To investigate the excess of deaths by specific causes, in the first half of 2020 in the city of São Paulo-Brazil, during the COVID-19 pandemic. Ecological study conducted from 01/01 to 06/30 of 2019 ...and 2020. Population and mortality data were obtained from DATASUS. The standardized mortality ratio (SMR) by age was calculated by comparing the standardized mortality rate in 2020 to that of 2019, for overall and specific mortality. The ratio between the standardized mortality rate due to COVID-19 in men as compared to women was calculated for 2020. Crude mortality rates were standardized using the direct method. COVID-19 was responsible for 94.4% of the excess deaths in São Paulo. In 2020 there was an increase in overall mortality observed among both men (SMR 1.3, 95% CI 1.17-1.42) and women (SMR 1.2, 95% CI 1.06-1.36) as well as a towards reduced mortality for all cancers. Mortality due to COVID-19 was twice as high for men as for women (SMR 2.1, 95% CI 1.67-2.59). There was an excess of deaths observed in men above 45 years of age, and in women from the age group of 60 to 79 years. There was an increase in overall mortality during the first six months of 2020 in São Paulo, which seems to be related to the COVID-19 pandemic. Chronic health conditions, such as cancer and other non-communicable diseases, should not be disregarded.
Abstract Purpose The purpose of the study is to identify risk factors for noninvasive ventilation (NIV) failure in cancer patients with acute respiratory failure (ARF). Materials and methods A ...retrospective cohort study of adult patients admitted to intensive care unit (ICU), who received NIV for treatment of ARF, was conducted. We conducted a chart review to estimate the NIV failure rate and used logistic regression to identify risk factors. Results Of 2258 patients admitted to the ICU during the study period, 114 (5%) received NIV for ARF. Noninvasive ventilation was successful in 67 patients (59%) and failed for 47 (41%), of whom 36 were intubated and 11 were sedated for palliation. Factors associated with NIV failure were infection as the primary cause of ARF (odds ratio OR, 4.90; 95% confidence interval CI, 1.78-13.45; P = .002), male sex (OR, 2.58; 95% CI, 1.20-5.56; P = .015), and Simplified Acute Physiology Score 3 (OR, 1.04; 95% CI, 1.01-1.07; P = .006). Overall ICU mortality was 40%, and hospital mortality was 56%. Noninvasive ventilation failure was the only independent predictor of ICU mortality (OR, 16.6; 95% CI, 6.5-41.5; P < .001). Conclusions Noninvasive ventilation can avert ARF for most ICU cancer patients with ARF. For patients with pulmonary infections and high severity scores, NIV should be used with caution. Identifying risk factors for NIV failure using a comprehensive diagnostic approach and monitoring of NIV are paramount to improve outcomes.
Early mobilization can be performed in critically ill patients and improves outcomes. A daily cycling exercise started from day 5 after ICU admission is feasible and can enhance functional capacity ...after hospital discharge. In the present study we verified the physiological changes and safety of an earlier cycling intervention (< 72 hrs of mechanical ventilation) in critical ill patients.
Nineteen hemodynamically stable and deeply sedated patients within the first 72 hrs of mechanical ventilation were enrolled in a single 20 minute passive leg cycling exercise using an electric cycle ergometer. A minute-by-minute evaluation of hemodynamic, respiratory and metabolic variables was undertaken before, during and after the exercise. Analyzed variables included the following: cardiac output, systemic vascular resistance, central venous blood oxygen saturation, respiratory rate and tidal volume, oxygen consumption, carbon dioxide production and blood lactate levels.
We enrolled 19 patients (42% male, age 55 ± 17 years, SOFA = 6 ± 3, SAPS3 score = 58 ± 13, PaO2/FIO2 = 223 ± 75). The median time of mechanical ventilation was 1 day (02), and 68% (n=13) of our patients required norepinephrine (maximum concentration = 0.47 µg.kg(-1).min(-1)). There were no clinically relevant changes in any of the analyzed variables during the exercise, and two minor adverse events unrelated to hemodynamic instability were observed.
