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Objective: To describe the implementation of a Tele-ICU program during the COVID-19 pandemic, as well as to describe and analyze the results of the first four months of operation of the program. Methods: This was a descriptive observational study of the implementation of a Tele-ICU program, followed by a retrospective analysis of clinical data of patients with COVID-19 admitted to ICUs between April and July of 2020. Results: The Tele-ICU program was implemented over a four-week period and proved to be feasible during the pandemic. Participants were trained remotely, and the program had an evidence-based design, the objective being to standardize care for patients with COVID-19. More than 100,000 views were recorded on the free online platforms and the mobile application. During the study period, the cases of 326 patients with COVID-19 were evaluated through the program. The median age was 60 years (IQR, 49-68 years). There was a predominance of males (56%). There was also a high prevalence of hypertension (49.1%) and diabetes mellitus (38.4%). At ICU admission, 83.7% of patients were on invasive mechanical ventilation, with a median PaO2/FiO2 ratio < 150. It was possible to use lung-protective ventilation in 75% of the patients. Overall, in-hospital mortality was 68%, and ICU mortality was 65%. Conclusions: Our Tele-ICU program provided multidisciplinary training to health care professionals and clinical follow-up for hundreds of critically ill patients. This public health care network initiative was unprecedented and proved to be feasible during the COVID-19 pandemic, encouraging the creation of similar projects that combine evidence-based practices, training, and Tele-ICU.

BACKGROUND: Noninvasive ventilation (NIV) reduces intubation and mortality in patients with COPD exacerbation who present with respiratory failure, and the type of mask may affect its success. Our objective was to compare the performance of 3 different NIV masks in a lung model. METHODS: We set the lung simulator mechanics and respiratory rate, and tested a small oronasal mask, a total face mask, and a large oronasal mask. We added CO2 at a constant rate into the system and monitored the end-tidal carbon dioxide. We used a mechanical ventilator to deliver NIV in 8 different combinations of inspiratory effort, pressure support, and expiratory positive airway pressure. We measured end-tidal carbon dioxide mask leakage, tidal volume, trigger time, time to achieve 90% of the inspiratory target during inspiration, and excess inspiratory time. RESULTS: We presented the mean ± SD of the 8 simulated conditions for each mask. The mean ± SD leakage was higher for the total face mask (51 ± 6 L/min) than for the small oronasal mask (37 ± 5 L/min) and for the large oronasal mask (21 ± 3 L/min), P CONCLUSIONS: In this model, we found that the type of mask had no impact on CO2 washout or on most synchrony variables.

In the past 12 years, advancements in the treatment of lung emphysema have been intrinsically linked to interventional bronchoscopy. The present chapter will focus on the most studied bronchoscopic lung volume reduction (BLVR) technique, the endobronchial valve (EBV). The definition of the ideal candidate for BLVR with EBV has evolved to include aspects of fissure integrity (≥90%) in addition to emphysema gradient >15 pp. Collateral ventilation is currently recognized as a crucial factor directly linked to lung volume reduction. Together, dynamic air trapping and the absence of collateral ventilation indicate the cases in which valve treatment is more likely to succeed. Emphysema is a complex condition, and much remains to be learned regarding pathophysiology, phenotypes, pulmonary vascular bed, interlobar airflow, exercise, nutrition, and other aspects, including the quality of sleep in emphysema patients. In addition, efforts must be made to devise interventions that underscore the biopsychosocial well-being of these patients.

