Browsing by Author "Jalil Contreras, Yorschua Frederick"

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    A deep look into the rib cage compression technique in mechanically ventilated patients: a narrative review
    (2022) Jalil Contreras, Yorschua Frederick; Damiani, L. Felipe; Basoalto, Roque; Bachmman, María Consuelo; Bruhn, Alejandro
    Defective management of secretions is one of the most frequent complications in invasive mechanically ventilated patients. Clearance of secretions through chest physiotherapy is a critical aspect of the treatment of these patients. Manual rib cage compression is one of the most practiced chest physiotherapy techniques in ventilated patients; however, its impact on clinical outcomes remains controversial due to methodological issues and poor understanding of its action. In this review, we present a detailed analysis of the physical principles involved in rib cage compression technique performance, as well as the physiological effects observed in experimental and clinical studies, which show that the use of brief and vigorous rib cage compression, based on increased expiratory flows (expiratory-inspiratory airflow difference of > 33L/minute), can improve mucus movement toward the glottis. On the other hand, the use of soft and gradual rib cage compression throughout the whole expiratory phase does not impact the expiratory flows, resulting in ineffective or undesired effects in some cases. More physiological studies are needed to understand the principles of the rib cage compression technique in ventilated humans. However, according to the evidence, rib cage compression has more potential benefits than risks, so its implementation should be promoted.
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    Disfunción Diafragmática en Ventilación Mecánica: Evaluación e Implicancias Clínicas
    (2020) Damiani Rebolledo, Luis Felipe; Jalil Contreras, Yorschua Frederick; Dubó, Sebastián
    La debilidad diafragmática es un problema relevante en pacientes admitidos a la unidad de cuidados intensivos (UCI). Su presencia ha sido asociada a mayor tiempo en ventilación mecánica, weaning dificultoso, mayor riesgo de readmisión hospitalaria y mayor mortalidad. Las causas de esta debilidad son múltiples incluyendo factores relacionados a la severidad de la enfermedad, las intervenciones en la UCI y el uso de ventilación mecánica, termino conocido como miotrauma. Se han propuesto cuatro diferentes mecanismos de miotrauma relacionados a la sobre asistencia ventilatoria, baja asistencia ventilatoria, ocurrencia de contracciones diafragmáticas excéntricas y efecto de la presión espiratoria al final de espiración. Una adecuada evaluación y monitoreo de la función diafragmática es, por lo tanto, un aspecto clave que debe ser realizado al lado de la cama del paciente. La prueba de referencia para medir la función del diafragma es la presión transdiafragmática calculada como la diferencia entre la presión gástrica y presión esofágica. Adicionalmente, otras técnicas disponibles para la evaluación de la función del diafragma corresponden a la ecografía y la medición de la actividad eléctrica. Desde un punto de vista clínico, basado en la evidencia sobre disfunción diafragmática en los pacientes ventilados mecánicamente, uno de los principales desafíos actuales es poder buscar estrategias ventilatorias que incorporen protección diafragmática mientras se mantiene una ventilación protectora pulmonar. En este sentido, favorecer un nivel de esfuerzo inspiratorio adecuado junto con optimizar la interacción entre el paciente y el ventilador constituyen los principales objetivos de una ventilación diafragmática protectora.
