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He H, Sun B, Liang L, Li Y, Wang H, Wei L, Li G, Guo S, Duan J, Li Y, Zhou Y, Chen Y, Li H, Yang J, Xu X, Song L, Chen J, Bao Y, Chen F, Wang P, Ji L, Zhang Y, Ding Y, Chen L, Wang Y, Yang L, Yang T, Weng H, Li H, Wang D, Tong J, Sun Y, Li R, Jin F, Li C, He B, Sun L, Wang C, Hu M, Yang X, Luo Q, Zhang J, Tan H, Wang C. A multicenter RCT of noninvasive ventilation in pneumonia-induced early mild acute respiratory distress syndrome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:300. [PMID: 31484582 PMCID: PMC6727327 DOI: 10.1186/s13054-019-2575-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 08/19/2019] [Indexed: 01/18/2023]
Abstract
RATIONALE Our pilot study suggested that noninvasive ventilation (NIV) reduced the need for intubation compared with conventional administration of oxygen on patients with "early" stage of mild acute respiratory distress syndrome (ARDS, PaO2/FIO2 between 200 and 300). OBJECTIVES To evaluate whether early NIV can reduce the need for invasive ventilation in patients with pneumonia-induced early mild ARDS. METHODS Prospective, multicenter, randomized controlled trial (RCT) of NIV compared with conventional administration of oxygen through a Venturi mask. Primary outcome included the numbers of patients who met the intubation criteria. RESULTS Two hundred subjects were randomized to NIV (n = 102) or control (n = 98) groups from 21 centers. Baseline characteristics were similar in the two groups. In the NIV group, PaO2/FIO2 became significantly higher than in the control group at 2 h after randomization and remained stable for the first 72 h. NIV did not decrease the proportion of patients requiring intubation than in the control group (11/102 vs. 9/98, 10.8% vs. 9.2%, p = 0.706). The ICU mortality was similar in the two groups (7/102 vs. 7/98, 4.9% vs. 3.1%, p = 0.721). Multivariate analysis showed minute ventilation greater than 11 L/min at 48 h was the independent risk factor for NIV failure (OR, 1.176 [95% CI, 1.005-1.379], p = 0.043). CONCLUSIONS Treatment with NIV did not reduce the need for intubation among patients with pneumonia-induced early mild ARDS, despite the improved PaO2/FIO2 observed with NIV compared with standard oxygen therapy. High minute ventilation may predict NIV failure. TRIAL REGISTRATION NCT01581229 . Registered 19 April 2012.
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Affiliation(s)
- Hangyong He
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Engineering Research Center for Diagnosis and Treatment of Pulmonary and Critical Care, Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Bing Sun
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Engineering Research Center for Diagnosis and Treatment of Pulmonary and Critical Care, Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Lirong Liang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Engineering Research Center for Diagnosis and Treatment of Pulmonary and Critical Care, Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Yanming Li
- Department of Respiratory and Critical Care Medicine, Beijing Hospital, Beijing, China
| | - He Wang
- Department of Respiratory and Critical Care Medicine, Beijing Hospital, Beijing, China
| | - Luqing Wei
- Department of Respiratory and Critical Care Medicine, Affiliated Hospital of Logistics College of Chinese Armed Police Forces, Tianjin, China
| | - Guofeng Li
- Department of Respiratory and Critical Care Medicine, Affiliated Hospital of Logistics College of Chinese Armed Police Forces, Tianjin, China
| | - Shuliang Guo
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jun Duan
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuping Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Ying Zhou
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Yusheng Chen
- The Pulmonary Department, Fujian Province Hospital, Fuzhou, Fujian Province, China
| | - Hongru Li
- The Pulmonary Department, Fujian Province Hospital, Fuzhou, Fujian Province, China
| | - Jingping Yang
- Department of Respiratory and Critical Care Medicine, The Third Affiliated Hospital of Inner Mongolia Medical College, Baotou, Inner Mongolia Autonomous Region, China
| | - Xiyuan Xu
- Department of Respiratory and Critical Care Medicine, The Third Affiliated Hospital of Inner Mongolia Medical College, Baotou, Inner Mongolia Autonomous Region, China
| | - Liqiang Song
- The Pulmonary Department, Xijing Hospital of the Fourth Military Medical University, Xi'an, Shanxi Province, China
| | - Jie Chen
- The Pulmonary Department, Xijing Hospital of the Fourth Military Medical University, Xi'an, Shanxi Province, China
| | - Yong Bao
- The Pulmonary Department, The Third People's Hospital of Chengdu, Chengdu, Sichuan Province, China
| | - Feng Chen
- The Pulmonary Department, The Third People's Hospital of Chengdu, Chengdu, Sichuan Province, China
| | - Ping Wang
- Department of Critical Care Medicine, Chengdu Fifth People's Hospital, Chengdu, Sichuan Province, China
| | - Lixi Ji
- Department of Critical Care Medicine, Chengdu Fifth People's Hospital, Chengdu, Sichuan Province, China
| | - Yongxiang Zhang
- Department of Respiratory Medicine, People's Hospital of Beijing Daxing District, Beijing, China
| | - Yanyan Ding
- Department of Respiratory Medicine, People's Hospital of Beijing Daxing District, Beijing, China
| | - Liangan Chen
- Department of Pulmonary and Critical Care Medicine, Chinese PLA General Hospital, Beijing, China
| | - Ying Wang
- Department of Pulmonary and Critical Care Medicine, Chinese PLA General Hospital, Beijing, China
| | - Lan Yang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi Province, China
| | - Tian Yang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi Province, China
| | - Heng Weng
- The Pulmonary Department, Lung Disease Hospital of Fujian Fuzhou, Fuzhou, Fujian Province, China
| | - Hongyan Li
- The Pulmonary Department, Lung Disease Hospital of Fujian Fuzhou, Fuzhou, Fujian Province, China
| | - Daoxin Wang
- The Pulmonary Department, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jin Tong
- The Pulmonary Department, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yongchang Sun
- The Pulmonary Department, Beijing Tongren Hospital, Beijing, China
| | - Ran Li
- The Pulmonary Department, Beijing Tongren Hospital, Beijing, China
| | - Faguang Jin
- Department of Respiratory and Critical Care Medicine, Tangdu Hospital, the Fourth Military Medical University, Xi'an, Shanxi Province, China
| | - Chunmei Li
- Department of Respiratory and Critical Care Medicine, Tangdu Hospital, the Fourth Military Medical University, Xi'an, Shanxi Province, China
| | - Bei He
- The Pulmonary Department, Peking University Third Hospital, Beijing, China
| | - Lina Sun
- The Pulmonary Department, Peking University Third Hospital, Beijing, China
| | - Changzheng Wang
- The Pulmonary Department, Xinqiao Hospital Army Medical University, Chongqing, China
| | - Mingdong Hu
- The Pulmonary Department, Xinqiao Hospital Army Medical University, Chongqing, China
| | - Xiaohong Yang
- Department of Respiratory and Critical Care Medicine, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Uygur Autonomous Region, China
| | - Qin Luo
- Department of Respiratory and Critical Care Medicine, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Uygur Autonomous Region, China
| | - Jin Zhang
- Department of Respiratory and Critical Care Medicine, General Hospital of Ningxia Medical University, Yinchuan, Ningxia Province, China
| | - Hai Tan
- Department of Respiratory and Critical Care Medicine, General Hospital of Ningxia Medical University, Yinchuan, Ningxia Province, China
| | - Chen Wang
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. .,Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, No.2 Yinghua East Road, Chaoyang District, Beijing, 100029, China. .,Department of Respiratory Medicine, Capital Medical University, Beijing, China. .,National Clinical Research Center for Respiratory Diseases, Beijing, China.
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Coudroy R, Pham T, Boissier F, Robert R, Frat JP, Thille AW. Is immunosuppression status a risk factor for noninvasive ventilation failure in patients with acute hypoxemic respiratory failure? A post hoc matched analysis. Ann Intensive Care 2019; 9:90. [PMID: 31414246 PMCID: PMC6692798 DOI: 10.1186/s13613-019-0566-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 08/03/2019] [Indexed: 12/15/2022] Open
Abstract
Background Recent European/American guidelines recommend noninvasive ventilation (NIV) as a first-line therapy to manage acute hypoxemic respiratory failure in immunocompromised patients. By contrast, NIV may have deleterious effects in nonimmunocompromised patients and experts have been unable to offer a recommendation. Immunocompromised patients have particularly high mortality rates when they require intubation. However, it is not clear whether immunosuppression status is a risk factor for NIV failure. We assessed the impact of immunosuppression status on NIV failure in a post hoc analysis pooling two studies including patients with de novo acute hypoxemic respiratory failure treated with NIV. Patients with hypercapnia, acute exacerbation of chronic lung disease, cardiogenic pulmonary edema, or with do-not-intubate order were excluded. Results Among the 208 patients included in the analysis, 71 (34%) were immunocompromised. They had higher severity scores upon ICU admission, higher pressure-support levels, and minute ventilation under NIV, and were more likely to have bilateral lung infiltrates than nonimmunocompromised patients. Intubation and in-ICU mortality rates were higher in immunocompromised than in nonimmunocompromised patients: 61% vs. 43% (p = 0.02) and 38% vs. 15% (p < 0.001), respectively. After adjustment or using a propensity score-matched analysis, immunosuppression was not associated with intubation, whereas it remained independently associated with ICU mortality with an adjusted odds ratio of 2.64 (95% CI 1.24–5.67, p = 0.01). Conclusions Immunosuppression status may directly influence mortality but does not seem to be associated with an increased risk of intubation in patients with de novo acute hypoxemic respiratory failure treated with NIV. Studies in this specific population are needed. Electronic supplementary material The online version of this article (10.1186/s13613-019-0566-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rémi Coudroy
- Service de Médecine Intensive et Réanimation, CHU de Poitiers, Poitiers, France.,INSERM CIC 1402, ALIVE, Université de Poitiers, Poitiers, France
| | - Tài Pham
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada.,Keenan Research Center and Li Ka Shing Knowledge Institute, Toronto, Canada
| | - Florence Boissier
- Service de Médecine Intensive et Réanimation, CHU de Poitiers, Poitiers, France.,INSERM CIC 1402, ALIVE, Université de Poitiers, Poitiers, France
| | - René Robert
- Service de Médecine Intensive et Réanimation, CHU de Poitiers, Poitiers, France.,INSERM CIC 1402, ALIVE, Université de Poitiers, Poitiers, France
| | - Jean-Pierre Frat
- Service de Médecine Intensive et Réanimation, CHU de Poitiers, Poitiers, France.,INSERM CIC 1402, ALIVE, Université de Poitiers, Poitiers, France
| | - Arnaud W Thille
- Service de Médecine Intensive et Réanimation, CHU de Poitiers, Poitiers, France. .,INSERM CIC 1402, ALIVE, Université de Poitiers, Poitiers, France.
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Abstract
PURPOSE OF REVIEW Hospital-acquired pneumonia (HAP) is the leading cause of death from hospital-acquired infection. Little work has been done on strategies for prevention of HAP. This review aims to describe potential HAP prevention strategies and the evidence supporting them. Oral care and aspiration precautions may attenuate some risk for HAP. Oral and digestive decontamination with antibiotics may be effective but could increase risk for resistant organisms. Other preventive measures, including isolation practices, remain theoretical or experimental. RECENT FINDINGS Hospital-acquired pneumonia occurs because of pharyngeal colonization with pathogenic organisms and subsequent aspiration of these pathogens. SUMMARY Most potential HAP prevention strategies remain unproven.
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254
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Coudroy R, Frat JP, Ehrmann S, Pène F, Terzi N, Decavèle M, Prat G, Garret C, Contou D, Bourenne J, Gacouin A, Girault C, Dellamonica J, Malacrino D, Labro G, Quenot JP, Herbland A, Jochmans S, Devaquet J, Benzekri D, Vivier E, Nseir S, Colin G, Thévenin D, Grasselli G, Assefi M, Guerin C, Bougon D, Lherm T, Kouatchet A, Ragot S, Thille AW. High-flow nasal oxygen therapy alone or with non-invasive ventilation in immunocompromised patients admitted to ICU for acute hypoxemic respiratory failure: the randomised multicentre controlled FLORALI-IM protocol. BMJ Open 2019; 9:e029798. [PMID: 31401603 PMCID: PMC6701687 DOI: 10.1136/bmjopen-2019-029798] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Non-invasive ventilation (NIV) is recommended as first-line therapy in respiratory failure of critically ill immunocompromised patients as it can decrease intubation and mortality rates as compared with standard oxygen. However, its recommendation is only conditional. Indeed, the use of NIV in this setting has been challenged recently based on results of trials finding similar outcomes with or without NIV or even deleterious effects of NIV. To date, NIV has been compared with standard oxygen but not to high-flow nasal oxygen therapy (HFOT) in immunocompromised patients. Several studies have found lower mortality rates using HFOT alone than when using HFOT with NIV sessions in patients with de novo respiratory failure, and even in immunocompromised patients. We are hypothesising that HFOT alone is more effective than HFOT with NIV sessions and reduces mortality of immunocompromised patients with acute hypoxemic respiratory failure. METHODS AND ANALYSIS This study is an investigator-initiated, multicentre randomised controlled trial comparing HFOT alone or with NIV in immunocompromised patients admitted to intensive care unit (ICU) for severe acute hypoxemic respiratory failure. Around 280 patients will be randomised with a 1:1 ratio in two groups. The primary outcome is the mortality rate at day 28 after inclusion. Secondary outcomes include the rate of intubation in each group, length of ICU and hospital stay and mortality up to day 180. ETHICS AND DISSEMINATION The study has been approved by the ethics committee and patients will be included after informed consent. The results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02978300.