BACKGROUND: Sleep-wake disorders are common in patients treated in Coronary Care Units (CCU). Forced bed-rest, reduced quality and quantity of sleep and the development of conditions such as post-traumatic stress disorder, have been studied in patients with Acute Coronary Syndrome (ACS) and cardiovascular diseases. Sleep disorders and even short sleep are considered risk factors for ACS recurrence and myocardial infarction (MI). OBJECTIVE: Evaluate subjective sleep quality in CCU patients. METHODS: Transversal study conducted from May to August 2015 in a public tertiary care hospital CCU. Inclusion criteria were age from 18- 80 years-old and CCU stay predicted to be over 24 hours. Patients with impaired cognition or communication were excluded. Sleep quality was daily assessed using the Richard-Campbell Sleep Questionnaire (RCSQ) and the Sleep in the Unit Care Questionnaires (SICUQ) upon CCU discharge. RESULTS: We evaluated 60 patients (63% male); mean age 62.7±12.2 years-old. Leading causes of hospitalization were non-ST elevationMI (36.7%) and ST-elevation MI (21.1%).The RCSQ scores (a 0 to 100 scale, higher scores indicating better sleep) were: sleep depth (65.6 ± 33,8); sleep latency (62.5 ± 32.8); and overall sleep quality (65.6 ± 33.8). According to patients9 perception, measured by the SICUQ, pain, light and noisy environment (especially heart monitor and intra venous pump alarm) were the main causes of sleep disruption. CONCLUSIONS: Factors related to the patient clinical conditions and its care may affect patients sleep quality in a CCU setting. The CCU team awareness and measures that could evaluate this issue must be addressed.

Background: Among bronchoscopic lung volume reduction modalities, Zephyr valves are the most widely studied. Collateral ventilation has been established as a phenomenon with major implications for patient selection and endobronchial valve (EBV) treatment outcome. Pneumothorax is now the major concern associated with large lung volume changes. Objectives: To describe our 13-year experience with negative pressure-related complications after EBV therapy. Methods: We retrospectively analyzed 176 EBV procedures in 129 patients with emphysema between June 2002 and January 2016. CT scan was used toevaluate volume reduction. Results: Of 129 patients, 8 were treated bilaterally (range 1 to 7 years later, mean 3.1). Lobar exclusion (LE) was done in 106 (77.4%). Non-lobar exclusion was the strategy in 31 (22.6%). Analyses of target lobe volume reduction (TLVR) of patients with the LE strategy demonstrate: 34 (32.08%) had TLVR 50%, and 34 (32.08%) had TLVR > 80%. Pulmonary edema in non-target lung, hemoptysis and pneumothorax were evaluated in groups according to TLVR. Seven patients (6.6%) had edema and/or pneumothorax ex vacuo, eight (7.5%) also had hemoptysis and seven patients (6.6%) had pneumothorax managed with a chest tube. Conclusions: Radiographic infiltrates in non-target lobe, hemoptysis and pneumothorax ex vacuo after massive volume reduction are signs of concern following EBV therapy for emphysema. In patients with complications, we recommend rest, oxygen therapy and pulmonary artery pressure evaluation, as well as ≥ 5 days of inpatient follow-up.

OBJECTIVES: We designed a cohort study to describe characteristics and outcomes of patients with coronavirus disease (COVID-19) admitted to the intensive care unit (ICU) in the largest public hospital in Sao Paulo, Brazil, as Latin America becomes the epicenter of the pandemic. METHODS: This is the protocol for a study being conducted at an academic hospital in Brazil with 300 adult ICU beds dedicated to COVID-19 patients. We will include adult patients admitted to the ICU with suspected or confirmed COVID-19 during the study period. The main outcome is ICU survival at 28 days. Data will be collected prospectively and retrospectively by trained investigators from the hospital’s electronic medical records, using an electronic data capture tool. We will collect data on demographics, comorbidities, severity of disease, and laboratorial test results at admission. Information on the need for advanced life support and ventilator parameters will be collected during ICU stay. Patients will be followed up for 28 days in the ICU and 60 days in the hospital. We will plot Kaplan-Meier curves to estimate ICU and hospital survival and perform survival analysis using the Cox proportional hazards model to identify the main risk factors for mortality. ClinicalTrials.gov: NCT04378582. RESULTS: We expect to include a large sample of patients with COVID-19 admitted to the ICU and to be able to provide data on admission characteristics, use of advanced life support, ICU survival at 28 days, and hospital survival at 60 days. CONCLUSIONS: This study will provide epidemiological data about critically ill patients with COVID-19 in Brazil, which could inform health policy and resource allocation in low- and middle-income countries.