Background: This study was designed to determine the results associated with the use of noninvasive mechanical ventilation (NIV) using the BiPAP S/T-AVAPS ventilation strategy in subjects with mild to moderate de novo hypoxaemic respiratory failure. Methods: This is a prospective study that includes subjects with de novo hypoxaemic respiratory failure (not produced by acute exacerbations of COPD, chronic lung disease, or congestive heart failure) with mild to moderate PaO 2 /FiO 2 , who were admitted to the Intensive Care Unit (ICU) of Santa Maria Clinic in Guayaquil, Ecuador. Subjects were divided into two groups and compared according to their PaO 2 /FiO 2 : higher than 100 and up to 200 mm Hg (moderate ARDS) or between 200 and 300 mm Hg (mild ARDS) (both groups were ventilated with the BiPAP S/T-AVAPS strategy). Results: A total of 38 subjects were analysed in this study. The total rate of intubation was 34.2% while the mortality rate was 28.9%. Significant differences were observed when comparing success versus failure in exhaled tidal volumes heart rate (P = 0.04), peak inspired pressure (P < 0.001), PaO 2 (P < 0.001), SaO 2 (P < 0.002), PaO 2 /FiO 2 (P < 0.002), arterial blood pressure (P < 0.001), HR (P < 0.001), and inspiratory time (P = 0.029) measured at baseline and at 12-hour, 24-hour and 48-hour intervals. Conclusion: The BiPAP S/T-AVAPS ventilatory mode can be used in subjects with de novo hypoxaemic respiratory failure with special vigilance concerning exhaled tidal volumes and inspired pressure.

Patient: Female, 86-year-old Final Diagnosis: Aspergillus fumigatus infection • azygos vein aneurysm with thrombosis Symptoms: Acute respiratory failure • paresthesia Medication: — Clinical Procedure: Bronchoscopy Specialty: Critical Care Medicine • General and Internal Medicine • Pulmonology Objective: Unusual clinical course Background: The venous system of the posterior thoracic wall merges into a single trunk called the azygos vein, located in the posterior mediastinum, before draining into the superior vena cava. An aneurysm in the azygos vein is extremely rare. Such aneurysms are discovered as incidental radiology findings or while investigating a mediastinal mass. Visualization via bronchoscopy is atypical. Case Report: An 86-year-old female patient presented to the Emergency Department with a 5-day complaint of dyspnea and chest pain. She was admitted because of worsening condition leading to respiratory failure and paresthesias. She underwent endotracheal intubation and invasive mechanical ventilatory support. A chest X-ray showed a thickened mediastinum, tortuous thoracic aorta, and bilateral perihilar infiltrate with right predominance. Bronchoscopy revealed bleeding along the right bronchus and a blue protrusion coated with white material at the entrance of the main right bronchus. A pulmonary computed tomography angiography confirmed the presence of an azygos vein dilatation. Culture of bronchoalveolar lavage revealed Aspergillus fumigatus . Conclusions: Bronchoscopy as a diagnostic method allows clinicians to verify the state and permeability of the airways during investigation of azygos vein aneurysms, which are rare entities but should be considered in the differential diagnosis of mediastinal masses and may be complicated by fungal pathogens such as Aspergillus fumigatus mostly in immunocompromised patients.