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Affiliation(s)
- Rémi Coudroy
- Médecine Intensive et Réanimation, INSERM CIC 1402, groupe ALIVE, Université de Poitiers, CHU de Poitiers, Poitiers, France
| | - Jean-Pierre Frat
- Médecine Intensive et Réanimation, INSERM CIC 1402, groupe ALIVE, Université de Poitiers, CHU de Poitiers, Poitiers, France
| | - Stephan Ehrmann
- Médecine Intensive et Réanimation, CIC 1415, CRICS-TriggerSEP research network, Centre d'étude des pathologies respiratoires, INSERM U1100, Université de Tours, CHRU de Tours, Tours, France
| | - Frédéric Pène
- Médecine Intensive et Réanimation, Université Paris Descartes, Hôpital Cochin, APHP, Paris, France
| | - Nicolas Terzi
- Médecine Intensive et Réanimation, INSERM, Université Grenoble-Alpes, U1042, HP2, CHU Grenoble Alpes, Grenoble, France
| | - Maxens Decavèle
- Service de Pneumologie, Médecine Intensive et Réanimation, Département R3S, AP-HP, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France
| | - Gwenaël Prat
- Médecine Intensive et Réanimation, CHU de Brest, Brest, France
| | - Charlotte Garret
- Médecine Intensive et Réanimation, CHU de Nantes, Nantes, France
| | - Damien Contou
- Service de Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, Argenteuil, France
| | - Jeremy Bourenne
- Médecine Intensive et Réanimation, Réanimation des Urgences, Aix-Marseille Université, CHU La Timone 2, Marseille, France
| | - Arnaud Gacouin
- Service des Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Hôpital Ponchaillou, Rennes, France
| | - Christophe Girault
- Service de Réanimation Médicale, Normandie Univ, Unirouen, UPRES EA-3830, Hôpital Charles Nicolle, CHU de Rouen, Rouen, France
| | | | | | - Guylaine Labro
- Medical Intensive Care Unit, Research Center EA3920, University of Franche-Comté, Hôpital Jean Minjoz, Besançon, France
| | - Jean-Pierre Quenot
- Service de Médecine Intensive-Réanimation, INSERM U1231, Equipe Lipness, Université Bourgogne-Franche-Comté, UMR1231 Lipides, Nutrition, Cancer, équipe Lipness, LipSTIC LabEx, Fondation de coopération scientifique Bourgogne-Franche-Comté, INSERM, CIC 1432, Module Epidémiologie Clinique, Centre d'Investigation Clinique, Module Epidémiologie Clinique/Essais Cliniques, CHU Dijon, Dijon, France
| | - Alexandre Herbland
- Service de Réanimation, Centre hospitalier Saint Louis, La Rochelle, France
| | - Sébastien Jochmans
- Service de Réanimation, Centre hospitalier Sud-Ile-de France, Melun, France
| | - Jérôme Devaquet
- Medical-Surgical Intensive Care Unit, Hôpital Foch, Suresnes, France
| | - Dalila Benzekri
- Médecine Intensive et Réanimation, Groupe Hospitalier Régional d'Orléans, Orléans, France
| | - Emmanuel Vivier
- Reanimation Polyvalente, Hôpital Saint Joseph Saint Luc, Lyon, France
| | - Saad Nseir
- Centre de Réanimation, Université de Lille, CHU de Lille, Lille, France
| | - Gwenhaël Colin
- Service de Médecine Intensive et Réanimation, Centre Hospitalier Départemental de Vendée, La Roche-sur-Yon, France
| | - Didier Thévenin
- Service de Réanimation Polyvalente, CH de Lens, Lens, France
| | - Giacomo Grasselli
- Department of Anesthesiology, Intensive Care and Emergency, Department of Pathophysiology and Transplantation, University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mona Assefi
- Multidisciplinary Intensive Care Unit, Department of Anesthesia and Critical Care Medicine, School of Medicine, University Pierre and Marie Curie (UPMC), Pitié-Salpétrière Hospital, APHP, Paris, France
| | - Claude Guerin
- Service de Médecine Intensive-Réanimation, Université de Lyon, INSERM 955, Créteil, Hôpital de La Croix-Rousse, Hospices civils de Lyon, Lyon, France
| | - David Bougon
- Service de Réanimation, Centre Hospitalier Annecy Genevois, Annecy, France
| | | | | | - Stéphanie Ragot
- INSERM CIC 1402, Biostatistics, Université de Poitiers, Poitiers, France
| | - Arnaud W Thille
- Médecine Intensive et Réanimation, INSERM CIC 1402, groupe ALIVE, Université de Poitiers, CHU de Poitiers, Poitiers, France
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Zeng JS, Qian SY, Wong JJM, Ong JSM, Gan CS, Anantasit N, Chor YK, Samransamruajkit R, Phuc PH, Phumeetham S, Feng X, Sultana R, Loh TF, Lee JH. Non-Invasive Ventilation in Children with Paediatric Acute Respiratory Distress Syndrome. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2019. [DOI: 10.47102/annals-acadmedsg.v48n7p224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction: Evidence supporting non-invasive ventilation (NIV) in paediatric acute respiratory distress syndrome (PARDS) remains sparse. We aimed to describe characteristics of patients with PARDS supported with NIV and risk factors for NIV failure. Materials and Methods: This is a multicentre retrospective study. Only patients supported on NIV with PARDS were included. Data on epidemiology and clinical outcomes were collected. Primary outcome was NIV failure which was defined as escalation to invasive mechanical ventilation within the first 7 days of PARDS. Patients in the NIV success and failure groups were compared. Results: There were 303 patients with PARDS; 53/303 (17.5%) patients were supported with NIV. The median age was 50.7 (interquartile range: 15.7-111.9) months. The Paediatric Logistic Organ Dysfunction score and oxygen saturation/fraction of inspired oxygen (SF) ratio were 2.0 (1.0-10.0) and 155.0 (119.4-187.3), respectively. Indications for NIV use were increased work of breathing (26/53 [49.1%]) and hypoxia (22/53 [41.5%]). Overall NIV failure rate was 77.4% (41/53). All patients with sepsis who developed PARDS experienced NIV failure. NIV failure was associated with an increased median paediatric intensive care unit stay (15.0 [9.5-26.5] vs 4.5 [3.0-6.8] days; P <0.001) and hospital length of stay (26.0 [17.0-39.0] days vs 10.5 [5.5-22.3] days; P = 0.004). Overall mortality rate was 32.1% (17/53). Conclusion: The use of NIV in children with PARDS was associated with high failure rate. As such, future studies should examine the optimal selection criteria for NIV use in these children.
Key words: Bi-level positive airway pressure, Continuous positive airway pressure, Non-invasive ventilation
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Affiliation(s)
- Jian Sheng Zeng
- Beijing Children’s Hospital, Capital Medical University, People’s Republic of China
| | - Su Yun Qian
- Beijing Children’s Hospital, Capital Medical University, People’s Republic of China
| | | | - Jacqueline SM Ong
- Khoo Teck Puat-National University Children’s Medical Institute, National University Hospital, Singapore
| | | | | | | | | | | | | | - Xu Feng
- Children's Hospital of Chongqing Medical University, People’s Republic of China
| | | | - Tsee Foong Loh
- Khoo Teck Puat-National University Children’s Medical Institute, National University Hospital, Singapore
| | - Jan Hau Lee
- Khoo Teck Puat-National University Children’s Medical Institute, National University Hospital, Singapore
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Predictors of Intubation in Patients With Acute Hypoxemic Respiratory Failure Treated With a Noninvasive Oxygenation Strategy. Crit Care Med 2019; 46:208-215. [PMID: 29099420 DOI: 10.1097/ccm.0000000000002818] [Citation(s) in RCA: 119] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES In patients with acute hypoxemic respiratory failure, noninvasive ventilation and high-flow nasal cannula oxygen are alternative strategies to conventional oxygen therapy. Endotracheal intubation is frequently needed in these patients with a risk of delay, and early predictors of failure may help clinicians to decide early. We aimed to identify factors associated with intubation in patients with acute hypoxemic respiratory failure treated with different noninvasive oxygenation techniques. DESIGN Post hoc analysis of a randomized clinical trial. SETTING Twenty-three ICUs. PATIENTS Patients with a respiratory rate greater than 25 breaths/min and a PaO2/FIO2 ratio less than or equal to 300 mm Hg. INTERVENTION Patients were treated with standard oxygen, high-flow nasal cannula oxygen, or noninvasive ventilation. MEASUREMENT AND MAIN RESULTS Respiratory variables one hour after treatment initiation. Under standard oxygen, patients with a respiratory rate greater than or equal to 30 breaths/min were more likely to need intubation (odds ratio, 2.76; 95% CI, 1.13-6.75; p = 0.03). One hour after high-flow nasal cannula oxygen initiation, increased heart rate was the only factor associated with intubation. One hour after noninvasive ventilation initiation, a PaO2/FIO2 ratio less than or equal to 200 mm Hg and a tidal volume greater than 9 mL/kg of predicted body weight were independent predictors of intubation (adjusted odds ratio, 4.26; 95% CI, 1.62-11.16; p = 0.003 and adjusted odds ratio, 3.14; 95% CI, 1.22-8.06; p = 0.02, respectively). A tidal volume above 9 mL/kg during noninvasive ventilation remained independently associated with 90-day mortality. CONCLUSIONS In patients with acute hypoxemic respiratory failure breathing spontaneously, the respiratory rate was a predictor of intubation under standard oxygen, but not under high-flow nasal cannula oxygen or noninvasive ventilation. A PaO2/FIO2 below 200 mm Hg and a high tidal volume greater than 9 mL/kg were the two strong predictors of intubation under noninvasive ventilation.
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Maggiore SM, Battilana M, Serano L, Petrini F. Ventilatory support after extubation in critically ill patients. THE LANCET RESPIRATORY MEDICINE 2019; 6:948-962. [PMID: 30629933 DOI: 10.1016/s2213-2600(18)30375-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 09/06/2018] [Accepted: 09/07/2018] [Indexed: 12/29/2022]
Abstract
The periextubation period represents a crucial moment in the management of critically ill patients. Extubation failure, defined as the need for reintubation within 2-7 days after a planned extubation, is associated with prolonged mechanical ventilation, increased incidence of ventilator-associated pneumonia, longer intensive care unit and hospital stays, and increased mortality. Conventional oxygen therapy is commonly used after extubation. Additional methods of non-invasive respiratory support, such as non-invasive ventilation and high-flow nasal therapy, can be used to avoid reintubation. The aim of this Review is to describe the pathophysiological mechanisms of postextubation respiratory failure and the available techniques and strategies of respiratory support to avoid reintubation. We summarise and discuss the available evidence supporting the use of these strategies to achieve a tailored therapy for an individual patient at the bedside.
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Affiliation(s)
- Salvatore Maurizio Maggiore
- University Department of Medical, Oral and Biotechnological Sciences, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy; Clinical Department of Anaesthesiology and Intensive Care Medicine, SS. Annunziata Hospital, Chieti, Italy.
| | - Mariangela Battilana
- University Department of Medical, Oral and Biotechnological Sciences, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Luca Serano
- University Department of Medical, Oral and Biotechnological Sciences, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Flavia Petrini
- University Department of Medical, Oral and Biotechnological Sciences, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy; Clinical Department of Anaesthesiology and Intensive Care Medicine, SS. Annunziata Hospital, Chieti, Italy
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258
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Elke G, Hartl WH, Kreymann KG, Adolph M, Felbinger TW, Graf T, de Heer G, Heller AR, Kampa U, Mayer K, Muhl E, Niemann B, Rümelin A, Steiner S, Stoppe C, Weimann A, Bischoff SC. Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM). Clin Nutr ESPEN 2019; 33:220-275. [PMID: 31451265 DOI: 10.1016/j.clnesp.2019.05.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of nutrient delivery, the amount and composition of macro- and micronutrients, and the choice of specific, immune-modulating substrates. Variations of clinical nutrition may affect clinical outcomes. The present guideline provides clinicians with updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. METHODS The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification, no systematic review of the available evidence was required to make recommendations, which, therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The liability of each recommendation was described linguistically. Each recommendation was finally validated and consented through a Delphi process. RESULTS In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease phases during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutrition status, the indication for clinical nutrition, the timing and route of nutrient delivery, and the amount and composition of substrates (macro- and micronutrients); furthermore, we discuss distinctive aspects of nutrition therapy in obese critically ill patients and those treated with extracorporeal support devices. CONCLUSION The current guideline provides clinicians with up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018-2023).