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    Eccentric Contractions of the Diaphragm During Mechanical Ventilation
    (2023) García Valdés, Patricio Hernán; Fernandez Mincone, Tiziana Rita; Jalil Contreras, Yorschua Frederick; Peñailillo, Luis; Damiani Rebolledo, L. Felipe
    Diaphragm dysfunction is a highly prevalent phenomenon in patients receiving mechanical ventilation, mainly due to ventilatory over-assistance and the development of diaphragm disuse atrophy. Promoting diaphragm activation whenever possible and facilitating an adequate interaction between the patient and the ventilator is encouraged at the bedside to avoid myotrauma and further lung injury. Eccentric contractions of the diaphragm are defined as muscle activation while muscle fibers are lengthening within the exhalation phase. There is recent evidence that suggests that eccentric activation of the diaphragm is very frequent and may occur during post-inspiratory activity or under different types of patient-ventilator asynchronies, which include ineffective efforts, premature cycling, and reverse triggering. The consequences of this eccentric contraction of the diaphragm may have opposite effects, depending on the level of breathing effort. For instance, during high or excessive effort, eccentric contractions can result in diaphragm dysfunction and injured muscle fibers. Conversely, when eccentric contractions of the diaphragm occur along with low breathing effort, a preserved diaphragm function, better oxygenation, and more aerated lung tissue are observed. Despite this controversial evidence, evaluating the level of breathing effort at the bedside seems crucial and is highly recommended to optimize ventilatory therapy. The impact of eccentric contractions of the diaphragm on the patient's outcome remains to be elucidated.
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    Effects of the First Spontaneous Breathing Trial in Children With Tracheostomy and Long-Term Mechanical Ventilation
    (NLM (Medline), 2023) Villarroel-Silva, Gregory; Jalil Contreras, Yorschua Frederick; Moya-Gallardo, E.; Oyarzun Aguirre, Ignacio Javier; Moscoso Altamira, Gonzalo Andrés; Astudillo Maggio, Claudia Ester; Damiani Rebolledo, Luis Felipe
    Copyright © 2023 by Daedalus Enterprises.BACKGROUND: Weaning and liberation from mechanical ventilation in pediatric patients with tracheostomy and long-term mechanical ventilation constitute a challenging process due to diagnosis heterogeneity and significant variability in the clinical condition. We aimed to evaluate the physiological response during the first attempt of a spontaneous breathing trial (SBT) and to compare variables in subjects who failed or passed the SBT. METHODS: This was a prospective observational study in tracheostomized children with long-term mechanical ventilation admitted to the Hospital Josefina Martinez, Santiago, Chile, between 2014-2020. Cardiorespiratory variables such as breathing pattern, use of accessory respiratory muscles, heart rate, breathing frequency, and oxygen saturation were registered at baseline and throughout a 2-h SBT with or without positive pressure depending on an SBT protocol. Comparison of demographic and ventilatory variables between groups (SBT failure and success) was performed. RESULTS: A total of 48 subjects were analyzed (median [IQR] age of 20.5 [17.0-35.0] months, 60% male). Chronic lung disease was the primary diagnosis in 60% of subjects. Eleven (23%) total subjects failed the SBT (< 2 h), with an average failure time of 69 ± 29 min. Subjects who failed the SBT had a significantly higher breathing frequency, heart rate, and end-tidal CO2 than subjects who succeeded (P < .001). In addition, subjects who failed the SBT had significantly shorter duration of mechanical ventilation before the SBT, higher proportion unassisted SBT, and higher rate of deviation SBT protocol in comparison with subjects who succeeded. CONCLUSIONS: Conducting an SBT to evaluate the tolerance and cardiorespiratory response in tracheostomized children with long-term mechanical ventilation is feasible. Time on mechanical ventilation before the first attempt and type of SBT (with or without positive pressure) could be associated with SBT failure.
