Archivos de bronconeumología
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Community-acquired pneumonia is a major cause of morbidity and mortality. Severity assessment is a fundamental tool in the management of pneumonia that allows patients to be stratified according to risk of death and the most appropriate treatment intensity to be provided. The most widely used scales are the PSI/Fine and CURB-65 scales, which have been widely validated and are easy to calculate in clinical practice. ⋯ With the experience acquired in the 2009 AH1/N1 influenza pandemic, virological diagnosis of pneumonia by rapid polymerase chain reaction techniques has recently begun to be used. Experience has also been gained in antiviral treatment and complications, especially bacterial superinfection as the main unfavorable event in viral pneumonias. Just as the use of antibiotics to treat infections radically changed their prognosis and treatment, reports in the literature have progressively began to appear of the immunomodulatory effect of drugs that were not initially designed for the treatment of pneumonia, leading to hope for the potential modification of outcome in these patients.
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The advent of non-invasive mechanical ventilation (NIMV) has radically changed the management of acute and chronic respiratory failure. Over the last few years, the number of possible applications of NIMV has progressively increased, both in the hospital and extrahospital setting. NIMV is now used in all hospitals and resident physicians currently receive specific training -nonexistent until a few years ago- in this modality. ⋯ The present review aims to provide a broad overview of NIMV, from the most theoretical knowledge (the physiopathology of NIMV) to the most practical skills (recognition of patient-ventilator asynchrony). Through this progression from the complex to the most basic, or from the basics to the most complex, depending on the perspective taken, we aim to provide deeper knowledge of the concepts required to understand the technical functioning of the ventilator, describing its distinct modes and parameters and the abilities that must be developed for the correct indication, use and monitoring of the technique. We provide a final reflection on other forms of respiratory support that can be offered to patients with ventilatory failure.
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Exacerbations of chronic obstructive pulmonary disease (COPD) are considered to be episodes of instability that favor disease progression, reduce quality of life, increase the risk of death and cause substantial healthcare resource use. These exacerbations are due to bacterial and viral infections and environmental stressors. However, other concomitant diseases such as heart disease, other lung diseases (e.g. pulmonary embolism, aspiration or pneumothorax) and other systemic processes can trigger or complicate these exacerbations. ⋯ The use of non-invasive mechanical ventilation should never delay intubation, if indicated. Hospital discharge criteria are based on both clinical and gasometric stabilization and on the patient's ability to manage his or her disease at home. Hospitalization at home can be a treatment option in COPD exacerbations and is as effective as conventional hospitalization.
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Arch. Bronconeumol. · Oct 2010
Review[Extracorporeal lung assist in severe respiratory failure and ARDS. Current situation and clinical applications].
Despite improvements in ventilation support techniques, lung protection strategies, and the application of new support treatment, acute respiratory distress syndrome continues to have a high mortality rate. Many strategies and treatments for this syndrome have been investigated over the last few year. However, the only therapeutic measure that has systematically shown to be able to improve survival is that of low volume lung protective ventilation. ⋯ On the other hand, it could be a potentially useful complementary method for an ultra-protective ventilation strategy, that is, by using even lower tidal volumes. The currently available extracorporeal lung assist systems are described in this article, including high flow systems such as traditional extracorporeal membrane oxygenation, CO₂ removal systems (interventional lung assist or iLA, with or without associated centrifugal pumps), and the new low flow and less invasive systems under development. The aim of this review is to update the latest available clinical and experimental data, the indications for these devices in adult respiratory distress syndrome (ARDS), and their potential indications in other clinical situations, such as the bridge to lung transplantation, multiple organ dysfunction syndrome, or COPD.
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Pulmonary thromboembolism is a frequent disease in emergency departments and often poses a diagnostic challenge that requires appropriate strategies. Clinical information, laboratory tests such as a D-dimer and imaging techniques such as computed tomography (CT) angiography, ventilation-perfusion scintigraphy or echocardiography help to establish clinical probability and the severity of the disease. ⋯ If the patient is at high risk, thrombolytic therapy is indicated, although possible contraindications should be thoroughly assessed. Supportive treatment may be considered in a few patients.