational actions toimprove compliance with the test may be helpful.In summary, we agree that a score could help in thedecision-making process in the ED, and it should serve as aguide. Given the retrospective nature of the study and the

Community-acquired pneumonia (CAP)—pneumonia occurring within 48 h after hospital admission or more than 2 weeks after discharge—leads to hospitalization rates of 20–35 % in Europe, with figures in Spain being even higher at 22–61 %. A substantial proportion of these cases (10 %) are defined as severe. These patients must be admitted to the intensive care unit (ICU) because of the possible need for ventilatory or hemodynamic support. Their mortality rate can be as high as 40 % [1]. In the rest of Europe the incidence of CAP is 5–11 cases per 1,000 person-years, and in Spain it drops to 1.6–1.8 cases per 1,000 person-years, with men and the elderly most often affected and mostly in winter [1].