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Objective: To describe clinical features, treatment, complications, and outcomes in cases of acute respiratory distress syndrome (ARDS) caused by H1N1 virus infection treated in an anesthesia department's recovery unit. Materials and methods: Patients were those admitted to our recovery unit with H1N1 virus infection confirmed by reverse transcription polymerase chain reaction, nasopharyngeal swabs, and/or bronchial aspirates. Results: From August to December 2009, we admitted 8 patients (mean age, 43 (range 24-46) years) to the recovery unit. Six were men, three were of Roma origin, and 50% had concomitant diseases. Mean (SD) time from symptom onset to admittance to the recovery unit was 3.25 (1.6) days. Four had received broad-spectrum antibiotics during the last month. Six had primary viral pneumonia, 1 had secondary bacterial pneumonia and 1 had exacerbated chronic obstructive pulmonary disease. Three had bacterial coinfection, and 4 developed multiple organ dysfunction syndrome and ARDS, requiring mechanical ventilation (5.75 (3.10) days) and vasopressors (4.25 (3.40) days). The mean ratio of PaO2 to the inspired oxygen fraction at admittance was 93.8 (31.0) and the mean positive end-expiratory pressure applied was 14.5 (4.2) cm H2O. Oseltamivir was administered (150 mg/12 h) with a mean delay of 3.88 (1.64) days. Additional inhaled zanamivir was administered on day 7 to a patient with a positive viral culture. Antibiotics were prescribed following the guidelines of the American Thoracic Society and Infectious Diseases Society of America for community-acquired pneumonia (50% of the cases) and healthcare-associated pneumonia (50%). Seven subjects received 1 mg·kg -1 ·day -1 of methylprednisolone. Patients with mechanical ventilation required continuous insulin infusion (maximum daily dosage, 87 (50.3) IU) to maintain blood glucose levels between 80 and 150 mg·dL -1 . Patients under mechanical ventilation achieved a negative net fluid balance. All patients survived and were discharged from the recovery unit in 7.38 (4.83) days (range, 2-16 days) and subsequently discharged home in 13.25 (7.74) days (range, 6-27 days). All were alive 60 days after discharge. Conclusion: In this series of critically ill patients with H1N1 virus infection that was initially life-threatening, all responded favorably to conventional treatment and could be discharged.

Resumen IntroduccioN El laringoscopio Airtraq es un nuevo dispositivo de intubacion que puede proporcionar mejores condiciones de vision frente al clasico Macintosh. Se compara la diferencia en la laringoscopia entre ambos: Airtraq y Macintosh; asi como si los predictores de intubacion son utiles para el Airtraq. Material Y MeTodos Estudio prospectivo incluyendo 215 pacientes, mayores de 18 anos, ASA I-III, sometidos a anestesia con intubacion endotraqueal. Se excluyo la cirugia urgente, los que habian presentado una intubacion dificil en episodios previos y la dificultad en la ventilacion durante la induccion de anestesia. Se estudiaron los datos demograficos, antropometricos, distancia tiromentoniana, apertura bucal, Mallampati y grado de vision laringoscopica Cormack-Lehane con cada dispositivo. Se clasifico a los pacientes segun su grado de Cormack-Lehane como buena vision si la vision era I o II y mala vision si era III o IV. Se utilizo la prueba de McNemar para comparar el grado de vision laringoscopica de ambos dispositivos en cada paciente y ji-cuadrado en el caso de los predictores de intubacion. Resultados La distribucion segun la vision laringoscopica con Macintosh fue: Cormack-Lehane I 65,3%, II 22,4%, III 11,3% y IV 1,4% y con Airtraq Cormack-Lehane I 96,2%, II 3,3%, III 0,5% y IV ninguno. Estas diferencias fueron estadisticamente significativas. Ni la distancia tiromentoniana, ni la apertura bucal, ni el grado de Mallampati se asociaron una mala vision laringoscopica con Airtraq. Conclusiones El dispositivo Airtraq disminuyo el numero de laringoscopias con mala vision y como consecuencia proporciono mejores condiciones de intubacion en relacion al Macintosh. Ademas los predictores de intubacion clasicos no parecieron tener utilidad cuando se utiliza el Airtraq. Comparison of the view of the glottic opening through Macintosh and AirTraq laryngoscopes in patients undergoing scheduled surgery