In our study, this very early passive cycling exercise in sedated, critically ill, mechanically ventilated patients was considered safe and was not associated with significant alterations in hemodynamic, respiratory or metabolic variables even in those requiring vasoactive agents.
Hematopoietic stem cell transplantation (HSCT) recipients requiring intensive care unit (ICU) admission early after transplantation have a poor prognosis. However, many studies have only focused on ...allogeneic HSCT recipients.
To describe the characteristics of HSCT recipients admitted to the ICU shortly after transplantation and assess differences in 1-year mortality between autologous and allogeneic HSCT recipients.
A single-center retrospective cohort study in a cancer center in Brazil.
We included all consecutive patients who underwent HSCT less than a year before ICU admission between 2009 and 2018. We collected clinical and demographic data and assessed the 1-year mortality of all patients. The effect of allogeneic HSCT compared with autologous HSCT on 1-year mortality risk was evaluated in an unadjusted model and an adjusted Cox proportional hazard model for age and Sequential Organ Failure Assessment (SOFA) at admission.
Of the 942 patients who underwent HSCT during the study period, 83 (8.8%) were included in the study (autologous HSCT = 57 68.7%, allogeneic HSCT = 26 31.3%). At 1 year after ICU admission, 21 (36.8%) and 18 (69.2%) patients who underwent autologous and allogeneic HSCT, respectively, had died. Allogeneic HSCT was associated with increased 1-year mortality (unadjusted hazard ratio, HR = 2.79 confidence interval, CI, 95%, 1.48-5.26; adjusted HR = 2.62 CI 95%, 1.29-5.31).
Allogeneic HSCT recipients admitted to the ICU had higher short- and long-term mortality rates than autologous HSCT recipients, even after adjusting for age and severity at ICU admission.
The diaphragm is the main muscle of respiration, acting continuously and uninterruptedly to sustain the task of breathing. Diaphragmatic dysfunction can occur secondary to numerous pathological ...conditions and is usually underdiagnosed in clinical practice because of its nonspecific presentation. Although several techniques have been used in evaluating diaphragmatic function, the diagnosis of diaphragmatic dysfunction is still problematic. Diaphragmatic ultrasound has gained importance because of its many advantages, including the fact that it is noninvasive, does not expose patients to radiation, is widely available, provides immediate results, is highly accurate, and is repeatable at the bedside. Various authors have described ultrasound techniques to assess diaphragmatic excursion and diaphragm thickening in the zone of apposition. Recent studies have proposed standardization of the methods. This article reviews the usefulness of ultrasound for the evaluation of diaphragmatic function, addressing the details of the technique, the main findings, and the clinical applications.
Fibrotic interstitial lung disease (FILD) patients are typically dyspneic and exercise-intolerant with consequent impairment of health-related quality of life (HRQoL). Respiratory muscle dysfunction ...is among the underlying mechanisms of dyspnea and exercise intolerance in FILD but may be difficult to diagnose. Using ultrasound, we compared diaphragmatic mobility and thickening in FILD cases and healthy controls and correlated these findings with dyspnea, exercise tolerance, HRQoL and lung function.
We measured diaphragmatic mobility and thickness during quiet (QB) and deep breathing (DB) and calculated thickening fraction (TF) in 30 FILD cases and 30 healthy controls. We correlated FILD cases' diaphragmatic findings with dyspnea, exercise tolerance (six-minute walk test), lung function and HRQoL (St. George's Respiratory Questionnaire).
Diaphragmatic mobility was similar between groups during QB but was lower in FILD cases during DB when compared to healthy controls (3.99 cm vs 7.02 cm; p < 0.01). FILD cases showed higher diaphragm thickness during QB but TF was lower in FILD when compared to healthy controls (70% vs 188%, p < 0.01). During DB, diaphragmatic mobility and thickness correlated with lung function, exercise tolerance and HRQoL, but inversely correlated with dyspnea. Most FILD cases (70%) presented reduced TF, and these patients had higher dyspnea and exercise desaturation, lower HRQoL and lung function.
Compared to healthy controls, FILD cases present with lower diaphragmatic mobility and thickening during DB that correlate to increased dyspnea, decreased exercise tolerance, worse HRQoL and worse lung function. FILD cases with reduced diaphragmatic thickening are more dyspneic and exercise-intolerant, have lower HRQoL and lung function.