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    Lung aeration estimated by chest electrical impedance tomography and lung ultrasound during extubation
    (2023) Joussellin, Vincent; Bonny, Vincent; Spadaro, Savino; Clerc, Sébastien; Parfait, Mélodie; Ferioli, Martina; Sieye, Antonin; Jalil Contreras, Yorschua Frederick; Janiak, Vincent; Pinna, Andrea; Dres, Martin
    Abstract: Background: This study hypothesized that patients with extubation failure exhibit a loss of lung aeration and heterogeneity in air distribution, which could be monitored by chest EIT and lung ultrasound. Patients at risk of extubation failure were included after a successful spontaneous breathing trial. Lung ultrasound [with calculation of lung ultrasound score (LUS)] and chest EIT [with calculation of the global inhomogeneity index, frontback center of ventilation (CoV), regional ventilation delay (RVD) and surface available for ventilation] were performed before extubation during pressure support ventilation (H0) and two hours after extubation during spontaneous breathing (H2). EIT was then repeated 6 h (H6) after extubation. EIT derived indices and LUS were compared between patients successfully extubated and patients with extubation failure. Results: 40 patients were included, of whom 12 (30%) failed extubation. Before extubation, when compared with patients with successful extubation, patients who failed extubation had a higher LUS (19 vs 10, p = 0.003) and a smaller surface available for ventilation (352 vs 406 pixels, p = 0.042). After extubation, GI index and LUS were higher in the extubation failure group, whereas the surface available for ventilation was lower. The RVD and the CoV were not different between groups. Conclusion: Before extubation, a loss of lung aeration was observed in patients who developed extubation failure afterwards. After extubation, this loss of lung aeration persisted and was associated with regional lung ventilation heterogeneity. Trial registration Clinical trials, NCT04180410, Registered 27 November 2019—prospectively registered. https://clinicaltrials.gov/ct2/show/NCT04180410
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    Reduction of Respiratory Rate in COVID-19-Associated ARDS
    (2022) Damiani, L. Felipe; Oviedo, Vanessa; Alegria, Leyla; Soto, Dagoberto; Basoalto, Roque; Consuelo Bachmann, M.; Jalil Contreras, Yorschua Frederick; Santis, Cesar; Vera, Magdalena; Retamal, Jaime; Bruhn, Alejandro; Bugedo, Guillermo
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    Role of neuromuscular electrical stimulation to prevent respiratory muscle weakness in critically ill patients and its association to changes in myokines profile: a randomized clinical trial
    (2024) Jalil Contreras, Yorschua Frederick; Bruhn, Alejandro; Pontificia Universidad Católica de Chile. Facultad de Medicina
    Introduction: Critically ill patients hospitalized at Intensive Care Units (ICU) are characterized by an accelerated muscle wasting, particularly of respiratory muscles, occurring early due to mechanical ventilation (MV). Although active muscle activation may prevent these alterations, it is usually not available at early stages of care because of sedation, favoring a vicious circle. Neuromuscular electrical stimulation (NMES) represents an alternative to achieve muscle contraction in this setting, being able to prevent local muscle wasting, and according to some reports, has the potential to shorten MV time. It has been suggested that this potential benefit might be explained by systemic effects of NMES on distant muscles due to the release of myokines, a diverse range of chemokines secreted by myocytes during contraction. However, no studies have evaluated whether NMES applied to peripheral muscles (quadriceps) in critically ill patients can exert distant muscle effects over the diaphragm, and if such effects are associated to changes in myokine concentrations. Objective: To determine the effects of NMES applied to both quadriceps on myokine plasmatic concentrations, and on peripheral and respiratory muscle function and structure, in mechanical ventilated ICU patients when initiated at an early phase of their critical illness. Methods: Exploratory randomized controlled trial of NMES applied to both quadriceps, twice a day, for 3 days, in comparison to standard care (control group, CG). For myokine characterization (IL-6, BDNF, Myostatin and Decorin), blood samples were obtained at baseline (T0), at the end of the NMES session (T1), and 2 and 6 hours later (T2 and T6). This sampling was repeated on days 1 and 3. For the control group (CG) blood samples were obtained only at