Resumen La ciclofosfamida es un farmaco inmunosupresor alquilante administrado principalmente en enfermedades neoplasicas e inmunologicas. La toxicidad pulmonar secundaria al tratamiento con ciclofosfamida, aunque rara, frecuentemente tiene un mal pronostico. El enfoque diagnostico de la lesion pulmonar se ve entorpecido por ser pacientes que asocian una inmunosupresion con el consiguiente riesgo de infecciones pulmonares oportunistas. Presentamos un paciente con un sindrome de distres respiratorio agudo tras tratamiento con ciclofosfamida por una glomerulonefritis proliferativa con semilunas. El diagnostico de lesion pulmonar secundaria a ciclofosfamida se basa en descartar otras posibles causas, y como principal herramienta el lavado bronquioalveolar. La evolucion del paciente que se presenta fue favorable respondiendo adecuadamente a la administracion de corticoides y terapia de mantenimiento sin necesidad de ventilacion mecanica.

To describe clinical features, treatment, complications, and outcomes in cases of acute respiratory distress syndrome (ARDS) caused by H1N1 virus infection treated in an anesthesia department's recovery unit.Patients were those admitted to our recovery unit with H1N1 virus infection confirmed by reverse transcription polymerase chain reaction, nasopharyngeal swabs, and/or bronchial aspirates.From August to December 2009, we admitted 8 patients (mean age, 43 [range 24-46] years) to the recovery unit. Six were men, three were of Roma origin, and 50% had concomitant diseases. Mean (SD) time from symptom onset to admittance to the recovery unit was 3.25 (1.6) days. Four had received broad-spectrum antibiotics during the last month. Six had primary viral pneumonia, 1 had secondary bacterial pneumonia and 1 had exacerbated chronic obstructive pulmonary disease. Three had bacterial coinfection, and 4 developed multiple organ dysfunction syndrome and ARDS, requiring mechanical ventilation (5.75 [3.10] days) and vasopressors (4.25 [3.40] days). The mean ratio of PaO2 to the inspired oxygen fraction at admittance was 93.8 (31.0) and the mean positive end-expiratory pressure applied was 14.5 (4.2) cm H2O. Oseltamivir was administered (150 mg/12 h) with a mean delay of 3.88 (1.64) days. Additional inhaled zanamivir was administered on day 7 to a patient with a positive viral culture. Antibiotics were prescribed following the guidelines of the American Thoracic Society and Infectious Diseases Society of America for community-acquired pneumonia (50% of the cases) and healthcare-associated pneumonia (50%). Seven subjects received 1 mg x kg(-1) x day(-1) of methylprednisolone. Patients with mechanical ventilation required continuous insulin infusion (maximum daily dosage, 87 [50.3] IU) to maintain blood glucose levels between 80 and 150 mg x dL(-1). Patients under mechanical ventilation achieved a negative net fluid balance. All patients survived and were discharged from the recovery unit in 7.38 (4.83) days (range, 2-16 days) and subsequently discharged home in 13.25 (7.74) days (range, 6-27 days). All were alive 60 days after discharge.In this series of critically ill patients with H1N1 virus infection that was initially life-threatening, all responded favorably to conventional treatment and could be discharged.

The AirTraq laryngoscope is a new intubation device that may provide better viewing conditions than can be achieved with the traditional Macintosh device. This study compared the AirTraq and Macintosh views and assessed whether predictors of intubation difficulty are useful when the AirTraq laryngoscope is used.Prospective study of 215 ASA 1-3 patients over the age of 18 years who were to receive anesthesia with endotracheal intubation. Excluded were patients who required emergency surgery, who had a history of difficult intubation, or for whom ventilation was difficult during induction of anesthesia. In addition to the usual patient characteristics, we recorded thyromental distance, mouth opening, and Mallampati score. The Cormack-Lehane laryngoscopy grade was recorded for each device. A Cormack-Lehane grade of 1 or 2 was considered a good view. A grade of 3 or 4 was considered a poor view. The McNemar test was used to compare laryngoscopy grade between the 2 devices in each patient. The chi2 test was used to compare predictors of intubation difficulty.The Macintosh laryngoscope achieved a Cormack-Lehane grade of 1 in 653% of the patients, of 2 in 22.4%, of 3 in 11.3%, and of 4 in 1.4%. The AirTraq scope gave a Cormack-Lehane grade of 1 in 96.2%, of 2 in 33%, of 3 in 0.5%, and of 4 in 0%. The differences were statistically significant. None of the predictors was associated a poor glottic view through the AirTraq device.Poor viewing conditions occurred less frequently when the AirTraq device was used. Intubation conditions were therefore better with the AirTraq than with the Macintosh device. The traditional predictors of difficult intubation do not seem to be relevant when the AirTraq device is to be used.

