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Lee KG, Roca O, Casey JD, Semler MW, Roman-Sarita G, Yarnell CJ, Goligher EC. When to intubate in acute hypoxaemic respiratory failure? Options and opportunities for evidence-informed decision making in the intensive care unit. THE LANCET. RESPIRATORY MEDICINE 2024:S2213-2600(24)00118-8. [PMID: 38801827 DOI: 10.1016/s2213-2600(24)00118-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 03/08/2024] [Accepted: 04/05/2024] [Indexed: 05/29/2024]
Abstract
The optimal timing of intubation in acute hypoxaemic respiratory failure is uncertain and became a point of controversy during the COVID-19 pandemic. Invasive mechanical ventilation is a potentially life-saving intervention but carries substantial risks, including injury to the lungs and diaphragm, pneumonia, intensive care unit-acquired muscle weakness, and haemodynamic impairment. In deciding when to intubate, clinicians must balance premature exposure to the risks of ventilation with the potential harms of unassisted breathing, including disease progression and worsening multiorgan failure. Currently, the optimal timing of intubation is unclear. In this Personal View, we examine a range of parameters that could serve as triggers to initiate invasive mechanical ventilation. The utility of a parameter (eg, the ratio of arterial oxygen tension to fraction of inspired oxygen) to predict the likelihood of a patient undergoing intubation does not necessarily mean that basing the timing of intubation on that parameter will improve therapeutic outcomes. We examine options for clinical investigation to make progress on establishing the optimal timing of intubation.
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Affiliation(s)
- Kevin G Lee
- Department of Physiology, Toronto, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Oriol Roca
- Servei de Medicina Intensiva, Parc Taulí Hospital Universitari, Institut de Recerca Parc Taulí-I3PT, Sabadell, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain; Ciber Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Christopher J Yarnell
- Interdepartmental Division of Critical Care Medicine University of Toronto, Toronto, ON, Canada; Department of Medicine, Division of Respirology, University Health Network, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation at the University of Toronto, Toronto, ON, Canada; Scarborough Health Network, Department of Critical Care Medicine, Toronto, ON, Canada; Scarborough Health Network Research Institute, Toronto, ON, Canada.
| | - Ewan C Goligher
- Department of Physiology, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine University of Toronto, Toronto, ON, Canada; Department of Medicine, Division of Respirology, University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada
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Demoule A, Baptiste A, Thille AW, Similowski T, Ragot S, Prat G, Mercat A, Girault C, Carteaux G, Boulain T, Perbet S, Decavèle M, Belin L, Frat JP. Dyspnea is severe and associated with a higher intubation rate in de novo acute hypoxemic respiratory failure. Crit Care 2024; 28:174. [PMID: 38783367 PMCID: PMC11118550 DOI: 10.1186/s13054-024-04903-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/05/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Dyspnea is a key symptom of de novo acute hypoxemic respiratory failure. This study explores dyspnea and its association with intubation and mortality in this population. METHODS This was a secondary analysis of a multicenter, randomized, controlled trial. Dyspnea was quantified by a visual analog scale (dyspnea-VAS) from zero to 100 mm. Dyspnea was measured in 259 of the 310 patients included. Factors associated with intubation were assessed with a competing risks model taking into account ICU discharge. The Cox model was used to evaluate factors associated with 90-day mortality. RESULTS At baseline (randomization in the parent trial), median dyspnea-VAS was 46 (interquartile range, 16-65) mm and was ≥ 40 mm in 146 patients (56%). The intubation rate was 45%. Baseline variables independently associated with intubation were moderate (dyspnea-VAS 40-64 mm) and severe (dyspnea-VAS ≥ 65 mm) dyspnea at baseline (sHR 1.96 and 2.61, p = 0.023), systolic arterial pressure (sHR 2.56, p < 0.001), heart rate (sHR 1.94, p = 0.02) and PaO2/FiO2 (sHR 0.34, p = 0.028). 90-day mortality was 20%. The cumulative probability of survival was lower in patients with baseline dyspnea-VAS ≥ 40 mm (logrank test, p = 0.049). Variables independently associated with mortality were SAPS 2 ≥ 25 (p < 0.001), moderate-to-severe dyspnea at baseline (p = 0.073), PaO2/FiO2 (p = 0.118), and treatment arm (p = 0.046). CONCLUSIONS In patients admitted to the ICU for de novo acute hypoxemic respiratory failure, dyspnea is associated with a higher risk of intubation and with a higher mortality. TRIAL REGISTRATION clinicaltrials.gov Identifier # NCT01320384.
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Affiliation(s)
- Alexandre Demoule
- INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, 75005, Paris, France.
- Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation (Département R3S), Hôpital Universitaire Pitié-Salpêtrière, AP-HP, 47-83 Boulevard de L'Hôpital, 75651, Paris Cedex 13, France.
| | - Amandine Baptiste
- Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Unité de Recherche Clinique, AP-HP, Paris, France
| | - Arnaud W Thille
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
- Centre d'Investigation Clinique 1402 ALIVE, Université de Poitiers, Poitiers, France
| | - Thomas Similowski
- INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, 75005, Paris, France
- Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Département R3S, AP-HP, 75013, Paris, France
| | - Stephanie Ragot
- Centre d'Investigation Clinique 1402 ALIVE, Université de Poitiers, Poitiers, France
| | - Gwénael Prat
- Service de Médecine Intensive et Réanimation, CHU de Brest, Brest, France
| | - Alain Mercat
- Service de Réanimation médicale et Médecine Hyperbare, Centre Hospitalier Régional Universitaire, Angers, France
| | - Christophe Girault
- UNIROUEN, UR 3830, Medical Intensive Care Unit, Rouen University Hospital, Normandie University, Rouen, France
| | - Guillaume Carteaux
- Hôpitaux Universitaires Henri Mondor, Service de Médecine Intensive Réanimation, Université Paris Est Créteil, Groupe de Recherche Clinique CARMAS, AP-HP, Créteil, France
| | - Thierry Boulain
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire d'Orléans, Orléans, France
| | - Sébastien Perbet
- Réanimation Médico-Chirurgicale, CHU de Clermont-Ferrand, Clermont-Ferrand, France
- GReD, UMR/CNRS 6293, INSERM U1103, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Maxens Decavèle
- INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, 75005, Paris, France
- Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation (Département R3S), Hôpital Universitaire Pitié-Salpêtrière, AP-HP, 47-83 Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
| | - Lisa Belin
- Site Pitié-Salpêtrière, Département de Santé Publique, INSERM, Institut Pierre Louis d'Epidémiologie Et de Santé Publique, AP-HP, APHP-Sorbonne Université, Paris, France
| | - Jean-Pierre Frat
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
- Centre d'Investigation Clinique 1402 ALIVE, Université de Poitiers, Poitiers, France
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Pagliaro R, Aronne L, Fomez R, Ferri V, Montella A, Sanduzzi Zamparelli S, Bianco A, Perrotta F. High-Flow Nasal Cannula System in Respiratory Failure Associated with Interstitial Lung Diseases: A Systematic Review and Narrative Synthesis. J Clin Med 2024; 13:2956. [PMID: 38792497 PMCID: PMC11122032 DOI: 10.3390/jcm13102956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/09/2024] [Accepted: 05/15/2024] [Indexed: 05/26/2024] Open
Abstract
Background: High-flow nasal cannula (HFNC) therapy has emerged as a promising treatment modality for interstitial lung disease (ILD)-related respiratory failure. This systematic review aims to evaluate the efficacy and safety of HFNC therapy in patients with ILDs. Methods: A comprehensive literature search was conducted using major electronic databases to identify relevant studies investigating the use of HFNC therapy in ILD patients with respiratory failure. Outcome measures of interest included improvements in oxygenation, dyspnea relief, respiratory rate control, hospital length of stay, and mortality. Results: Twelve studies were analyzed with an overall population of 715 patients included. Idiopathic Pulmonary Fibrosis (IPF) was the most prevalent type of ILD. Evaluated clinical settings were acute (7 studies), chronic (2 studies), and end-stage (3 studies) ILDs. The HFNC as a support for acute respiratory failure seems not inferior to non-invasive ventilation while offering better comfort and patient's perception. Poor data are available about use in chronic/long-term or rehabilitative settings. In end of life/palliative care, an HFNC might improve quality of life. Despite the promising results, further research is warranted to establish optimal HFNC protocols, identify patient subgroups most likely to benefit, and explore long-term outcomes. Conclusions: Overall, the HFNC appears to be a valuable therapeutic option for managing respiratory failure in ILD patients, offering potential improvements in oxygenation and symptom relief.
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Affiliation(s)
- Raffaella Pagliaro
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (R.P.); (R.F.); (V.F.); (A.M.); (A.B.)
- U.O.C. Clinica Pneumologica L. Vanvitelli, A. O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Luigi Aronne
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (R.P.); (R.F.); (V.F.); (A.M.); (A.B.)
- U.O.C. Clinica Pneumologica L. Vanvitelli, A. O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Ramona Fomez
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (R.P.); (R.F.); (V.F.); (A.M.); (A.B.)
- U.O.C. Clinica Pneumologica L. Vanvitelli, A. O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Vincenzo Ferri
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (R.P.); (R.F.); (V.F.); (A.M.); (A.B.)