T0 and T6. An additional blood sample was also taken on Day 4 (T0) for both groups. Muscle characterization was performed at days 1 and 3 (T0 and T6 respectively). This consisted in ultrasonography of quadriceps muscle layer thickness (MLT), and diaphragmatic thickening fraction (TFdi), along with tracheal tube pressure derived from phrenic nerve magnetic stimulation (Ptr,tw), for diaphragmatic function. Results: 11 patients were randomized: 6 to CG and 5 to NMES. No differences were observed between groups at baseline. No significant interaction was detected between time (across the 4-day protocol) and intervention (NMES or not) for quadriceps MLT change (p-value of 0.12). However, time as factor had a significant impact on MLT explained by a decrease from 1.92 ± 0.81 cm on day 1 to 1.63 ± 0.85 cm on day 3 in the CG, with a p-value of 0.003, while no change along time was observed in the NMES group (Change from 1.76 ± 0.62 cm on day 1 to 1.66 ± 0.61 cm on day 3, with a p-value of 0.51). Concerning diaphragmatic thickening fraction (TFdi), a significant interaction was detected between time (across the 4-day protocol) and intervention (NMES or not) (p-value of 0.006). While in the CG there was an absolute TFdi decrease of 8.93% ± 6.4 (-32.6 ± 25.3 % of relative change) along time, in the NMES group TFdi increased 5.14± 6.55 % (+38.15 ± 58.6 % of relative change). Considering Twitch tracheal pressure (Ptr,tw), a significant interaction was detected between time (across the 4-day protocol) and intervention (NMES or not) (p-value of 0.04). In the control group, Ptr,tw exhibited an absolute change of -1.43 ± 0.68 cmH20, corresponding to a relative decrease of 19.49% ± 16.98 from baseline values to day 3, while the NMES group experienced an absolute change of +2.5 ± 3.8 cmH2O, equivalent to a relative increase of 46.4 ± 45.6 %. Analyzing the raw plasmatic concentrations of myokines, no significant interaction was detected between time (across the 4-day protocol) and intervention (NMES or not) for any of the myokine concentrations (Decorin, Myostatin, IL-6 and BDNF). Moreover, there were no significant changes observed either within or between groups at any time point. Conclusion: The preliminary data analysed supports the notion that peripheral NMES can preserve respiratory muscle function. It appears that this effect is not mediated by changes in any of the myokines included in the present study. Therefore, alternative mechanisms should be considered to explain how NMES may favour respiratory muscle preservation. The results observed on peripheral muscle layer thickness are yet unconclusive with the limited sample size analysed. Data from a larger number of patients is required to confirm these preliminary conclusions.
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    The COVID-19 Driving Force: How It Shaped the Evidence of Non-Invasive Respiratory Support
    (2023) Jalil Contreras, Yorschua Frederick; Ferioli, Martina; Dres, Martin
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    Utilidad de los cuestionarios de tamizaje para trastornos respiratorios del sueño en pediatría
    (2017) Damiani Rebolledo, L. Felipe; Jalil Contreras, Yorschua Frederick; Brockmann Veloso, Pablo
    La presencia de trastornos respiratorios del sueño (TRS) en la población pediátrica ha sido asociada a múltiples e importantes problemas de salud. Desafortunadamente, gran parte de los TRS continúan siendo subdiagnosticados debido a diferentes factores tales como reducida disponibilidad para la realización de exámenes de referencia en la población o limitadas herramientas diagnósticas. Intentando superar estas barreras, la utilización de cuestionarios como herramienta diagnóstica emerge como una alternativa de tamizaje efectiva para la detección de los TRS. Dependiendo de los parámetros a evaluar, se pueden encontrar cuestionarios que valoran aspectos relacionados a los TRS o bien parámetros específicos del sueño como su duración o calidad. En la actualidad el cuestionario “Pediatric sleep Questionnaire” (PSQ) constituye una de las herramientas validadas para la detección de TRS a nivel mundial. En Chile, la exactitud diagnóstica del PSQ fue evaluada en 83 niños entre 0 y 15 años, observando un área bajo la curva (AUC) de 0.687 (IC95% 0.567–0.808), una sensibilidad de 0.78 y una especificidad de 0.72. Basado en la información presentada en este trabajo, la aplicación de cuestionarios de tamizaje, específicamente el PSQ en la población pediátrica es factible, constituyendo una alternativa para la detección de los TRS en el contexto clínico nacional y durante el proceso de investigación en medicina del sueño.