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Affiliation(s)
- Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 12, 24105, Kiel, Germany.
| | - Wolfgang H Hartl
- Department of Surgery, University School of Medicine, Grosshadern Campus, Ludwig-Maximilian University, Marchioninistr. 15, 81377 Munich, Germany.
| | | | - Michael Adolph
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany.
| | - Thomas W Felbinger
- Department of Anesthesiology, Critical Care and Pain Medicine, Neuperlach and Harlaching Medical Center, The Munich Municipal Hospitals Ltd, Oskar-Maria-Graf-Ring 51, 81737, Munich, Germany.
| | - Tobias Graf
- Medical Clinic II, University Heart Center Lübeck, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Geraldine de Heer
- Center for Anesthesiology and Intensive Care Medicine, Clinic for Intensive Care Medicine, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Axel R Heller
- Clinic for Anesthesiology and Surgical Intensive Care Medicine, University of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany.
| | - Ulrich Kampa
- Clinic for Anesthesiology, Lutheran Hospital Hattingen, Bredenscheider Strasse 54, 45525, Hattingen, Germany.
| | - Konstantin Mayer
- Department of Internal Medicine, Justus-Liebig University Giessen, University of Giessen and Marburg Lung Center, Klinikstr. 36, 35392, Gießen, Germany.
| | - Elke Muhl
- Eichhörnchenweg 7, 23627, Gross Grönau, Germany.
| | - Bernd Niemann
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Rudolf-Buchheim-Str. 7, 35392, Gießen, Germany.
| | - Andreas Rümelin
- Clinic for Anesthesia and Surgical Intensive Care Medicine, HELIOS St. Elisabeth Hospital Bad Kissingen, Kissinger Straße 150, 97688, Bad Kissingen, Germany.
| | - Stephan Steiner
- Department of Cardiology, Pneumology and Intensive Care Medicine, St Vincenz Hospital Limburg, Auf dem Schafsberg, 65549, Limburg, Germany.
| | - Christian Stoppe
- Department of Intensive Care Medicine and Intermediate Care, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, Klinikum St. Georg, Delitzscher Straße 141, 04129, Leipzig, Germany.
| | - Stephan C Bischoff
- Department for Nutritional Medicine, University of Hohenheim, Fruwirthstr. 12, 70599, Stuttgart, Germany.
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Hill NS, Ruthazer R. Predicting Outcomes of High-Flow Nasal Cannula for Acute Respiratory Distress Syndrome. An Index that ROX. Am J Respir Crit Care Med 2019; 199:1300-1302. [PMID: 30694696 PMCID: PMC6543722 DOI: 10.1164/rccm.201901-0079ed] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Affiliation(s)
- Nicholas S Hill
- 1 Division of Pulmonary, Critical Care and Sleep Medicine Tufts Medical Center Boston, Massachusetts and
| | - Robin Ruthazer
- 2 Institute for Clinical Research and Health Policy Studies Tufts Medical Center Boston, Massachusetts
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260
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Noninvasive ventilation versus oxygen therapy in patients with acute respiratory failure. Curr Opin Anaesthesiol 2019; 32:150-155. [PMID: 30817387 DOI: 10.1097/aco.0000000000000705] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW High-flow nasal cannula oxygen therapy (HFOT) is becoming an alternative to noninvasive ventilation (NIV) and standard oxygen in management of patients with acute respiratory failure. RECENT FINDINGS Patients with de novo acute respiratory failure should be managed with HFOT rather than NIV. Indeed, the vast majority of patients with de novo respiratory failure meet the criteria for ARDS, and NIV does not seem protective, as patients generate overly high tidal volume that may worsen underlying lung injury. However, NIV remains the first-line oxygenation strategy in postoperative patients and those with acute hypercapnic respiratory failure when pH is equal to or below 7.35. During preoxygenation, NIV also seems to be more efficient than standard oxygen using valve-bag mask to prevent profound oxygen desaturation. In postoperative cardiothoracic patients, HFOT could be an alternative to NIV in the management of acute respiratory failure. SUMMARY Recent recommendations for managing patients with acute respiratory failure have been established on the basis of studies comparing NIV with standard oxygen. Growing use of HFOT will lead to new studies comparing NIV versus HFOT in view of more precisely defining the appropriate indications for each treatment.
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261
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Spinelli E, Villa A, Zazzeron L, Grasselli G. What's New in Noninvasive Ventilation: Factors Associated with Failure, Patterns of Use in Acute Asthma, and the Role of New Interfaces. Am J Respir Crit Care Med 2019; 196:520-522. [PMID: 28598218 DOI: 10.1164/rccm.201609-1801rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Elena Spinelli
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda-Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Alessandro Villa
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda-Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Luca Zazzeron
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda-Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Grasselli
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda-Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
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262
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Sklar MC, Patel BK, Beitler JR, Piraino T, Goligher EC. Optimal Ventilator Strategies in Acute Respiratory Distress Syndrome. Semin Respir Crit Care Med 2019; 40:81-93. [PMID: 31060090 PMCID: PMC7117088 DOI: 10.1055/s-0039-1683896] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Mechanical ventilation practices in patients with acute respiratory distress syndrome (ARDS) have progressed with a growing understanding of the disease pathophysiology. Paramount to the care of affected patients is the delivery of lung-protective mechanical ventilation which prioritizes tidal volume and plateau pressure limitation. Lung protection can probably be further enhanced by scaling target tidal volumes to the specific respiratory mechanics of individual patients. The best procedure for selecting optimal positive end-expiratory pressure (PEEP) in ARDS remains uncertain; several relevant issues must be considered when selecting PEEP, particularly lung recruitability. Noninvasive ventilation must be used with caution in ARDS as excessively high respiratory drive can further exacerbate lung injury; newer modes of delivery offer promising approaches in hypoxemic respiratory failure. Airway pressure release ventilation offers an alternative approach to maximize lung recruitment and oxygenation, but clinical trials have not demonstrated a survival benefit of this mode over conventional ventilation strategies. Rescue therapy with high-frequency oscillatory ventilation is an important option in refractory hypoxemia. Despite a disappointing lack of benefit (and possible harm) in patients with moderate or severe ARDS, possibly due to lung hyperdistention and right ventricular dysfunction, high-frequency oscillation may improve outcome in patients with very severe hypoxemia.
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Affiliation(s)
- Michael C Sklar
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University, New York, New York
| | - Thomas Piraino
- Keenan Centre for Biomedical Research, St. Michael's Hospital, Toronto, Ontario, Canada.,Division of Critical Care, Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada.,Department of Respiratory Therapy, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada.,Department of Medicine, Division of Respirology, University Health Network, Toronto, Ontario, Canada
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263
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Hui DS, Chow BK, Lo T, Tsang OTY, Ko FW, Ng SS, Gin T, Chan MTV. Exhaled air dispersion during high-flow nasal cannula therapy versus CPAP via different masks. Eur Respir J 2019; 53:13993003.02339-2018. [PMID: 30705129 DOI: 10.1183/13993003.02339-2018] [Citation(s) in RCA: 221] [Impact Index Per Article: 44.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 01/16/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND High-flow nasal cannula (HFNC) is an emerging therapy for respiratory failure but the extent of exhaled air dispersion during treatment is unknown. We examined exhaled air dispersion during HFNC therapy versus continuous positive airway pressure (CPAP) on a human patient simulator (HPS) in an isolation room with 16 air changes·h-1. METHODS The HPS was programmed to represent different severity of lung injury. CPAP was delivered at 5-20 cmH2O via nasal pillows (Respironics Nuance Pro Gel or ResMed Swift FX) or an oronasal mask (ResMed Quattro Air). HFNC, humidified to 37°C, was delivered at 10-60 L·min-1 to the HPS. Exhaled airflow was marked with intrapulmonary smoke for visualisation and revealed by laser light-sheet. Normalised exhaled air concentration was estimated from the light scattered by the smoke particles. Significant exposure was defined when there was ≥20% normalised smoke concentration. RESULTS In the normal lung condition, mean±sd exhaled air dispersion, along the sagittal plane, increased from 186±34 to 264±27 mm and from 207±11 to 332±34 mm when CPAP was increased from 5 to 20 cmH2O via Respironics and ResMed nasal pillows, respectively. Leakage from the oronasal mask was negligible. Mean±sd exhaled air distances increased from 65±15 to 172±33 mm when HFNC was increased from 10 to 60 L·min-1. Air leakage to 620 mm occurred laterally when HFNC and the interface tube became loose. CONCLUSION Exhaled air dispersion during HFNC and CPAP via different interfaces is limited provided there is good mask interface fitting.
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Affiliation(s)
- David S Hui
- Dept of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China.,Stanley Ho Center for Emerging Infectious Diseases, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Benny K Chow
- Stanley Ho Center for Emerging Infectious Diseases, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Thomas Lo
- Dept of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Owen T Y Tsang
- Dept of Medicine, Princess Margaret Hospital, Hong Kong, Hong Kong SAR, China
| | - Fanny W Ko
- Dept of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Susanna S Ng
- Dept of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Tony Gin
- Dept of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Matthew T V Chan
- Dept of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China.,Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
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264
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Alraddadi BM, Qushmaq I, Al-Hameed FM, Mandourah Y, Almekhlafi GA, Jose J, Al-Omari A, Kharaba A, Almotairi A, Al Khatib K, Shalhoub S, Abdulmomen A, Mady A, Solaiman O, Al-Aithan AM, Al-Raddadi R, Ragab A, Balkhy HH, Al Harthy A, Sadat M, Tlayjeh H, Merson L, Hayden FG, Fowler RA, Arabi YM. Noninvasive ventilation in critically ill patients with the Middle East respiratory syndrome. Influenza Other Respir Viruses 2019; 13:382-390. [PMID: 30884185 PMCID: PMC6586182 DOI: 10.1111/irv.12635] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 01/08/2019] [Accepted: 01/21/2019] [Indexed: 12/13/2022] Open
Abstract
Background Noninvasive ventilation (NIV) has been used in patients with the Middle East respiratory syndrome (MERS) with acute hypoxemic respiratory failure, but the effectiveness of this approach has not been studied. Methods Patients with MERS from 14 Saudi Arabian centers were included in this analysis. Patients who were initially managed with NIV were compared to patients who were managed only with invasive mechanical ventilation (invasive MV). Results Of 302 MERS critically ill patients, NIV was used initially in 105 (35%) patients, whereas 197 (65%) patients were only managed with invasive MV. Patients who were managed with NIV initially had lower baseline SOFA score and less extensive infiltrates on chest radiograph compared with patients managed with invasive MV. The vast majority (92.4%) of patients who were managed initially with NIV required intubation and invasive mechanical ventilation, and were more likely to require inhaled nitric oxide compared to those who were managed initially with invasive MV. ICU and hospital length of stay were similar between NIV patients and invasive MV patients. The use of NIV was not independently associated with 90‐day mortality (propensity score‐adjusted odds ratio 0.61, 95% CI [0.23, 1.60] P = 0.27). Conclusions In patients with MERS and acute hypoxemic respiratory failure, NIV failure was very high. The use of NIV was not associated with improved outcomes.