Abstract Purpose The purposes of this study were to evaluate the clinical course and to identify independent predictors of mortality in patients with cancer with sepsis. Materials and Methods This is ...a secondary analysis of a prospective cohort study conducted at an oncological medical-surgical intensive care unit. Logistic regression was used to identify predictors of hospital mortality. Results A total of 563 patients (77% solid tumor, 23% hematologic malignancies) were included over a 55-month period. The most frequent sites of infection were the lung, abdomen, and urinary tract; 91% patients had severe sepsis/septic shock. Gram-negative bacteria were responsible for more than half of the episodes of infection; 38% of patients had polymicrobial infections. Intensive care unit, hospital, and 6-month mortality rates were 51%, 65%, and 72%, respectively. In multivariate analyses, sepsis in the context of medical complications; active disease; compromised performance status; presence of 3 to 4 systemic inflammatory response syndrome criteria; and the presence of respiratory, renal, and cardiovascular failures were associated with increased mortality. Adjusting for other covariates, patients with non–urinary tract infections, mostly represented by patients with pneumonia and abdominal infections, had worse outcomes. Conclusions Sepsis remains a frequent complication in patients with cancer and associated with high mortality. Our results can be of help to assist intensivists in clinical decisions and to improve characterization and risk stratification in these patients.
Very elderly critically ill patients (ie, those older than 75 or 80 years) are an increasing population in intensive care units. However, patients with cancer have encompassed only a minority in ...epidemiological studies of very old critically-ill patients. We aimed to describe clinical characteristics and identify factors associated with hospital mortality in a cohort of patients aged 80 or older with cancer admitted to intensive care units (ICUs). This was a retrospective cohort study in 94 ICUs in Brazil. We included patients aged 80 years or older with active cancer who had an unplanned admission. We performed a mixed effect logistic regression model to identify variables independently associated with hospital mortality. Of 4604 included patients, 1807 (39.2%) died in hospital. Solid metastatic (OR = 2.46; CI 95%, 2.01-3.00), hematological cancer (OR = 2.32; CI 95%, 1.75-3.09), moderate/severe performance status impairment (OR = 1.59; CI 95%, 1.33-1.90) and use of vasopressors (OR = 4.74; CI 95%, 3.88-5.79), mechanical ventilation (OR = 1.54; CI 95%, 1.25-1.89) and renal replacement (OR = 1.81; CI 95%, 1.29-2.55) therapy were independently associated with increased hospital mortality. Emergency surgical admissions were associated with lower mortality compared to medical admissions (OR = 0.71; CI 95%, 0.52-0.96). Hospital mortality rate in very elderly critically ill patients with cancer with unplanned ICU admissions are lower than expected a priori. Cancer characteristics, performance status impairment and acute organ dysfunctions are associated with increased mortality.
Impairment of (inspiratory and expiratory) respiratory muscles is a common clinical finding, not only in patients with neuromuscular disease but also in patients with primary disease of the lung ...parenchyma or airways. Although such impairment is common, its recognition is usually delayed because its signs and symptoms are nonspecific and late. This delayed recognition, or even the lack thereof, occurs because the diagnostic tests used in the assessment of respiratory muscle strength are not widely known and available. There are various methods of assessing respiratory muscle strength during the inspiratory and expiratory phases. These methods are divided into two categories: volitional tests (which require patient understanding and cooperation); and non-volitional tests. Volitional tests, such as those that measure maximal inspiratory and expiratory pressures, are the most commonly used because they are readily available. Non-volitional tests depend on magnetic stimulation of the phrenic nerve accompanied by the measurement of inspiratory mouth pressure, inspiratory esophageal pressure, or inspiratory transdiaphragmatic pressure. Another method that has come to be widely used is ultrasound imaging of the diaphragm. We believe that pulmonologists involved in the care of patients with respiratory diseases should be familiar with the tests used in order to assess respiratory muscle function.Therefore, the aim of the present article is to describe the advantages, disadvantages, procedures, and clinical applicability of the main tests used in the assessment of respiratory muscle strength.