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RESUMEN Introducción: Los pacientes con neumonía grave por COVID-19 pueden requerir in tubación orotraqueal, ventilación mecánica prolongada, y traqueostomía. La presencia de una cánula de traqueostomía no implica por sí misma el desarrollo de disfagia, pero la frecuencia de disfagia en estos pacientes es alta con riesgo de aspiración. Objetivo: Describir la prevalencia disfagia orofaríngea en pacientes que requirieron traqueostomía luego de ventilación mecánica prolongada secundaria a COVID-19, valorada mediante un método instrumental. Como objetivo secundario, evaluar la asociación entre la presencia de disfagia y variables clínico-demográficas, duración de la ventilación mecánica invasiva, días de vía aérea artificial, presencia de lesiones laríngeas y días de estadía en terapia intensiva. Material y métodos: Estudio observacional, longitudinal y retrospectivo, realizado en el hospital Juan A. Fernández, CABA, Argentina. Se incluyeron de manera consecutiva pacientes con diagnóstico de COVID-19 traqueostomizados. La presencia de disfagia se valoró mediante estudio endoscópico de la deglución al momento de la decanulación. Resultados: Un total de 69 pacientes traqueostomizados en proceso de decanulación ingresaron al estudio. De ellos, 65 pacientes fueron analizados y evaluados mediante endoscopía de la deglución y cincuenta se diagnosticaron con disfagia (76,9 %). La me diana de días de traqueostomía fue de 32; al comparar los días de traqueostomía entre el grupo sin disfagia (mediana veintiún días) y el grupo con disfagia (mediana 36), se observaron diferencias estadísticamente significativas entre ambos grupos (p = 0,015). Conclusión: La disfagia orofaríngea fue prevalente en esta cohorte de pacientes con COVID 19. Los pacientes que tuvieron más días de traqueostomía hasta la decanulación se asociaron significativamente con el desarrollo de disfagia.
ABSTRACT Introduction: Patients with severe COVID-19 pneumonia may require orotracheal intubation, prolonged mechanical ventilation, and tracheostomy. The presence of a tracheostomy cannula does not contribute by itself to the development of dysphagia, but the frequency of dysphagia in these patients is high and with risk of aspiration. Objective: To describe the prevalence of oropharyngeal dysphagia in patients who required tracheostomy after prolonged mechanical ventilation secondary to COVID-19, assessed by an instrumental method. As a secondary objective, to evaluate the as sociation between the presence of dysphagia and clinical-demographic variables, the duration of invasive mechanical ventilation, days of artificial airway, presence of laryngeal injuries, and length of stay in the Intensive Care. Methods: Observational, longitudinal, retrospective study conducted at the Hospital Juan A. Fernández, Autonomous City of Buenos Aires (CABA), Argentina. Tracheos tomized patients diagnosed with COVID-19 were consecutively included in the study. The presence of dysphagia was assessed by an endoscopic study of swallowing at the time of decannulation. Results: A total of 69 tracheostomized patients undergoing decannulation were included in the study. 65 of these patients were evaluated through swallowing endoscopy, and 50 were diagnosed with dysphagia (76.9%). The median number of tracheostomy days was 32. When comparing tracheostomy days between the group without dysphagia (median of 21 days) and the group with dysphagia (median of 36 days), statistically significant differences were reported between both groups (p=0.015). Conclusion: Oropharyngeal dysphagia was prevalent in this cohort of COVID-19 pa tients. A significant association was found between patients with more tracheostomy days until decannulation and the development of dysphagia.
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Introducción: Los pacientes con neumonía grave por COVID-19 pueden requerir intubación orotraqueal, ventilación mecánica prolongada y traqueostomía. La presencia de la vía aérea artificial puede generar lesiones laríngeas y estar asociada a disfunción deglutoria con aumento del riesgo de aspiración. Objetivo: Describir la prevalencia de lesiones laríngeas y disfagia orofaríngea en los pacientes críticos traqueostomizados por COVID-19. Como objetivo secundario, evaluar la asociación entre la presencia de lesión laríngea y disfagia y de cada una de ellas con antecedentes del paciente, duración de la vía aérea artificial y maniobra de decúbito prono. Material y métodos: Estudio observacional, longitudinal y retrospectivo, realizado en el hospital Juan A. Fernández, CABA, Argentina. Se incluyeron de manera consecutiva pacientes con diagnóstico de COVID-19 traqueostomizados. La presencia de lesiones laríngeas y disfagia se valoró mediante estudio endoscópico de la deglución al momento de la decanulación. Resultados: Se analizaron 32 pacientes, de los cuales, 28 (87,5%) evidenciaron al menos una lesión laríngea, principalmente en la región glótica. La prevalencia de disfagia fue de 65,6% (21/32). No se encontró asociación significativa entre lesiones laríngeas y disfagia (p = 0,70). Conclusión: En esta cohorte de pacientes, las lesiones laríngeas y la disfagia fueron altamente prevalentes. La evaluación precoz mediante endoscopia de la deglución nos ha facilitado un diagnóstico oportuno para guiar el tratamiento de manera individual hasta la decanulación y resolución de la disfagia encontrada.