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Affiliation(s)
- Basem M Alraddadi
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia.,Department of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Ismael Qushmaq
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Fahad M Al-Hameed
- Department of Intensive Care, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Yasser Mandourah
- Prince Sultan Military Medical City, Military Medical Services, Ministry of Defense, Riyadh, Saudi Arabia
| | - Ghaleb A Almekhlafi
- Prince Sultan Military Medical City, Military Medical Services, Ministry of Defense, Riyadh, Saudi Arabia
| | - Jesna Jose
- Department of Biostatistics and Bioinformatics, King Abdullah International Medical Research Center, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Awad Al-Omari
- Department of Intensive Care, Dr. Sulaiman Al-Habib Group Hospitals, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Ayman Kharaba
- Department of Critical Care, Ohoud Hospitals, King Fahad Hospital, Al-Madinah Al-Monawarah, Saudi Arabia
| | | | - Kasim Al Khatib
- Intensive Care Department, Al-Noor Specialist Hospital, Makkah, Saudi Arabia
| | - Sarah Shalhoub
- Department of Medicine, Division of Infectious Diseases, University of Western Ontario, London, Canada.,Department of Medicine, Division of Infectious Diseases, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | | | - Ahmed Mady
- Department of Anesthesiology, Intensive Care, Tanta University Hospitals, Tanta, Egypt.,Intensive Care Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Othman Solaiman
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Rajaa Al-Raddadi
- Department of Family and Community Medicine, King Abdulaziz University Hospital, Ministry of Health, Jeddah, Saudi Arabia
| | - Ahmed Ragab
- Intensive Care Department, King Fahd Hospital, Jeddah, Saudi Arabia
| | - Hanan H Balkhy
- Infection Prevention and Control Department, King Abdullah International Medical Research Center, College of Medicine, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Musharaf Sadat
- Intensive Care Department, King Abdullah International Medical Research Center, College of Medicine, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Haytham Tlayjeh
- Intensive Care Department, King Abdullah International Medical Research Center, College of Medicine, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Laura Merson
- Infectious Diseases Data Observatory, Churchill Hospital, Oxford University, International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC), Headington, UK
| | - Frederick G Hayden
- Department of Medicine, Division of Infectious Diseases and International Health, University of Virginia School of Medicine, International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC), Charlottesville, Virginia
| | - Robert A Fowler
- Department of Critical Care Medicine and Department of Medicine, Sunnybrook Hospital, Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada
| | - Yaseen M Arabi
- Intensive Care Department, King Abdullah International Medical Research Center, College of Medicine, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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Grieco DL, Menga LS, Eleuteri D, Antonelli M. Patient self-inflicted lung injury: implications for acute hypoxemic respiratory failure and ARDS patients on non-invasive support. Minerva Anestesiol 2019; 85:1014-1023. [PMID: 30871304 DOI: 10.23736/s0375-9393.19.13418-9] [Citation(s) in RCA: 129] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The role of spontaneous breathing among patients with acute hypoxemic respiratory failure and ARDS is debated: while avoidance of intubation with noninvasive ventilation (NIV) or high-flow nasal cannula improves clinical outcome, treatment failure worsens mortality. Recent data suggest patient self-inflicted lung injury (P-SILI) as a possible mechanism aggravating lung damage in these patients. P-SILI is generated by intense inspiratory effort yielding: (A) swings in transpulmonary pressure (i.e. lung stress) causing the inflation of big volumes in an aerated compartment markedly reduced by the disease-induced aeration loss; (B) abnormal increases in transvascular pressure, favouring negative-pressure pulmonary edema; (C) an intra-tidal shift of gas between different lung zones, generated by different transmission of muscular force (i.e. pendelluft); (D) diaphragm injury. Experimental data suggest that not all subjects are exposed to the development of P-SILI: patients with a PaO2/FiO2 ratio below 200 mmHg may represent the most at risk population. For them, current evidence indicates that high-flow nasal cannula alone may be superior to intermittent sessions of low-PEEP NIV delivered through face mask, while continuous high-PEEP helmet NIV likely promotes treatment success and may mitigate lung injury. The optimal initial noninvasive treatment of hypoxemic respiratory failure/ARDS remains however uncertain; high-flow nasal cannula and high-PEEP helmet NIV are promising tools to enhance success of the approach, but the best balance between these techniques has yet to be identified. During noninvasive support, careful clinical monitoring remains mandatory for prompt detection of treatment failure, in order not to delay intubation and protective ventilation.
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Affiliation(s)
- Domenico L Grieco
- Institute of Anesthesiology and Resuscitation, Sacred Heart Catholic University, Rome, Italy - .,Department of Emergency, Anesthesiology and Resuscitation Sciences, A. Gemelli University Polyclinic, IRCCS and Foundation, Rome, Italy -
| | - Luca S Menga
- Institute of Anesthesiology and Resuscitation, Sacred Heart Catholic University, Rome, Italy.,Department of Emergency, Anesthesiology and Resuscitation Sciences, A. Gemelli University Polyclinic, IRCCS and Foundation, Rome, Italy
| | - Davide Eleuteri
- Institute of Anesthesiology and Resuscitation, Sacred Heart Catholic University, Rome, Italy.,Department of Emergency, Anesthesiology and Resuscitation Sciences, A. Gemelli University Polyclinic, IRCCS and Foundation, Rome, Italy
| | - Massimo Antonelli
- Institute of Anesthesiology and Resuscitation, Sacred Heart Catholic University, Rome, Italy.,Department of Emergency, Anesthesiology and Resuscitation Sciences, A. Gemelli University Polyclinic, IRCCS and Foundation, Rome, Italy
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266
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Nam H, Cho JH, Choi EY, Chang Y, Choi WI, Hwang JJ, Moon JY, Lee K, Kim SW, Kang HK, Sim YS, Park TS, Park SY, Park S. Current Status of Noninvasive Ventilation Use in Korean Intensive Care Units: A Prospective Multicenter Observational Study. Tuberc Respir Dis (Seoul) 2019; 82:242-250. [PMID: 30841017 PMCID: PMC6609522 DOI: 10.4046/trd.2018.0064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/29/2018] [Accepted: 11/22/2018] [Indexed: 11/24/2022] Open
Abstract
Background Data on noninvasive ventilation (NIV) use in intensive care units (ICUs) are very limited in South Korea. Methods A prospective observational study was performed in 20 ICUs of university-affiliated hospitals from June 2017 to February 2018. Adult patients (age>18 years) who were admitted to the ICU and received NIV treatment for acute respiratory failure were included. Results A total of 156 patients treated with NIV were enrolled (mean age, 71.9±11.6 years). The most common indications for NIV were acute hypercapnic respiratory failure (AHRF, n=89) and post-extubation respiratory failure (n=44). The main device for NIV was an invasive mechanical ventilator with an NIV module (61.5%), and the majority of patients (87.2%) used an oronasal mask. After the exclusion of 32 do-not-resuscitate patients, NIV success rate was 68.5% (85/124); ICU and hospital mortality rates were 8.9% and 15.3%, respectively. However, the success rate was lower in patients with de novo respiratory failure (27.3%) compared to that of patients with AHRF (72.8%) or post-extubation respiratory failure (75.0%). In multivariate analysis, immunocompromised state, de novo respiratory failure, post-NIV (2 hours) respiratory rate, NIV mode (i.e., non-pressure support ventilation mode), and the change of NIV device were significantly associated with a lower success rate of NIV. Conclusion AHRF and post-extubation respiratory failure were the most common indications for NIV in Korean ICUs. Overall NIV success was achieved in 68.5% of patients, with the lowest rate in patients with de novo respiratory failure.
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Affiliation(s)
- Hyunseung Nam
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Jae Hwa Cho
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Young Choi
- Department of Pulmonary and Critical Care Medicine, Yeungnam University Hospital, Daegu, Korea
| | - Youjin Chang
- Department of Pulmonary and Critical Care Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Won Il Choi
- Department of Internal Medicine, Kyeimyung University Dongsan Hospital, Daegu, Korea
| | - Jae Joon Hwang
- Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Jae Young Moon
- Department of Pulmonary and Critical Care Medicine, Chungnam University Hospital, Daejeon, Korea
| | - Kwangha Lee
- Department of Internal Medicine, Pusan National University Hospital, Busan, Korea
| | - Sei Won Kim
- Department of Pulmonary, Critical Care and Sleep Medicine, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyung Koo Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Yun Su Sim
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Tai Sun Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Seung Yong Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Chonbuk National University Hospital, Jeonju, Korea
| | - Sunghoon Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea.
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Cuneo A, Barosi G, Danesi R, Fagiuoli S, Ghia P, Marzano A, Montillo M, Poletti V, Viale P, Zinzani PL. Management of adverse events associated with idelalisib treatment in chronic lymphocytic leukemia and follicular lymphoma: A multidisciplinary position paper. Hematol Oncol 2019; 37:3-14. [PMID: 30187496 PMCID: PMC6585802 DOI: 10.1002/hon.2540] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 07/09/2018] [Accepted: 07/10/2018] [Indexed: 01/05/2023]
Abstract
The introduction of new therapeutic agents in chronic lymphocytic leukemia (CLL) and follicular lymphoma (FL), including the new kinase inhibitor idelalisib, has changed the therapeutic landscape of these diseases. However, the use of idelalisib is associated with a peculiar profile of side effects, which require an optimization of the current approach to prophylaxis and supportive treatment. Moving from the recognition that the abovementioned issue represents an unmet need in CLL and FL, a multidisciplinary panel of experts was convened to produce a consensus document aiming to provide practical recommendations for the management of the side effects during idelalisib therapy for CLL and FL. The present publication represents a consensus document from a series of meetings held during 2017. The Panel generated clinical key questions using the criterion of clinical relevance through a Delphi process and explored 4 domains, ie, diarrhea/colitis, transaminitis, pneumonitis, and infectious complications. Using the consensus method, the Panel was able to shape recommendations which may assist hematologist to minimize adverse events and guarantee adherence to treatment in patients with CLL and FL candidate to receive idelalisib.
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MESH Headings
- Aldehyde Oxidase/metabolism
- Algorithms
- Animals
- Antineoplastic Agents/adverse effects
- Antineoplastic Agents/pharmacokinetics
- Antineoplastic Agents/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Colitis/diagnosis
- Colitis/etiology
- Cytochrome P-450 CYP3A/metabolism
- Diarrhea/diagnosis
- Diarrhea/etiology
- Disease Management
- Drug Interactions
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Lymphoma, Follicular/diagnosis
- Lymphoma, Follicular/drug therapy
- Lymphoma, Follicular/metabolism
- Purines/adverse effects
- Purines/pharmacokinetics
- Purines/therapeutic use
- Quinazolinones/adverse effects
- Quinazolinones/pharmacokinetics
- Quinazolinones/therapeutic use
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Affiliation(s)
- Antonio Cuneo
- Hematology Section, Department of Medical Sciences, Azienda Ospedaliero‐Universitaria, Arcispedale S. AnnaUniversity of FerraraFerraraItaly
| | | | - Romano Danesi
- Clinical Pharmacology and Pharmacogenetics Unit, Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
| | - Stefano Fagiuoli
- Gastroenterology and Transplant Hepatology“Papa Giovanni XXIII” HospitalBergamoItaly
| | - Paolo Ghia
- Università Vita‐Salute San Raffaele and IRCCS Istituto Scientifico San RaffaeleMilanItaly
| | - Alfredo Marzano
- Division of Gastroenterology, San Giovanni Battista HospitalUniversity of TorinoTurinItaly
| | - Marco Montillo
- Department of HematologyNiguarda Cancer Center Niguarda Hospital MilanoMilanItaly
| | - Venerino Poletti
- Department of Diseases of the ThoraxOspedale GB MorgagniForlìItaly
- Department of Respiratory Diseases & AllergyAarhus University HospitalAarhusDenmark
| | - Pierluigi Viale
- Infectious Disease Unit, Teaching Hospital S. Orsola‐MalpighiAlma Mater Studiorum ‐ University of BolognaBolognaItaly
| | - Pier Luigi Zinzani
- Institute of Hematology Lorenzo e Ariosto SeràgnoliUniversity of BolognaBolognaItaly
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268
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Korula PJ, Nayyar V, Stachowski E, Karuppusami R, Peter JV. An observational study on the practice of noninvasive ventilation at a tertiary level Australian intensive care unit. Aust Crit Care 2019; 33:89-96. [PMID: 30670345 DOI: 10.1016/j.aucc.2018.11.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 11/16/2018] [Accepted: 11/23/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Failure of Non-Invasive Ventilation (NIV) is associated with increased morbidity and mortality among critically ill patients. Although there is evidence of association between disease related factors and NIV failure, it is unclear whether factors related to NIV application contribute to NIV failure. OBJECTIVES To evaluate NIV failure rate and factors associated with NIV failure. DESIGN, SETTINGS AND OUTCOMES Prospective, observational, pilot study conducted in a 23-bed, tertiary care Intensive Care Unit (ICU). NIV failure was defined as application of NIV resulting in intubation or death in ICU. RESULTS Amongst 238 patients admitted with respiratory failure, NIV was administered to 60 patients (34 males, 26 females) for a total of 70 application episodes. The etiology of respiratory failure included acute pulmonary edema (28.6%), acute lung injury (22.9%) and pneumonia (15.7%). The mean (SD) age was 62 (17.6) years, BMI 32.0 (8.5) kg/m2 and median APACHE-II score 17.5 (14.0-23.8). NIV failure occurred in 22 out of 70 applications (31.4% [95%CI 20.0-43.0]). NIV failure assessed by simple logistic regression analysis, was associated with admission diagnosis (OR 6.0, 95%CI: 1.3-28.7, p = 0.03), use of bi-level NIV-PS (OR 5.00, 95%CI: 1.04-24.1, p = 0.04), presence of nasogastric tube (OR 6.20, 95%CI: 1.9-19.8, p < 0.01) and with short NIV breaks in the 2nd 24-hours (OR 0.96, 95%CI: 0.91-0.99, p = 0.04). CONCLUSION NIV failure was observed in 31.4%. Factors associated with NIV failure were etiology of respiratory illness, type of NIV support and short NIV breaks, presumably reflecting illness severity or progress of disease. The presence of a nasogastric tube during application of NIV may adversely impact NIV application.
