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High Flow Nasal Cannula (HFNC) is an alternative treatment for acute respiratory failure. Although, due to its highly cost in Brazil, HFNC is not widely used. Objective:To describe the use of HFNC in the clinical practice of a single hospital in Brazil. Methods:Retrospective study performed at a single private tertiary hospital in Brazil, analyzing a specific HFNC database of the physiotherapy department. Consecutive adult patients admitted to the critically ill department requiring HFNC between June 2016 and June 2018 were included, and palliative care patients were excluded. The following variables from the database were analyzed: demographic data, reason for and days on HFNC, rate of patients alternating with noninvasive ventilation (NIV), HFNC success rate (defined as no need for intubation or not dependent of NIV), and related adverse events. Results:Fifth five patients were included in the analysis, 31 (56.4%) of whom were female, and a median age of 67 (range of 17-102) years old. The most prevalent reason for HFNC was due to hypoxemic acute respiratory failure [65% (36/55)], followed by intolerance of NIV use [20% (11/55)], hypercapnic acute respiratory failure and for postextubation in high-risk patients [5.5%], and 3.6% on "mixed" acute respiratory failure. Patients remained on HFNC for a mean time of 3.2(± 2.6) days, and 56.4% [31/55] alternated with NIV. The success rate was 78.2% [43/55], with the need for intubation as the most prevalent reason of unsuccess [75% (9/12)]. Adverse events were reported in 9.1% [5/55) of patients, all due to circuit condensation. Conclusion:HFNC were mostly used in hypoxemic acute respiratory failure, up to 72 hours of use, with a high success rate, and low incidence of adverse events.

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Introduction: Heart rate (HR) has been a simple and easy-to-use physiological parameter widely used to determine exercise intensity. The critical power fatigue limit model, known as the critical heart rate (CHR), can be extrapolated to HR. However, an estimate for a CHR mathematical model has not yet been extrapolated for upper limb exercise in the elderly. Objective: To compare the mathematical model previously used to estimate CHR with the heart rate values at the critical power (CP) during arm-ergometer exercises in elderly subjects. Methods: After an initial maximum-incremental exercise test on a cycle arm-ergometer, seven elderly people performed four high-intensity constant-load tests to the limit of tolerance (Tlim), to determine CP and critical heart rate (CHR). For each power output, the heart rate of the last five seconds (HRlim) and total time to exhaustion (in minutes) were obtained. The slope coefficients of the regression lines between HRlim and Tlim were defined as CHR, and between Wlim and Tlim as CP. A square-wave test was performed on a different day, in the power determined as equivalent to CP, and the heart rate at CP (CPHR) was assessed. Results: The HR-Tlim relationship was found to be hyperbolic in all subjects, who were able to sustain upper-limb exercise at CP for 20 min. CP attained 66.8±9.4% of peak work rate in the ramp test. The real average HR measured in the CP test was strikingly similar to the CHR calculated by the mathematical model of PC (137.6±16.9 versus 139.7±13.3bpm, respectively, p=0.53). There was strong correlation between the real and the estimated CHR. Conclusion: This study indicated that the maximal sustainable exercise intensity can be based on a physiological variable such as HR, and the CHR test can define exercise endurance, which can be useful in performance assessment and training prescription. Level of evidence II; Diagnostic studies – Investigating a diagnostic test.

Background Transcatheter tricuspid valve–in–valve replacement for patients with degenerative tricuspid surgical bioprosthesis disease has emerged in recent years as a new treatment possibility in patients that required tricuspid valve replacement at young age and in circumstances where redo tricuspid valve replacement is not feasible because of the remarkable morbidity and mortality. Case presentation. A 76 year–old Caucasian male was referred to our center for worsening dyspnoea and fatigue. He had a pacemaker implanted for third degree atrio–ventricular block in 1996. After massive endocarditis affecting the tricuspid valve and the pacemaker right ventricular lead, the patient underwent surgical tricuspid valve replacement with a 32 mm Liotta BioImplant L.P.B., right ventricular lead extraction and concomitant epicardial pacemaker reimplantation. Transthoracic echocardiogram at hospital admission denoted a degenerative stenosis of the tricuspid prosthesis with a trans–valvular mean gradient of 8 mmHg associated with right atrial and inferior vena cava dilatation. Given the high surgical risk due to comorbidities (systemic arterial hypertension, paroxysmal atrial fibrillation in DOAC, grade II obesity, smoking history and chronic lymphoproliferative leukemia) the patient was deemed not suitable for a re–do surgical tricuspid valve replacement and was offered a percutaneous replacement. Preprocedural planning with computed tomography allowed accurate reconstruction of the tricuspidal prosthetic annulus and correct sizing of Edwards SAPIEN valve, the most used in valve–in–valve procedures. The degenerated prosthesis was not visible at fluoroscopy meaning no fluoroscopic landmarks available to provide an anatomic view for valve deployment. Therefore, a combination of balloon valvuloplasty and right atrium angiographies before the valve–in–valve deployment were critical to provide the correct valve position and yield the procedure effective and safe. Hemodynamic gradient post–TVIV was absent and no paravalvular leaks were observed. Clinical and echocardiographic improvement were confirmed after the procedure and at 1 year–follow up. Conclusion Tricuspid valve–in–valve replacement can be technically feasible and a safer alternative to re–do surgical valve replacement, also in radiolucent bioprosthesis. In our case the successful procedural outcome not only relied on meticulous planning before the procedure, but also on specific intra–procedural adjustments.

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