Introduction: Patients with severe pneumonia due to COVID-19 may require orotracheal intubation, prolonged mechanical ventilation and tracheostomy. The presence of an artificial airway can generate laryngeal lesions and it is associated with swallowing dysfunction and increased risk of aspiration. Objective: The main objective of this study is to describe the prevalence of laryngeal lesions and oropharyngeal dysphagia in critically ill tracheostomized patients due to COVID-19. As a secondary objective, is to evaluate the association between the presence of laryngeal injury and dysphagia and each of them with other variables related to the patient's history, duration of the artificial airway and the prone position maneuver. Methods: This is an observational, longitudinal and retrospective study, conducted at the Juan A Fernández Hospital, CABA, Argentina. Tracheostomized patients diagnosed with COVID-19 were consecutively included. The presence of laryngeal lesions and dysphagia was recorded by fibroscopic evaluation of swallowing at the time of decannulation. Results: 32 patients were analyzed, of which 28 (87.5%) showed at least one laryngeal lesion, mainly in the glottic region. The prevalence of dysphagia was 65.6% (21/32). No significant association was found between laryngeal injuries and dysphagia (p = 0.70). Conclusion: laryngeal injuries and dysphagia were highly prevalent in this cohort of patients. The early evaluation through fibroscopic evaluation of swallowing for the protocolized follow-up of these patients, has provided us a timely diagnosis to guide treatment individually until decannulation and resolution of the dysphagia found.
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OBJECTIVES: To provide evidence-based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research. METHODS: A taskforce composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system. RESULTS: The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified, of which 226 publications were chosen. The taskforce generated a total of 19 recommendations, 10 positive (1B, 3; 2C, 3; 2D, 4) and 9 negative (1B, 8; 2C, 1). A recommendation was not possible in 6 questions. CONCLUSIONS: Percutaneous techniques are associated with a lower risk of infections compared with surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.
Assuntos
Cuidados Críticos , Estado Terminal/terapia , Respiração Artificial/métodos , Traqueostomia/métodos , Comitês Consultivos , Medicina Baseada em Evidências , Custos de Cuidados de Saúde , Humanos , Tempo de Internação , Pneumonia/epidemiologia , Sociedades Médicas , Fatores de Tempo , Traqueostomia/economiaRESUMO
INTRODUCTION: Most cases of the 2009 influenza A (H1N1) infection are self-limited, but occasionally the disease evolves to a severe condition needing hospitalization. Here we describe the evolution of the respiratory compromise, ventilatory management and laboratory variables of patients with diffuse viral pneumonitis caused by pandemic 2009 influenza A (H1N1) admitted to the ICU. METHOD: This was a multicenter, prospective inception cohort study including adult patients with acute respiratory failure requiring mechanical ventilation (MV) admitted to 20 ICUs in Argentina between June and September of 2009 during the influenza A (H1N1) pandemic. In a standard case-report form, we collected epidemiological characteristics, results of real-time reverse-transcriptase--polymerase-chain-reaction viral diagnostic tests, oxygenation variables, acid-base status, respiratory mechanics, ventilation management and laboratory tests. Variables were recorded on ICU admission and at days 3, 7 and 10. RESULTS: During the study period 178 patients with diffuse viral pneumonitis requiring MV were admitted. They were 44 ± 15 years of age, with Acute Physiology And Chronic Health Evaluation II (APACHE II) scores of 18 ± 7, and most frequent comorbidities were obesity (26%), previous respiratory disease (24%) and immunosuppression (16%). Non-invasive ventilation (NIV) was applied in 49 (28%) patients on admission, but 94% were later intubated.Acute respiratory distress syndrome (ARDS) was present throughout the entire ICU stay in the whole group (mean PaO2/FIO2 170 ± 25). Tidal-volumes used were 7.8 to 8.1 ml/kg (ideal body weight), plateau pressures always remained < 30 cmH2O, without differences between survivors and non-survivors; and mean positive end-expiratory pressure (PEEP) levels used were between 8 to 12 cm H2O. Rescue therapies, like recruitment maneuvers (8 to 35%), prone positioning (12 to 24%) and tracheal gas insufflation (3%) were frequently applied. At all time points, pH, platelet count, lactate dehydrogenase assay (LDH) and Sequential Organ Failure Assessment (SOFA) differed significantly between survivors and non-survivors. Lack of recovery of platelet count and persistence of leukocytosis were characteristic of non-survivors. Mortality was high (46%); and length of MV was 10 (6 to 17) days. CONCLUSIONS: These patients had severe, hypoxemic respiratory failure compatible with ARDS that persisted over time, frequently requiring rescue therapies to support oxygenation. NIV use is not warranted, given its high failure rate. Death and evolution to prolonged mechanical ventilation were common outcomes. Persistence of thrombocytopenia, acidosis and leukocytosis, and high LDH levels found in non-survivors during the course of the disease might be novel prognostic findings.