BACKGROUND: Laboratory studies suggest applying positive pressure without endotracheal suction during cuff deflation and extubation. Although some studies reported better physiological outcomes (e.g. arterial blood gases) with this technique, the safety of positive pressure extubation technique has not been well studied. The aim of this study was to determine the safety of the positive-pressure extubation technique compared with the traditional extubation technique in terms of incidence of complications. METHODS: Adult subjects who were critically ill and on invasive mechanical ventilation who met extubation criteria were included. The subjects were randomly assigned to positive-pressure extubation (n ‫؍‬ 120) or to traditional extubation (n ‫؍‬ 120). Sequential tests for noninferiority and, when appropriate, for superiority were performed. Positive pressure was considered noninferior if the upper limit of the CI for the absolute risk difference did not exceed a threshold of 15% in favor of the traditional group, both in per protocol and intentionto-treat analyses. A P value of <.05 was considered significant. RESULTS: A total of 236 subjects were included in the primary analysis (per protocol) (119 in the positive-pressure group and 117 in the traditional group). The incidence of overall major and minor complications, pneumonia, extubation failure, and reintubation was lower in the positive-pressure group than in the traditional group, with statistical significance for noninferiority both in the per protocol (P < .001) and intention-to-treat (P < .001) analyses. The lower incidence of major complications found in the positive-pressure group reached statistical significance for the superiority comparison, both in per protocol (P ‫؍‬ .03) and intention-to-treat (P ‫؍‬ .049) analyses. No statistically significant differences were found in the superiority comparison for overall complications, minor complications, pneumonia, extubation failure, and reintubation. CONCLUSIONS: Positive pressure was safe and noninferior to traditional extubation methods. Furthermore, positive pressure has shown to be superior in terms of a lower incidence of major complications. (ClinicalTrials.gov registration NCT03174509.

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BackgroundDespite research supporting the use of care coordination in chronic obstructive pulmonary disease (COPD), there is relatively little known about the comparative effectiveness of different strategies used to organize care for patients. To investigate the most important COPD care coordination strategies, community-based stakeholder input is needed, especially from medically underserved populations. Web-based platforms are electronic tools now being used to bring together individuals from underrepresented populations to share input and obtain clarification on comparative effectiveness research (CER) ideas, questions, and hypotheses.ObjectiveUse low computer-literate, collaborative survey technology to evaluate stakeholder priorities for CER in COPD care coordination.MethodsA mixed-method, concurrent triangulation design was used to collect survey data from a virtual advisory board of community-based stakeholders including medically underserved patients with COPD, informal caregivers, clinicians, and research scientists. The eDelphi method was used to conduct 3 iterative rounds of Web-based surveys. In the first 2 survey rounds, panelists viewed a series of “mini research prospectus” YouTube video presentations and rated their level of agreement with the importance of 10 COPD care coordination topics using 7-point Likert scales. In the final third-round survey, panelists ranked (1=most important, 8=least important) and commented on 8 remaining topics that panelists favored most throughout the first 2 survey rounds. Following the third-round survey, panelists were asked to provide feedback on the potential impact of a Web-based stakeholder engagement network dedicated to improving CER in COPD.ResultsThirty-seven panelists rated the following care coordination topics as most important (lower means indicate greater importance): (1) measurement of quality of care (mean 2.73, SD 1.95); (2) management of COPD with other chronic health issues (mean 2.92, SD 1.67); (3) pulmonary rehabilitation as a model for care (mean 3.72; SD 1.93); (4) quality of care coordination (mean 4.12, SD 2.41); and (5) comprehensive COPD patient education (mean 4.27, SD 2.38). Stakeholder comments on the relative importance of these care coordination topics primarily addressed the importance of comparing strategies for COPD symptom management and evaluating new methods for patient-provider communication. Approximately one half of the virtual panel assembled indicated that a Web-based stakeholder engagement network could enable more online community meetings (n=19/37, 51%) and facilitate more opportunities to suggest, comment on, and vote for new CER ideas in COPD (n=18/37, 49%).ConclusionsMembers of this unique virtual advisory board engaged in a structured Web-based communication process that identified the most important community-specific COPD care coordination research topics and questions. Findings from this study support the need for more CER that evaluates quality of care measures used to assess the delivery of treatments and inte...

Objetivo: Describir el estado funcional, calidad de vida y el grado de debilidad adquirida de los sujetos que ingresan a la sala de clínica médica (SCM) luego de haber cursado internación en área cerrada. Materiales y método: Estudio descriptivo. Se incluyeron mayores de 18 años con al menos 48 hs de internación en área cerrada, que ingresaron a un hospital público de CABA desde el 1° de junio hasta el 31 de octubre de 2019. Se registraron variables demográficas, calidad de vida y capacidad funcional. Se realizó un seguimiento telefónico al mes y tres meses del alta hospitalaria. Para la evaluación de las variables primarias se utilizaron el EuroQol 5D-5L (EQ-5D y EQ-VAS) y el Índice de Barthel (IB). Resultados: Se analizaron 36 sujetos. El EQ-VAS de ingreso fue de 50 (37,5-57,5) y de egreso 65 (50-70). El EQ-5D para sus cinco esferas se modificó positivamente durante la estadía en SCM. La mayoría se reportó como independiente previo al ingreso hospitalario, pero al ingresar a la SCM, al egreso y durante el seguimiento, mantuvieron algún nivel de dependencia. Conclusión: Este estudio describe la calidad de vida y capacidad funcional de 36 sujetos al ingreso a SCM, su evolución hasta el alta hospitalaria y un seguimiento a un mes y tres meses.

Introducción: La pandemia de la enfermedad por coronavirus de 2019 (COVID-19) se ha desarrollado rápidamente y desafía los sistemas de salud y a la sociedad. Se describe el primer paciente con COVID-19 con ventilación mecánica (VM) prolongada y traqueostomía (TQT) en la unidad de cuidados intensivos (UCI) de nuestro hospital.Presentación del caso: Paciente masculino de 42 años, con COVID-19 que desarrolló insuficiencia respiratoria aguda, requirió intubación orotraqueal y VM. Por sospecha de destete prolongado se le realizó TQT, posteriormente logró ser desvinculado de la VM y decanulado. Luego de 50 días de internación en UCI, evolucionó favorablemente y fue dado de alta.Conclusión: Este fue el primer paciente con COVID-19 que requirió VM y TQT en nuestro hospital. Los protocolos de VM, decanulación y rehabilitación pudieron adaptarse y ser llevados a cabo. Egresó decanulado y sin polineuropatía.