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Affiliation(s)
| | - Vineet Nayyar
- University of Sydney, Intensive Care Unit, Westmead, Australia
| | | | - Reka Karuppusami
- Dept of Biostatistics, Christian Medical College and Hospital, Vellore, India
| | - John Victor Peter
- Division of Critical Care, Christian Medical College, Vellore, India
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269
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Xu B, Ge Y, Lu Y, Chen Q, Zhang H. Risk factors and prognosis of acute respiratory distress syndrome following abdominal surgery. Exp Ther Med 2019; 17:159-164. [PMID: 30651777 PMCID: PMC6307425 DOI: 10.3892/etm.2018.6928] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 10/16/2018] [Indexed: 12/25/2022] Open
Abstract
Risk factors and prognosis of acute respiratory distress syndrome (ARDS) following abdominal surgery were investigated. Five hundred and thirty-two patients who underwent abdominal surgery in Dongyang People's Hospital from February 2006 to May 2016 were enrolled. Among them, 113 patients had ARDS after surgery and 45 patients died. Those patients were included in observation group. The 419 patients who did not develop ARDS were included in control group, and 11 patients died. General data of patients were statistically analyzed, and the factors with statistical significance were subjected to multivariate logistic regression analysis to analyze the risk factors of ARDS. There was a significant difference in age, infection, trauma-to-surgery time, and prognosis between the two groups (P<0.05). Perioperative blood loss, blood transfusion volume, and fluid volume in the observation group were significantly higher than those in the control group (P<0.05). Heart rate, ratio of PaO2/FiO2, ratio of high (low) blood glucose, levels of procalcitonin (PCT) and albumin (ALB) were significantly different between the two groups. Heart rate, PCT, long-term health assessment (APACHE) II scores were higher in observation group than those in control group (P<0.05). Percentage of hyperglycemic patients, PaO2/FiO2, and ALB were lower in observation group than those in control group (P<0.05). Occurrence of ARDS after abdominal surgery was related to age, infection, heart rate, PaO2/FiO2, and PCT levels (P<0.05). Age, infection, heart rate, PaO2/FiO2, ALB and APACHE II scores were related to the prognosis of patients with ARDS after abdominal surgery (P<0.05). Age, infection, heart rate, PaO2/FiO2, PCT levels, blood loss, blood transfusion volume, and infusion volume may be risk factors for ARDS after abdominal surgery. Age, infection, heart rate, PaO2/FiO2, ALB, and APACHE II scores may be related to prognosis of patients with ARDS after abdominal surgery.
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Affiliation(s)
- Bingzheng Xu
- Department of Emergency, Dongyang People's Hospital, Dongyang, Zhejiang 322100, P.R. China
| | - Yangli Ge
- Department of Radiotherapy, Dongyang People's Hospital, Dongyang, Zhejiang 322100, P.R. China
| | - Yangzhen Lu
- Department of Emergency, Dongyang People's Hospital, Dongyang, Zhejiang 322100, P.R. China
| | - Qianqian Chen
- Department of Emergency, Dongyang People's Hospital, Dongyang, Zhejiang 322100, P.R. China
| | - Hongjin Zhang
- Department of Emergency, Dongyang People's Hospital, Dongyang, Zhejiang 322100, P.R. China
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270
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Abstract
Sepsis is defined as organ dysfunction resulting from the host's deleterious response to infection. One of the most common organs affected is the kidneys, resulting in sepsis associated acute kidney injury (SA-AKI) that contributes to the morbidity and mortality of sepsis. A growing body of knowledge has illuminated the clinical risk factors, pathobiology, response to treatment, and elements of renal recovery that have advanced our ability to prevent, detect, and treat SA-AKI. Despite these advances, SA-AKI remains an important concern and clinical burden, and further study is needed to reduce the acute and chronic consequences. This review summarizes the relevant evidence, with a focus on the risk factors, early recognition and diagnosis, treatment, and long term consequences of SA-AKI. In addition to literature pertaining to SA-AKI specifically, pertinent sepsis and acute kidney injury literature relevant to SA-AKI was included.
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Affiliation(s)
- Jason T Poston
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago
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271
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Mauri T, Spinelli E, Mariani M, Guzzardella A, Del Prete C, Carlesso E, Tortolani D, Tagliabue P, Pesenti A, Grasselli G. Nasal High Flow Delivered within the Helmet: A New Noninvasive Respiratory Support. Am J Respir Crit Care Med 2019; 199:115-117. [DOI: 10.1164/rccm.201806-1124le] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Tommaso Mauri
- Department of Pathophysiology and TransplantationUniversity of Milan, Italy
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilan, Italyand
| | - Elena Spinelli
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilan, Italyand
| | | | - Amedeo Guzzardella
- Department of Pathophysiology and TransplantationUniversity of Milan, Italy
| | - Chiara Del Prete
- Department of Pathophysiology and TransplantationUniversity of Milan, Italy
| | - Eleonora Carlesso
- Department of Pathophysiology and TransplantationUniversity of Milan, Italy
| | | | - Paola Tagliabue
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilan, Italyand
| | - Antonio Pesenti
- Department of Pathophysiology and TransplantationUniversity of Milan, Italy
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilan, Italyand
| | - Giacomo Grasselli
- Department of Pathophysiology and TransplantationUniversity of Milan, Italy
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilan, Italyand
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272
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Abstract
The acute respiratory distress syndrome (ARDS) is a common cause of respiratory failure in critically ill patients and is defined by the acute onset of noncardiogenic pulmonary oedema, hypoxaemia and the need for mechanical ventilation. ARDS occurs most often in the setting of pneumonia, sepsis, aspiration of gastric contents or severe trauma and is present in ~10% of all patients in intensive care units worldwide. Despite some improvements, mortality remains high at 30-40% in most studies. Pathological specimens from patients with ARDS frequently reveal diffuse alveolar damage, and laboratory studies have demonstrated both alveolar epithelial and lung endothelial injury, resulting in accumulation of protein-rich inflammatory oedematous fluid in the alveolar space. Diagnosis is based on consensus syndromic criteria, with modifications for under-resourced settings and in paediatric patients. Treatment focuses on lung-protective ventilation; no specific pharmacotherapies have been identified. Long-term outcomes of patients with ARDS are increasingly recognized as important research targets, as many patients survive ARDS only to have ongoing functional and/or psychological sequelae. Future directions include efforts to facilitate earlier recognition of ARDS, identifying responsive subsets of patients and ongoing efforts to understand fundamental mechanisms of lung injury to design specific treatments.
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273
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Yehya N, Thomas NJ. Sepsis and Pediatric Acute Respiratory Distress Syndrome. J Pediatr Intensive Care 2018; 8:32-41. [PMID: 31073506 DOI: 10.1055/s-0038-1676133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 10/17/2018] [Indexed: 12/13/2022] Open
Abstract
The epidemiology of the acute respiratory distress syndrome (ARDS) in pediatric sepsis is poorly defined. With significant data extrapolated from adult studies in sepsis and ARDS, sometimes with uncertain applicability, better pediatric-specific guidelines and dedicated investigations are warranted. The recent publication of a consensus definition for pediatric ARDS (PARDS) is the first step in addressing this knowledge gap. The aim of this review is to frame our current understanding of PARDS as it relates to pediatric sepsis, encompassing epidemiology, pathophysiology, and management. We argue that addressing the role of PARDS in pediatric sepsis requires significant attention to details with respect to how PARDS and sepsis are defined to accurately describe their epidemiology, natural history, and outcomes. Finally, we highlight certain aspects of PARDS management as they relate to the septic child and offer suggestion for future directions in this field.
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Affiliation(s)
- Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Neal J Thomas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health Science, Penn State Hershey Children's Hospital, Hershey, Pennsylvania, United States
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274
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Bourke SC, Piraino T, Pisani L, Brochard L, Elliott MW. Beyond the guidelines for non-invasive ventilation in acute respiratory failure: implications for practice. THE LANCET RESPIRATORY MEDICINE 2018; 6:935-947. [DOI: 10.1016/s2213-2600(18)30388-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 09/13/2018] [Accepted: 09/13/2018] [Indexed: 12/31/2022]
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275
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Derwall M, Martin L, Rossaint R. The acute respiratory distress syndrome: pathophysiology, current clinical practice, and emerging therapies. Expert Rev Respir Med 2018; 12:1021-1029. [PMID: 30431366 DOI: 10.1080/17476348.2018.1548280] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION More than fifty years after the first description of acute respiratory distress syndrome (ARDS) by Ashbaugh and colleagues, no specific treatment of the underlying pathophysiological processes is available. The current therapeutic regime is comprised of supportive measures such as lung protective ventilation, restrictive fluid management, paralyzing drugs, and prone positioning. Although vast improvements have been made in ARDS-treatment during the last five decades, mortality among patients with severe ARDS remains at an unacceptable rate of 45%. Areas covered: This article reviews the evolution of the currently used definition, established pathophysiological mechanism, highlights the current best clinical practice to treat ARDS, gives a brief outlook on cutting edge trends in ARDS research and closes with an expert opinion on the subject. Expert commentary: Individualizing the provided measures to specific genotypes is the key challenge in ARDS research today. The ongoing digital revolution will help to individualize ARDS-treatment and will therefore presumably improve survival and quality of life.
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Affiliation(s)
- Matthias Derwall
- a Klinik für Anästhesiologie , Uniklinik RWTH Aachen, Medizinische Fakultät RWTH Aachen , Aachen , Germany.,b Klinik für Operative Intensivmedizin und Intermediate Care , Uniklinik RWTH Aachen, Medizinische Fakultät RWTH Aachen , Aachen , Germany
| | - Lukas Martin
- a Klinik für Anästhesiologie , Uniklinik RWTH Aachen, Medizinische Fakultät RWTH Aachen , Aachen , Germany.,b Klinik für Operative Intensivmedizin und Intermediate Care , Uniklinik RWTH Aachen, Medizinische Fakultät RWTH Aachen , Aachen , Germany
| | - Rolf Rossaint
- a Klinik für Anästhesiologie , Uniklinik RWTH Aachen, Medizinische Fakultät RWTH Aachen , Aachen , Germany.,b Klinik für Operative Intensivmedizin und Intermediate Care , Uniklinik RWTH Aachen, Medizinische Fakultät RWTH Aachen , Aachen , Germany
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276
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Lucchini A, Elli S, Bambi S, De Felippis C, Vimercati S, Minotti D, Pasquali S, Cannizzo L, Fumagalli R, Foti G. How different helmet fixing options could affect patients' pain experience during helmet‐continuous positive airway pressure. Nurs Crit Care 2018; 24:369-374. [DOI: 10.1111/nicc.12399] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 10/02/2018] [Accepted: 10/05/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Alberto Lucchini
- General Intensive Care Unit, Emergency Department, ASST Monza – San Gerardo Hospital, University of Milano‐Bicocca Monza, MB Italy
| | - Stefano Elli
- General Intensive Care Unit, Emergency Department, ASST Monza – San Gerardo Hospital, University of Milano‐Bicocca Monza, MB Italy
| | - Stefano Bambi
- Emergency, ECMO and Trauma Intensive Care Unit, Azienda Ospedaliero Careggi University Hospital Florence Italy
| | - Christian De Felippis
- General Intensive Care Unit, Emergency Department, ASST Monza – San Gerardo Hospital, University of Milano‐Bicocca Monza, MB Italy
| | - Simona Vimercati
- General Intensive Care Unit, Emergency Department, ASST Monza – San Gerardo Hospital, University of Milano‐Bicocca Monza, MB Italy
| | - Dario Minotti
- General Intensive Care Unit, Emergency Department, ASST Monza – San Gerardo Hospital, University of Milano‐Bicocca Monza, MB Italy
| | - Sara Pasquali
- General Intensive Care Unit, Emergency Department, ASST Monza – San Gerardo Hospital, University of Milano‐Bicocca Monza, MB Italy
| | - Luigi Cannizzo
- General Intensive Care Unit, Emergency Department, ASST Monza – San Gerardo Hospital, University of Milano‐Bicocca Monza, MB Italy
| | - Roberto Fumagalli
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, University Hospital of Milano‐Bicocca Milan Italy
| | - Giuseppe Foti
- General Intensive Care Unit, Emergency Department, ASST Monza – San Gerardo Hospital, University of Milano‐Bicocca Monza, MB Italy
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277
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Major VJ, Chiew YS, Shaw GM, Chase JG. Biomedical engineer's guide to the clinical aspects of intensive care mechanical ventilation. Biomed Eng Online 2018; 17:169. [PMID: 30419903 PMCID: PMC6233601 DOI: 10.1186/s12938-018-0599-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 11/01/2018] [Indexed: 12/16/2022] Open
Abstract
Background Mechanical ventilation is an essential therapy to support critically ill respiratory failure patients. Current standards of care consist of generalised approaches, such as the use of positive end expiratory pressure to inspired oxygen fraction (PEEP–FiO2) tables, which fail to account for the inter- and intra-patient variability between and within patients. The benefits of higher or lower tidal volume, PEEP, and other settings are highly debated and no consensus has been reached. Moreover, clinicians implicitly account for patient-specific factors such as disease condition and progression as they manually titrate ventilator settings. Hence, care is highly variable and potentially often non-optimal. These conditions create a situation that could benefit greatly from an engineered approach. The overall goal is a review of ventilation that is accessible to both clinicians and engineers, to bridge the divide between the two fields and enable collaboration to improve patient care and outcomes. This review does not take the form of a typical systematic review. Instead, it defines the standard terminology and introduces key clinical and biomedical measurements before introducing the key clinical studies and their influence in clinical practice which in turn flows into the needs and requirements around how biomedical engineering research can play a role in improving care. Given the significant clinical research to date and its impact on this complex area of care, this review thus provides a tutorial introduction around the review of the state of the art relevant to a biomedical engineering perspective. Discussion This review presents the significant clinical aspects and variables of ventilation management, the potential risks associated with suboptimal ventilation management, and a review of the major recent attempts to improve ventilation in the context of these variables. The unique aspect of this review is a focus on these key elements relevant to engineering new approaches. In particular, the need for ventilation strategies which consider, and directly account for, the significant differences in patient condition, disease etiology, and progression within patients is demonstrated with the subsequent requirement for optimal ventilation strategies to titrate for patient- and time-specific conditions. Conclusion Engineered, protective lung strategies that can directly account for and manage inter- and intra-patient variability thus offer great potential to improve both individual care, as well as cohort clinical outcomes.