Rare co-existance of disease or pathology Background: Spontaneous pneumothorax can be secondary to a wide variety of lung diseases. Spontaneous pneumothorax secondary to pulmonary tuberculosis occurs in rare cases of residual fibrosis with retractions and bullae. Case Report: We present the case of a 65-year-old male patient from a rural area in the province of Los Ríos in Babahoyo, Ecuador, with no history of contact with tuberculosis. The patient arrived at the Emergency Department of the Regional Hospital of the Instituto Ecuatoriano de Seguridad Social (IESS), Babahoyo, due to acute respiratory failure, preceded by 10 days of evolution due to cough accompanied by greenish expectoration, chest pain, asthenia, and weight loss. On chest radiography, a left pneumothorax and interstitial pulmonary infiltrate were reported. A chest tube was placed, and the patient was intubated and was placed on invasive mechanical ventilation due to severe respiratory failure. Use of the GeneXpert MTB/RIF System detected Mycobacterium tuberculosis without resistance to rifampicin. Ziehl-Neelsen (ZN) staining for the identification of bacillus acid-resistant alcohol was positive in alveolar bronchial lavage. MALDI-TOF mass spectrometry and phenotypic analysis showed the presence of Pseudomonas aeruginosa and Klebsiella pneumonia with carbapenemases resistance mechanism, and the KPC type enzyme was identified. The culture for Mycobacterium tuberculosis was positive from the fourth week. Conclusions: Secondary pneumothorax due to rupture of the polymicrobial cavity and especially of tuberculous origin is a very special form of acute respiratory failure in patients with previous structural pulmonary lesions in the Emergency Department.

Ischemic stroke and disseminated tuberculosis Symptoms:Aphasia • deterioration of the level of consciousness • deviation of the labial commissure Medication:-Clinical Procedure:-Specialty:Critical Care Medicine Objective:Unusual clinical course Background:Tuberculosis (TB) continues to be a major public health problem worldwide. Extrapulmonary tuberculosis at the level of the central nervous system is the most devastating and deadly form of tuberculosis. Case Report:We present the case of a 73-year-old male Ecuadorian patient with no history of contact with tuberculosis and with a clinical picture of 4 days of evolution characterized by aphasia, deviation of the labial commissure, and deterioration of the level of consciousness with a Glasgow coma score of 7/15. A brain tomography showed evidence of indirect signs of cerebral ischemia; the patient was therefore diagnosed with non-specific cerebrovascular disease. Due to the critical nature of his clinical picture, the patient entered the Intensive Care Unit (ICU), where a chest x-ray was performed and bilateral perihilar alveolar opacities with a reticular and nodular pattern were visualized. These results, combined with the bronchoalveolar brushing, evidenced the presence of Mycobacterium tuberculosis. Adenosine of deaminase (ADA) was also detected in the cerebrospinal fluid with 30.7 µ/L and a molecular biology technique was used with high-multiplex real-time polymerase matrix MALDI-TOF mass spectrometry (Brucker Daltonics) for rapid identification of the causative agent. DNA/polymerase chain reaction (PCR) analyses were used for detection of M. tuberculosis, subsequently confirming the presence of cerebral tuberculosis. Conclusions:This case illustrated an infrequent form of disseminated tuberculosis in a critically ill patient. Timely diagnosis and appropriate management are essential to reducing mortality.

Flexible video bronchoscopy is a procedure that plays an important role in diagnosing various types of pulmonary lesions and abnormalities. Case 1 is a 68-year-old male patient with a lesion in the right lung apex of approximately 4 mm × 28 mm with atelectasis bands due to a crash injury. High-flow system with 35 L/min and fraction of inspired oxygen (FiO2) 0.45 and temperature of 34 °C was installed prior to the video bronchoscopy. SpO2 was maintained at 98%–100%. The total dose of sedative was 50 mg of propofol. In Case 2, a 64-year-old male patient with bronchiectasis, cystic lesions and pulmonary fibrosis of the left lung field was placed on a high-flow system with 45 L/min and 0.35 FiO2 at a temperature of 34 °C. SpO2 was maintained at 100%. The total duration of the procedure was 25 min; SpO2 of 100% was sustained with oxygenation during maintenance time with the flexible bronchoscope within the airway. The total dose of propofol to reach the degree of desired sedation was 0.5–1 mg/kg. Both patients presented hypotension. For the patient of case 1, a vasopressor (norepinephrine at doses of 0.04 µg/kg/min) was given, and for the patient of case 2, only saline volume expansion was used. The video bronchoscopy with propofol sedation and high-flow nasal cannula allows adequate oxygenation during procedure in the intensive care unit.