Cyclophosphamide is an alkylating immunosuppressant drug that is used mainly in neoplastic and immunologic diseases. Lung toxicity due to treatment with cyclophosphamide, though rare, often has a poor prognosis. Diagnosis of the lung lesion is difficult because these patients have associated immunosuppression and a consequent risk of opportunistic lung infections. We report the case of a man with acute respiratory distress syndrome after treatment with cyclophosphamide for proliferative crescentic glomerulonephritis. The diagnosis of lung lesion due to cyclophosphamide was based on ruling out other possible causes. The principal diagnostic tool used was bronchoalveolar lavage. The patient progressed satisfactorily, responding adequately to corticosteroids and then maintenance therapy, without the need for mechanical ventilation.

Purpura fulminans is a serious disease associated with high rates of morbidity and mortality. It usually leads to disseminated intravascular coagulation and septic shock related to reduced levels of protein C. Recombinant protein C (rPC) activator has been used successfully to inhibit this process. Intracranial hemorrhages are the most important, life-threatening adverse effects of treatment with rPC activator. We report 3 cases of patients with meningococcal purpura fulminans who developed septic shock and multiorgan dysfunction. They were treated with the protocol for septic shock, antibiotics and rPC activator from the time of admission, and improvement in hemodynamic dysfunction was observed within hours in all patients. All received platelet replacement transfusions. Subarachnoid bleeding complications occurred in 2 patients. One patient died 5 days after admission and 2 were discharged from the intensive recovery care unit 28 days after admission.

The potential benefits of non-invasive mechanical breathing in clinically stable COPD patients are still not well known, nor have they been sufficiently studied. We evaluate whether non-invasive mechanical ventilation is beneficial to these patients.A cross sectional study was carried out evaluating the application of non-invasive home mechanical ventilation (BIPAP), during the nocturnal rest in 23 COPD patients, who presented hypercapnia in basal arterial gasometry during clinical stability. Clinical, gasometric and spirometric evaluations were carried out 3, 6 and 12 months after initiating this therapy. Similarly, an evaluation was made of the number of admissions due to worsening of the underlying respiratory pathology during one year. Results. The patients included in the study had an average age of 68.83 years. Sixty point nine percent (60.9%) presented a severe degree of COPD. Sixty-nine point six percent (69.6%) of the total sample had previously received continuous oxygenotherapy at home; 75% of them presented severe or very severe COPD. During the period of time of the study a fall was recorded in the number of hospital admissions due to worsening (0.61+/-0.15 annual admissions on average) with respect to the period of time prior to the non-invasive mechanical ventilation (1.07+/-0.16 admissions on average), with greater benefits obtained by those who had previously shown a higher number of admissions and those with associated comorbidity. A reduction was also appreciated in the arterial pressure of carbon dioxide (PaCO2) in the majority of cases, principally those who at the start of the study presented a PaCO263.32 mm of Hg; this improvement was appreciated from the first three months of treatment.

Background. The potential benefits of non-invasive mechanical breathing in clinically stable COPD patients are still not well known, nor have they been sufficiently studied. We evaluate whether non-invasive mechanical ventilation is beneficial to these patients. Methods. A cross sectional study was carried out evaluating the application of non-invasive home mechanical ventilation (BIPAP), during the nocturnal rest in 23 COPD patients, who presented hypercapnia in basal arterial gasometry during clinical stability. Clinical, gasometric and spirometric evaluations were carried out 3, 6 and 12 months after initiating this therapy. Similarly, an evaluation was made of the number of admissions due to worsening of the underlying respiratory pathology during one year. Results. The patients included in the study had an average age of 68.83 years. Sixty point nine percent (60.9%) presented a severe degree of COPD. Sixty-nine point six percent (69.6%) of the total sample had previously received continuous oxygenotherapy at home; 75% of them presented severe or very severe COPD. During the period of time of the study a fall was recorded in the number of hospital admissions due to worsening (0.61±0.15 annual admissions on average) with respect to the period of time prior to the non-invasive mechanical ventilation (1.07±0.16 admissions on average), with greater benefits obtained by those who had previously shown a higher number of admissions and those with associated comorbidity. A reduction was also appreciated in the arterial pressure of carbon dioxide (PaCO2) in the majority of cases, principally those who at the start of the study presented a PaCO2>63.32 mm of Hg; this improvement was appreciated from the first three months of treatment.

Mortality trends in Taranto, Italy, from around 1600 to 1860 are analyzed using data from parish records. Attention is given to mortality changes over time and to infant mortality.