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Affiliation(s)
- Vincent J Major
- Department of Population Health, NYU Langone Health, New York, NY, USA.
| | - Yeong Shiong Chiew
- School of Engineering, Monash University Malaysia, Subang Jaya, Malaysia
| | - Geoffrey M Shaw
- Department of Intensive Care, Christchurch Hospital, Christchurch, New Zealand
| | - J Geoffrey Chase
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
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278
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Frat JP, Coudroy R, Thille AW. Non-invasive ventilation or high-flow oxygen therapy: When to choose one over the other? Respirology 2018; 24:724-731. [PMID: 30406954 DOI: 10.1111/resp.13435] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 10/03/2018] [Accepted: 10/11/2018] [Indexed: 12/20/2022]
Abstract
It has been found that high-flow oxygen therapy (HFOT) can reduce mortality of patients admitted to intensive care unit (ICU) for de novo acute respiratory failure (ARF) as compared to non-invasive ventilation (NIV). HFOT might therefore be considered as a first-line strategy of oxygenation in these patients. The beneficial effects of HFOT may be explained by its good tolerance and by physiological characteristics including delivery of high FiO2 , positive end expiratory pressure (PEEP) effect and continuous dead space washout contributing to decreased work of breathing. In contrast, NIV should be used cautiously in patients with de novo ARF due to high tidal volumes promoted by pressure support and that may potentially worsen pre-existing lung injury. Although recent studies have reported no benefit and even deleterious effects of NIV in immunocompromised patients with ARF, the experts have recommended its use as a first-line strategy. In patients with acute-on-chronic respiratory failure and respiratory acidosis, it has been clearly shown that NIV is the best strategy of oxygenation. However, HFOT seems able to reverse respiratory acidosis and further studies are needed to evaluate whether HFOT could represent an alternative to standard oxygen. Although NIV is recommended to treat ARF in post-operative patients or to prevent post-extubation respiratory failure in ICU, recent large-scale randomized studies suggest that HFOT could be equivalent to NIV. While recent recommendations have been established from studies comparing NIV with standard oxygen, new studies are needed to compare NIV versus HFOT in order to better define the appropriate indications for both treatments.
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Affiliation(s)
- Jean-Pierre Frat
- Médecine Intensive Réanimation, CHU de Poitiers, Poitiers, France.,CIC-1402 ALIVE, INSERM, Poitiers, France.,Faculté de Médecine et de Pharmacie de Poitiers, Université de Poitiers, Poitiers, France
| | - Rémi Coudroy
- Médecine Intensive Réanimation, CHU de Poitiers, Poitiers, France.,CIC-1402 ALIVE, INSERM, Poitiers, France.,Faculté de Médecine et de Pharmacie de Poitiers, Université de Poitiers, Poitiers, France
| | - Arnaud W Thille
- Médecine Intensive Réanimation, CHU de Poitiers, Poitiers, France.,CIC-1402 ALIVE, INSERM, Poitiers, France.,Faculté de Médecine et de Pharmacie de Poitiers, Université de Poitiers, Poitiers, France
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279
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Is there still a place for noninvasive ventilation in acute hypoxemic respiratory failure? Intensive Care Med 2018; 44:2248-2250. [PMID: 30353381 DOI: 10.1007/s00134-018-5416-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 10/11/2018] [Indexed: 01/12/2023]
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280
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Spoletini G, Mega C, Pisani L, Alotaibi M, Khoja A, Price LL, Blasi F, Nava S, Hill NS. High-flow nasal therapy vs standard oxygen during breaks off noninvasive ventilation for acute respiratory failure: A pilot randomized controlled trial. J Crit Care 2018; 48:418-425. [PMID: 30321833 DOI: 10.1016/j.jcrc.2018.10.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 09/18/2018] [Accepted: 10/04/2018] [Indexed: 01/12/2023]
Abstract
PURPOSE To assess the role of high-flow nasal therapy (HFNT) compared to standard oxygen (SO) as complementary therapy to non-invasive ventilation (NIV). METHODS Multicenter trial including patients (n = 54) anticipated to receive NIV for ≥24 h due to acute or acute-on-chronic respiratory failure. Subjects were randomized (1:1) to SO or HFNT during breaks off NIV. Primary outcome was total time on and off NIV. Secondary outcomes were comfort and dyspnea, respiratory rate (RR), oxygen saturation (SpO2), tolerance and side effects. RESULTS Total time per patient on NIV (1315 vs 1441 min) and breaks (1362 vs 1196 min), and mean duration of each break (520 vs 370 min) were similar in the HFNT and SO arms (p > .05). Comfort score was higher on HFNT than on SO (8.3 ± 2.7 vs 6.9 ± 2.3, p = .001). Dyspnea, RR and SpO2 were similar in the two arms, but the increase in RR and dyspnea seen with SO during breaks did not occur with HFNT. CONCLUSION Compared to SO, HFNT did not reduce time on NIV. However, it was more comfortable and the increase in RR and dyspnea seen with SO did not occur with HFNT. Therefore, HFNT could be a suitable alternative to SO during breaks off NIV.
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Affiliation(s)
- Giulia Spoletini
- Pulmonary, Critical Care and Sleep Medicine Division, Tufts Medical Center, Boston, MA, USA
| | - Chiara Mega
- Pulmonary, Critical Care and Sleep Medicine Division, Tufts Medical Center, Boston, MA, USA
| | - Lara Pisani
- Pulmonary, Critical Care and Sleep Medicine Division, Tufts Medical Center, Boston, MA, USA
| | - Mona Alotaibi
- Pulmonary, Critical Care and Sleep Medicine Division, Tufts Medical Center, Boston, MA, USA
| | - Alia Khoja
- Pulmonary, Critical Care and Sleep Medicine Division, Tufts Medical Center, Boston, MA, USA
| | - Lori Lyn Price
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA; The Institute for Clinical Research and Health Policy Study, Tufts Medical Center, Boston, MA, USA
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, IRCCS Fondazione Ospedale Maggiore Policlinico Ca' Granda, Milan, Italy
| | - Stefano Nava
- Department of Clinical, Integrated and Experimental Medicine (DIMES), Respiratory and Critical Care Unit, Ospedale Sant'Orsola Malpighi, Alma Mater University, Bologna, Italy
| | - Nicholas S Hill
- Pulmonary, Critical Care and Sleep Medicine Division, Tufts Medical Center, Boston, MA, USA.
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281
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The authors reply. Crit Care Med 2018; 46:e1019-e1020. [DOI: 10.1097/ccm.0000000000003318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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282
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Noninvasive Ventilation Versus High-Flow Nasal Oxygen for Acute Respiratory Distress Syndrome. Crit Care Med 2018; 46:e1018-e1019. [DOI: 10.1097/ccm.0000000000003284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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283
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Moreno RP, Nassar AP. Is APACHE II a useful tool for clinical research? Rev Bras Ter Intensiva 2018; 29:264-267. [PMID: 29044301 PMCID: PMC5632966 DOI: 10.5935/0103-507x.20170046] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 02/22/2017] [Indexed: 12/26/2022] Open
Affiliation(s)
- Rui P Moreno
- Hospital de São José, Centro Hospitalar de Lisboa Central - Lisboa, Portugal
| | - Antonio Paulo Nassar
- Unidade de Terapia Intensiva, A.C. Camargo Cancer Center - São Paulo (SP), Brasil
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284
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Approaches and techniques to avoid development or progression of acute respiratory distress syndrome. Curr Opin Crit Care 2018; 24:10-15. [PMID: 29194057 DOI: 10.1097/mcc.0000000000000477] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Despite major improvement in ventilation strategies, hospital mortality and morbidity of the acute respiratory distress syndrome (ARDS) remain high. A lot of therapies have been shown to be ineffective for established ARDS. There is a growing interest in strategies aiming at avoiding development and progression of ARDS. RECENT FINDINGS Recent advances in this field have explored identification of patients at high-risk, nonspecific measures to limit the risks of inflammation, infection and fluid overload, prevention strategies of ventilator-induced lung injury and patient self-inflicted lung injury, and pharmacological treatments. SUMMARY There is potential for improvement in the management of patients admitted to intensive care unit to reduce ARDS incidence. Apart from nonspecific measures, prevention of ventilator-induced lung injury and patient self-inflicted lung injury are of major importance.
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285
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Wang BC, Pei T, Lin CB, Guo R, Elashoff D, Lin JA, Pineda C. Clinical characteristics and outcomes associated with nasal intermittent mandatory ventilation in acute pediatric respiratory failure. World J Crit Care Med 2018; 7:46-51. [PMID: 30211019 PMCID: PMC6134265 DOI: 10.5492/wjccm.v7.i4.46] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 07/25/2018] [Accepted: 08/05/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To characterize the clinical course and outcomes of nasal intermittent mandatory ventilation (NIMV) use in acute pediatric respiratory failure.
METHODS We identified all patients treated with NIMV in the pediatric intensive care unit (PICU) or inpatient general pediatrics between January 2013 and December 2015 at two academic centers. Patients who utilized NIMV with other modes of noninvasive ventilation during the same admission were included. Data included demographics, vital signs on admission and prior to initiation of NIMV, pediatric risk of mortality III (PRISM-III) scores, complications, respiratory support characteristics, PICU and hospital length of stays, duration of respiratory support, and complications. Patients who did not require escalation to mechanical ventilation were defined as NIMV responders; those who required escalation to mechanical ventilation (MV) were defined as NIMV non-responders. NIMV responders were compared to NIMV non-responders.
RESULTS Forty-two patients met study criteria. Six (14%) failed treatment and required MV. The majority of the patients (74%) had a primary diagnosis of bronchiolitis. The median age of these 42 patients was 4 mo (range 0.5-28.1 mo, IQR 7, P = 0.69). No significant difference was measured in other baseline demographics and vitals on initiation of NIMV; these included age, temperature, respiratory rate, O2 saturation, heart rate, systolic blood pressure, diastolic blood pressure, and PRISM-III scores. The duration of NIMV was shorter in the NIMV non-responder vs NIMV responder group (6.5 h vs 65 h, P < 0.0005). Otherwise, NIMV failure was not associated with significant differences in PICU length of stay (LOS), hospital LOS, or total duration of respiratory support. No patients had aspiration pneumonia, pneumothorax, or skin breakdown.
CONCLUSION Most of our patients responded to NIMV. NIMV failure is not associated with differences in hospital LOS, PICU LOS, or duration of respiratory support.
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Affiliation(s)
- Billy C Wang
- Department of Pediatrics, Division of Critical Care Medicine, Loma Linda University Children’s Hospital, Loma Linda, CA 92354, United States
| | - Theodore Pei
- Department of Pediatrics, Division of Pediatric Critical Care, Floating Hospital for Children at Tufts, Boston, MA 02111, United States
| | - Cheryl B Lin
- Department of Pediatrics, Division of Pediatric Critical Care, Floating Hospital for Children at Tufts, Boston, MA 02111, United States
| | - Rong Guo
- Department of Medicine, Biostatistics Core, UCLA David Geffen School of Medicine, Los Angeles, CA 90024, United States
| | - David Elashoff
- Department of Medicine, Biostatistics Core, UCLA David Geffen School of Medicine, Los Angeles, CA 90024, United States
| | - James A Lin
- Department of Pediatrics, Mattel Children’s Hospital at UCLA, Los Angeles, CA 90095, United States
| | - Carol Pineda
- Department of Pediatrics, Division of Pediatric Critical Care, Floating Hospital for Children at Tufts, Boston, MA 02111, United States
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286
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Abstract
Acute respiratory distress syndrome (ARDS) is a clinically and biologically heterogeneous disorder associated with many disease processes that injure the lung, culminating in increased non-hydrostatic extravascular lung water, reduced compliance, and severe hypoxemia. Despite enhanced understanding of molecular mechanisms, advances in ventilatory strategies, and general care of the critically ill patient, mortality remains unacceptably high. The Berlin definition of ARDS has now replaced the American-European Consensus Conference definition. The recently concluded Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG-SAFE) provided worldwide epidemiological data of ARDS including prevalence, geographic variability, mortality, and patterns of mechanical ventilation use. Failure of clinical therapeutic trials prompted the investigation and subsequent discovery of two distinct phenotypes of ARDS (hyper-inflammatory and hypo-inflammatory) that have different biomarker profiles and clinical courses and respond differently to the random application of positive end expiratory pressure (PEEP) and fluid management strategies. Low tidal volume ventilation remains the predominant mainstay of the ventilatory strategy in ARDS. High-frequency oscillatory ventilation, application of recruitment maneuvers, higher PEEP, extracorporeal membrane oxygenation, and alternate modes of mechanical ventilation have failed to show benefit. Similarly, most pharmacological therapies including keratinocyte growth factor, beta-2 agonists, and aspirin did not improve outcomes. Prone positioning and early neuromuscular blockade have demonstrated mortality benefit, and clinical guidelines now recommend their use. Current ongoing trials include the use of mesenchymal stem cells, vitamin C, re-evaluation of neuromuscular blockade, and extracorporeal carbon dioxide removal. In this article, we describe advances in the diagnosis, epidemiology, and treatment of ARDS over the past decade.
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Affiliation(s)
- Rahul S Nanchal
- Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jonathon D Truwit
- Pulmonary and Critical Care Medicine, Froedtert & Medical College of Wisconsin, Milwaukee, WI, USA
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287
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Non-invasive positive pressure ventilation in lung transplant recipients with acute respiratory failure: Beyond the perioperative period. J Crit Care 2018; 47:287-294. [PMID: 30098575 DOI: 10.1016/j.jcrc.2018.07.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 07/30/2018] [Accepted: 07/31/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE The purpose of this study is to evaluate outcomes in MICU lung transplant recipients with acute respiratory failure treated with non-invasive positive pressure ventilation (NPPV) and identify factors associated with NPPV failure (need for intubation). METHODS Retrospective chart review of all lung transplant recipients who were admitted with acute respiratory failure to the MICU from January 2009-August 2016 was completed. Logistic regression analysis was performed to determine which factors were independently associated with NPPV failure. RESULTS Of 156 patients included in the study, 125 (80.1%) were tried on NPPV. Sixty-eight (54.4%) were managed successfully with NPPV with a hospital survival rate of 94.1%. Subjects who failed NPPV had higher hospital mortality, similar to those intubated from the outset (15 [48.3%]; 22 [38.6%], p = .37). In multivariate analyses, APACHE III scores >78 (9.717 [3.346, 28.22]) and PaO2/FiO2 ≤ 151 (4.54 [1.72, 11.99]) were associated with greater likelihood of NPPV failure. There was no difference in NPPV failure based on the presence of BOS. In patients with high severity of illness, there was no difference in mortality between initial IMV and NPPV failure when stratified on the basis of hypoxemia (PaO2/FiO2 > 151, p-value 0.34; PaO2/FiO2 ≤ 151, p-value 0.99). CONCLUSIONS NPPV is a viable option for lung transplant recipients with acute respiratory failure. Extreme caution should be exercised when used in patients with high severity of illness (APACHE III >78) and/or severe hypoxemia (PaO2/FiO2 ≤ 151).
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288
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Carvalho NC, Portes LL, Beda A, Tallarico LMS, Aguirre LA. Recurrence plots for the assessment of patient-ventilator interactions quality during invasive mechanical ventilation. CHAOS (WOODBURY, N.Y.) 2018; 28:085707. [PMID: 30180626 DOI: 10.1063/1.5020371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 05/10/2018] [Indexed: 06/08/2023]
Abstract
Inappropriate patient-ventilator interactions' (PVI) quality is associated with adverse clinical consequences, such as patient anxiety/fear and increased need of sedative and paralytic agents. Thus, technological devices/tools to support the recognition and monitoring of different PVI quality are of great interest. In the present study, we investigate two tools based on a recent landmark study which applied recurrence plots (RPs) and recurrence quantification analysis (RQA) techniques in non-invasive mechanical ventilation. Our interest is in how this approach could be a daily part of critical care professionals' routine (which are not familiar with dynamical systems theory methods and concepts). Two representative time series of three typical PVI "scenarios" were selected from 6 critically ill patients subjected to invasive mechanical ventilation. First, both the (i) main signatures in RPs and the (ii) respective signals that provide the most (visually) discriminant RPs were identified. This allows one to propose a visual identification protocol for PVIs' quality through the RPs' overall aspect. Support for the effectiveness of this visual based assessment tool is given by a RQA-based assessment tool. A statistical analysis shows that both the recurrence rate and the Shannon entropy are able to identify the selected PVI scenarios. It is then expected that the development of an objective method can reliably identify PVI quality, where the results corroborate the potential of RPs/RQA in the field of respiratory pattern analysis.
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Affiliation(s)
- Nadja C Carvalho
- Graduate Program in Electrical Engineering (PPGEE), Universidade Federal de Minas Gerais, Av. Antônio Carlos 6627, 31270-901 Belo Horizonte, Minas Gerais, Brazil
| | - Leonardo L Portes
- Graduate Program in Electrical Engineering (PPGEE), Universidade Federal de Minas Gerais, Av. Antônio Carlos 6627, 31270-901 Belo Horizonte, Minas Gerais, Brazil
| | - Alessandro Beda
- Departamento de Engenharia Eletrônica, Universidade Federal de Minas Gerais, Av. Antônio Carlos 6627, 31270-901 Belo Horizonte, Minas Gerais, Brazil
| | - Lucinara M S Tallarico
- Hospital Risoleta Tolentino Neves, Rua das Gabirobas 1, 31744-012 Belo Horizonte, Minas Gerais, Brazil
| | - Luis A Aguirre
- Departamento de Engenharia Eletrônica, Universidade Federal de Minas Gerais, Av. Antônio Carlos 6627, 31270-901 Belo Horizonte, Minas Gerais, Brazil
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289
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Reuß CJ, Bernhard M, Beynon C, Hecker A, Jungk C, Michalski D, Nusshag C, Weigand MA, Brenner T. [Intensive care studies from 2016/2017]. Anaesthesist 2018; 66:690-713. [PMID: 28667421 PMCID: PMC7095915 DOI: 10.1007/s00101-017-0339-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- C J Reuß
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - C Beynon
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - A Hecker
- Klinik für Allgemein- Viszeral‑, Thorax- Transplantations- und Kinderchirurgie, Universitätsklinikum Gießen und Marburg, Standort Gießen, Gießen, Deutschland
| | - C Jungk
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - D Michalski
- Neurologische Intensivstation und Stroke Unit, Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - C Nusshag
- Klinik für Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - T Brenner
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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290
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Cortegiani A, Madotto F, Gregoretti C, Bellani G, Laffey JG, Pham T, Van Haren F, Giarratano A, Antonelli M, Pesenti A, Grasselli G. Immunocompromised patients with acute respiratory distress syndrome: secondary analysis of the LUNG SAFE database. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:157. [PMID: 29895331 PMCID: PMC5998562 DOI: 10.1186/s13054-018-2079-9] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 05/22/2018] [Indexed: 12/15/2022]
Abstract
Background The aim of this study was to describe data on epidemiology, ventilatory management, and outcome of acute respiratory distress syndrome (ARDS) in immunocompromised patients. Methods We performed a post hoc analysis on the cohort of immunocompromised patients enrolled in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) study. The LUNG SAFE study was an international, prospective study including hypoxemic patients in 459 ICUs from 50 countries across 5 continents. Results Of 2813 patients with ARDS, 584 (20.8%) were immunocompromised, 38.9% of whom had an unspecified cause. Pneumonia, nonpulmonary sepsis, and noncardiogenic shock were their most common risk factors for ARDS. Hospital mortality was higher in immunocompromised than in immunocompetent patients (52.4% vs 36.2%; p < 0.0001), despite similar severity of ARDS. Decisions regarding limiting life-sustaining measures were significantly more frequent in immunocompromised patients (27.1% vs 18.6%; p < 0.0001). Use of noninvasive ventilation (NIV) as first-line treatment was higher in immunocompromised patients (20.9% vs 15.9%; p = 0.0048), and immunodeficiency remained independently associated with the use of NIV after adjustment for confounders. Forty-eight percent of the patients treated with NIV were intubated, and their mortality was not different from that of the patients invasively ventilated ab initio. Conclusions Immunosuppression is frequent in patients with ARDS, and infections are the main risk factors for ARDS in these immunocompromised patients. Their management differs from that of immunocompetent patients, particularly the greater use of NIV as first-line ventilation strategy. Compared with immunocompetent subjects, they have higher mortality regardless of ARDS severity as well as a higher frequency of limitation of life-sustaining measures. Nonetheless, nearly half of these patients survive to hospital discharge. Trial registration ClinicalTrials.gov, NCT02010073. Registered on 12 December 2013. Electronic supplementary material The online version of this article (10.1186/s13054-018-2079-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andrea Cortegiani
- Department of Biopathology and Medical Biotechnologies (DIBIMED), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Via del vespro 129, 90127, Palermo, Italy.
| | - Fabiana Madotto
- Research Center on Public Health, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Cesare Gregoretti
- Department of Biopathology and Medical Biotechnologies (DIBIMED), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Via del vespro 129, 90127, Palermo, Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - John G Laffey
- Anesthesia, School of Medicine, National University of Ireland, Galway, Ireland.,Interdepartemental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Center for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Tai Pham
- Interdepartemental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Center for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Frank Van Haren
- College of Medicine, Biology and Environment, Australian National University, Canberra, Australia.,Intensive Care Unit, Canberra Hospital, Canberra, Australia
| | - Antonino Giarratano
- Department of Biopathology and Medical Biotechnologies (DIBIMED), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Via del vespro 129, 90127, Palermo, Italy
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care, Università Cattolica del Sacro Cuore - Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Antonio Pesenti
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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291
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Abstract
IMPORTANCE Acute respiratory distress syndrome (ARDS) is a life-threatening form of respiratory failure that affects approximately 200 000 patients each year in the United States, resulting in nearly 75 000 deaths annually. Globally, ARDS accounts for 10% of intensive care unit admissions, representing more than 3 million patients with ARDS annually. OBJECTIVE To review advances in diagnosis and treatment of ARDS over the last 5 years. EVIDENCE REVIEW We searched MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews from 2012 to 2017 focusing on randomized clinical trials, meta-analyses, systematic reviews, and clinical practice guidelines. Articles were identified for full text review with manual review of bibliographies generating additional references. FINDINGS After screening 1662 citations, 31 articles detailing major advances in the diagnosis or treatment of ARDS were selected. The Berlin definition proposed 3 categories of ARDS based on the severity of hypoxemia: mild (200 mm Hg<Pao2/Fio2≤300 mm Hg), moderate (100 mm Hg<Pao2/Fio2≤200 mm Hg), and severe (Pao2/Fio2 ≤100 mm Hg), along with explicit criteria related to timing of the syndrome's onset, origin of edema, and the chest radiograph findings. The Berlin definition has significantly greater predictive validity for mortality than the prior American-European Consensus Conference definition. Clinician interpretation of the origin of edema and chest radiograph criteria may be less reliable in making a diagnosis of ARDS. The cornerstone of management remains mechanical ventilation, with a goal to minimize ventilator-induced lung injury (VILI). Aspirin was not effective in preventing ARDS in patients at high-risk for the syndrome. Adjunctive interventions to further minimize VILI, such as prone positioning in patients with a Pao2/Fio2 ratio less than 150 mm Hg, were associated with a significant mortality benefit whereas others (eg, extracorporeal carbon dioxide removal) remain experimental. Pharmacologic therapies such as β2 agonists, statins, and keratinocyte growth factor, which targeted pathophysiologic alterations in ARDS, were not beneficial and demonstrated possible harm. Recent guidelines on mechanical ventilation in ARDS provide evidence-based recommendations related to 6 interventions, including low tidal volume and inspiratory pressure ventilation, prone positioning, high-frequency oscillatory ventilation, higher vs lower positive end-expiratory pressure, lung recruitment maneuvers, and extracorporeal membrane oxygenation. CONCLUSIONS AND RELEVANCE The Berlin definition of acute respiratory distress syndrome addressed limitations of the American-European Consensus Conference definition, but poor reliability of some criteria may contribute to underrecognition by clinicians. No pharmacologic treatments aimed at the underlying pathology have been shown to be effective, and management remains supportive with lung-protective mechanical ventilation. Guidelines on mechanical ventilation in patients with acute respiratory distress syndrome can assist clinicians in delivering evidence-based interventions that may lead to improved outcomes.
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Affiliation(s)
- Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Department of Medicine, University Health Network and Sinai Health System, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Keenan Research Center, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
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292
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Cost Analysis of Noninvasive Helmet Ventilation Compared with Use of Noninvasive Face Mask in ARDS. Can Respir J 2018; 2018:6518572. [PMID: 29670676 PMCID: PMC5833880 DOI: 10.1155/2018/6518572] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 01/04/2018] [Indexed: 12/13/2022] Open
Abstract
Intensive care unit (ICU) costs have doubled since 2000, totalling 108 billion dollars per year. Acute respiratory distress syndrome (ARDS) has a prevalence of 10.4% and a 28-day mortality of 34.8%. Noninvasive ventilation (NIV) is used in up to 30% of cases. A recent randomized controlled trial by Patel et al. (2016) showed lower intubation rates and 90-day mortality when comparing helmet to face mask NIV in ARDS. The population in the Patel et al. trial was used for cost analysis in this study. Projections of cost savings showed a decrease in ICU costs by $2527 and hospital costs by $3103 per patient, along with a 43.3% absolute reduction in intubation rates. Sensitivity analysis showed consistent cost reductions. Projected annual cost savings, assuming the current prevalence of ARDS, were $237538 in ICU costs and $291682 in hospital costs. At a national level, using yearly incidence of ARDS cases in American ICUs, this represents $449 million in savings. Helmet NIV, compared to face mask NIV, in nonintubated patients with ARDS, reduces ICU and hospital direct-variable costs along with intubation rates, LOS, and mortality. A large-scale cost-effectiveness analysis is needed to validate the findings.
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293
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Hill NS, Garpestad E, Schumaker G, Spoletini G. Judicious Use of Noninvasive Ventilatory Modalities for Severe Pneumonia/ARDS. Turk J Anaesthesiol Reanim 2018; 46:3-4. [PMID: 30140494 DOI: 10.5152/tjar.2018.130202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Nicholas S Hill
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA 02111
| | - Erik Garpestad
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA 02111
| | - Greg Schumaker
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA 02111
| | - Giulia Spoletini
- Respiratory Department, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK
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294
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Gregoretti C, Cortegiani A, Accurso G, Raineri SM, Giarratano A. Noninvasive Ventilation for Acute Hypoxemic Respiratory Failure/ARDS: the Show Must Go on. Turk J Anaesthesiol Reanim 2018; 46:1-2. [PMID: 30140493 DOI: 10.5152/tjar.2018.290118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Cesare Gregoretti
- Department of Biopathology and Medical Biotechnologies (DIBIMED). Section of Anesthesia, Analgesia, Intensive Care and Emergency. Policlinico P. Giaccone. University of Palermo, Italy
| | - Andrea Cortegiani
- Department of Biopathology and Medical Biotechnologies (DIBIMED). Section of Anesthesia, Analgesia, Intensive Care and Emergency. Policlinico P. Giaccone. University of Palermo, Italy
| | - Giuseppe Accurso
- Department of Biopathology and Medical Biotechnologies (DIBIMED). Section of Anesthesia, Analgesia, Intensive Care and Emergency. Policlinico P. Giaccone. University of Palermo, Italy
| | - Santi Maurizio Raineri
- Department of Biopathology and Medical Biotechnologies (DIBIMED). Section of Anesthesia, Analgesia, Intensive Care and Emergency. Policlinico P. Giaccone. University of Palermo, Italy
| | - Antonino Giarratano
- Department of Biopathology and Medical Biotechnologies (DIBIMED). Section of Anesthesia, Analgesia, Intensive Care and Emergency. Policlinico P. Giaccone. University of Palermo, Italy
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295
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Nichtinvasive Beatmung zur Behandlung akuter respiratorischer Insuffizienz. Med Klin Intensivmed Notfmed 2018; 113:59-72. [DOI: 10.1007/s00063-017-0385-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 09/25/2017] [Accepted: 10/18/2017] [Indexed: 10/18/2022]
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296
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Paolini V, Faverio P, Aliberti S, Messinesi G, Foti G, Sibila O, Monzani A, De Giacomi F, Stainer A, Pesci A. Positive end expiratory pressure in acute hypoxemic respiratory failure due to community acquired pneumonia: do we need a personalized approach? PeerJ 2018; 6:e4211. [PMID: 29404202 PMCID: PMC5796278 DOI: 10.7717/peerj.4211] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 12/09/2017] [Indexed: 11/20/2022] Open
Abstract
Background Acute respiratory failure (ARF) is a life-threatening complication in patients with community acquired pneumonia (CAP). The use of non-invasive ventilation is controversial. With this prospective, observational study we aimed to describe a protocol to assess whether a patient with moderate-to-severe hypoxemic ARF secondary to CAP benefits, in clinical and laboratoristic terms, from the application of a positive end expiratory pressure (PEEP) + oxygen vs oxygen alone. Methods Patients who benefit from PEEP application (PEEP-responders) were defined as those with partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) increase >20% and/or reduction of respiratory distress during PEEP + oxygen therapy compared to oxygen therapy alone. Clinical characteristics and outcomes were compared between PEEP-responders and PEEP-non responders. Results Out of 41 patients, 27 (66%) benefit from PEEP application (PEEP-responders), the best response was obtained with a PEEP of 10 cmH2O in 13 patients, 7.5 cmH2O in eight and 5 cmH2O in six. PEEP-responders were less likely to present comorbidities compared to PEEP-non responders. No differences between groups were found in regards to endotracheal intubation criteria fullfillment, intensive care unit admission and in-hospital mortality, while PEEP-responders had a shorter length of hospital stay. Discussion The application of a protocol to evaluate PEEP responsiveness might be useful in patients with moderate-to-severe hypoxemic ARF due to CAP in order to personalize and maximize the effectiveness of therapy, and prevent the inappropriate PEEP use. PEEP responsiveness does not seem to be associated with better outcomes, with the exception of a shorter length of hospital stay.
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Affiliation(s)
- Valentina Paolini
- Dipartimento Cardio-Toraco-Vascolare, Respiratory Unit, San Gerardo Hospital, ASST di Monza, University of Milan-Bicocca, Monza, Italy
| | - Paola Faverio
- Dipartimento Cardio-Toraco-Vascolare, Respiratory Unit, San Gerardo Hospital, ASST di Monza, University of Milan-Bicocca, Monza, Italy
| | - Stefano Aliberti
- Department of Pathophysiology and Transplantation, Cardio-thoracic unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milano, Italy
| | - Grazia Messinesi
- Dipartimento Cardio-Toraco-Vascolare, Respiratory Unit, San Gerardo Hospital, ASST di Monza, University of Milan-Bicocca, Monza, Italy
| | - Giuseppe Foti
- Department of Anesthesia and Intensive Care, San Gerardo Hospital, ASST-Monza, University of Milan- Bicocca, Monza, Italy
| | - Oriol Sibila
- Respiratory Department, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona (UAB), and Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Anna Monzani
- Dipartimento Cardio-Toraco-Vascolare, Respiratory Unit, San Gerardo Hospital, ASST di Monza, University of Milan-Bicocca, Monza, Italy
| | - Federica De Giacomi
- Dipartimento Cardio-Toraco-Vascolare, Respiratory Unit, San Gerardo Hospital, ASST di Monza, University of Milan-Bicocca, Monza, Italy
| | - Anna Stainer
- Dipartimento Cardio-Toraco-Vascolare, Respiratory Unit, San Gerardo Hospital, ASST di Monza, University of Milan-Bicocca, Monza, Italy
| | - Alberto Pesci
- Dipartimento Cardio-Toraco-Vascolare, Respiratory Unit, San Gerardo Hospital, ASST di Monza, University of Milan-Bicocca, Monza, Italy
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297
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Kim DK, Lee J, Park JH, Yoo KH. What Can We Apply to Manage Acute Exacerbation of Chronic Obstructive Pulmonary Disease with Acute Respiratory Failure? Tuberc Respir Dis (Seoul) 2018; 81:99-105. [PMID: 29372630 PMCID: PMC5874148 DOI: 10.4046/trd.2017.0094] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 08/20/2017] [Accepted: 08/23/2017] [Indexed: 12/13/2022] Open
Abstract
Acute exacerbation(s) of chronic obstructive pulmonary disease (AECOPD) tend to be critical and debilitating events leading to poorer outcomes in relation to chronic obstructive pulmonary disease (COPD) treatment modalities, and contribute to a higher and earlier mortality rate in COPD patients. Besides pro-active preventative measures intended to obviate acquisition of AECOPD, early recovery from severe AECOPD is an important issue in determining the long-term prognosis of patients diagnosed with COPD. Updated GOLD guidelines and recently published American Thoracic Society/European Respiratory Society clinical recommendations emphasize the importance of use of pharmacologic treatment including bronchodilators, systemic steroids and/or antibiotics. As a non-pharmacologic strategy to combat the effects of AECOPD, noninvasive ventilation (NIV) is recommended as the treatment of choice as this therapy is thought to be most effective in reducing intubation risk in patients diagnosed with AECOPD with acute respiratory failure. Recently, a few adjunctive modalities, including NIV with helmet and helium-oxygen mixture, have been tried in cases of AECOPD with respiratory failure. As yet, insufficient documentation exists to permit recommendation of this therapy without qualification. Although there are too few findings, as yet, to allow for regular andr routine application of those modalities in AECOPD, there is anecdotal evidence to indicate both mechanical and physiological benefits connected with this therapy. High-flow nasal cannula oxygen therapy is another supportive strategy which serves to improve the symptoms of hypoxic respiratory failure. The therapy also produced improvement in ventilatory variables, and it may be successfully applied in cases of hypercapnic respiratory failure. Extracorporeal carbon dioxide removal has been successfully attempted in cases of adult respiratory distress syndrome, with protective hypercapnic ventilatory strategy. Nowadays, it is reported that it was also effective in reducing intubation in AECOPD with hypercapnic respiratory failure. Despite the apparent need for more supporting evidence, efforts to improve efficacy of NIV have continued unabated. It is anticipated that these efforts will, over time, serve toprogressively decrease the risk of intubation and invasive mechanical ventilation in cases of AECOPD with acute respiratory failure.
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Affiliation(s)
- Deog Kyeom Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea.
| | - Jungsil Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Ju Hee Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang Ha Yoo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
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298
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Bos LD, Martin-Loeches I, Schultz MJ. ARDS: challenges in patient care and frontiers in research. Eur Respir Rev 2018; 27:27/147/170107. [PMID: 29367411 PMCID: PMC9489095 DOI: 10.1183/16000617.0107-2017] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 12/13/2017] [Indexed: 12/05/2022] Open
Abstract
This review discusses the clinical challenges associated with ventilatory support and pharmacological interventions in patients with acute respiratory distress syndrome (ARDS). In addition, it discusses current scientific challenges facing researchers when planning and performing trials of ventilatory support or pharmacological interventions in these patients. Noninvasive mechanical ventilation is used in some patients with ARDS. When intubated and mechanically ventilated, ARDS patients should be ventilated with low tidal volumes. A plateau pressure <30 cmH2O is recommended in all patients. It is suggested that a plateau pressure <15 cmH2O should be considered safe. Patient with moderate and severe ARDS should receive higher levels of positive end-expiratory pressure (PEEP). Rescue therapies include prone position and neuromuscular blocking agents. Extracorporeal support for decapneisation and oxygenation should only be considered when lung-protective ventilation is no longer possible, or in cases of refractory hypoxaemia, respectively. Tracheotomy is only recommended when prolonged mechanical ventilation is expected. Of all tested pharmacological interventions for ARDS, only treatment with steroids is considered to have benefit. Proper identification of phenotypes, known to respond differently to specific interventions, is increasingly considered important for clinical trials of interventions for ARDS. Such phenotypes could be defined based on clinical parameters, such as the arterial oxygen tension/inspiratory oxygen fraction ratio, but biological marker profiles could be more promising. Treatment of ARDS is mainly through the prevention of ventilation-induced lung injuryhttp://ow.ly/DeJC30hGWfi
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Affiliation(s)
- Lieuwe D Bos
- Dept of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Amsterdam, The Netherlands .,Respiratory Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Marcus J Schultz
- Dept of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Amsterdam, The Netherlands.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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299
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Frat JP, Coudroy R, Thille A. Y a-t-il une place pour l’oxygénothérapie nasale à haut débit dans l’insuffisance respiratoire aiguë? Oui. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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300
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Patel BK, Wolfe KS, Hall JB, Kress JP. A Word of Caution Regarding Patient Self-inflicted Lung Injury and Prophylactic Intubation. Am J Respir Crit Care Med 2017; 196:936. [PMID: 28460177 DOI: 10.1164/rccm.201702-0410le] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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