- U.O.C. Clinica Pneumologica L. Vanvitelli, A. O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Antonia Montella
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (R.P.); (R.F.); (V.F.); (A.M.); (A.B.)
- U.O.C. Clinica Pneumologica L. Vanvitelli, A. O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | | | - Andrea Bianco
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (R.P.); (R.F.); (V.F.); (A.M.); (A.B.)
- U.O.C. Clinica Pneumologica L. Vanvitelli, A. O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Fabio Perrotta
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80131 Naples, Italy; (R.P.); (R.F.); (V.F.); (A.M.); (A.B.)
- U.O.C. Clinica Pneumologica L. Vanvitelli, A. O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
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Xu X, Ma M, Min Y, Hu W, Bai L, Duan J. PaCO 2 is nonlinearly associated with NIV failure in patients with hypoxemic respiratory failure. BMC Pulm Med 2024; 24:228. [PMID: 38730395 PMCID: PMC11088174 DOI: 10.1186/s12890-024-03023-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/18/2024] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVE To explore the association between PaCO2 and noninvasive ventilation (NIV) failure in patients with hypoxemic respiratory failure. METHODS A retrospective study was performed in a respiratory ICU of a teaching hospital. Patients admitted to ICU between 2011 and 2019 were screened. We enrolled the patients with hypoxemic respiratory failure. However, patients who used NIV due to acute-on-chronic respiratory failure or heart failure were excluded. Data before the use of NIV were collected. Requirement of intubation was defined as NIV failure. RESULTS A total of 1029 patients were enrolled in final analysis. The rate of NIV failure was 45% (461/1029). A nonlinear relationship between PaCO2 and NIV failure was found by restricted cubic splines (p = 0.03). The inflection point was 32 mmHg. The rate of NIV failure was 42% (224/535) in patients with PaCO2 >32 mmHg. However, it increased to 48% (237/494) in those with PaCO2 ≤ 32 mmHg. The crude and adjusted hazard ratio (HR) for NIV failure was 1.36 (95%CI:1.13-1.64) and 1.23(1.01-1.49), respectively, if the patients with PaCO2 >32 mmHg were set as reference. In patients with PaCO2 ≤ 32 mmHg, one unit increment of PaCO2 was associated with 5% reduction of NIV failure. However, it did not associate with NIV failure in patients with PaCO2 >32 mmHg. CONCLUSIONS PaCO2 and NIV failure was nonlinear relationship. The inflection point was 32 mmHg. Below the inflection point, lower PaCO2 was associated with higher NIV failure. However, it did not associate with NIV failure above this point.
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Affiliation(s)
- Xiaoping Xu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, P. R. China
| | - Mengyi Ma
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, P. R. China
| | - Yiwei Min
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, P. R. China
| | - Wenhui Hu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, P. R. China
| | - Linfu Bai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, P. R. China
| | - Jun Duan
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, P. R. China.
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Carrillo-Aleman L, Agamez-Luengas AA, Guia M, Renedo-Villarroya A, Alonso-Fernández N, Lopez-Gomez L, Bayoumy-Delis P, Sanchez-Nieto JM, Pascual-Figal D, Carrillo-Alcaraz A. Effectiveness and safety of non-invasive ventilation in the management of cardiogenic shock. Rev Port Cardiol 2024; 43:259-273. [PMID: 37949366 DOI: 10.1016/j.repc.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 07/11/2023] [Accepted: 08/14/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES Cardiogenic shock (CS) has long been considered a contraindication for the use of non-invasive ventilation (NIV). The main objective of this study was to analyze the effectiveness, measured as NIV success, in patients with respiratory failure due to CS. As secondary objective, we studied risk factors for NIV failure and compared the outcome of patients treated with NIV versus invasive mechanical ventilation (IMV). METHODS Retrospective study on a prospective database, over a period of 25 years, of all consecutively patients admitted to an intensive care unit, with a diagnosis of CS and treated with NIV. A comparison was made between patients on NIV and patients on IMV using propensity score matching analysis. RESULTS Three hundred patients were included, mean age 73.8 years, mean SAPS II 49. The main cause of CS was acute myocardial infarction (AMI): 164 (54.7%). NIV failure occurred in 153 (51%) cases. Independent factors for NIV failure included D/E stages of CS, AMI, NIV related complications, and being transferred from the ward. In the propensity analysis, hospital mortality (OR 1.69, 95% CI 1.09-2.63) and 1 year mortality (OR 1.61, 95% CI 1.04-2.51) was higher in IMV. Mortality was lower with NIV (vs. EIT-IMV) in C stage (10.1% vs. 32.9%; p<0.001) but did not differ in D stage or E stage. CONCLUSIONS NIV seems to be relatively effective and safe in the treatment of early-stage CS.
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Affiliation(s)
| | | | - Miguel Guia
- Sleep and Non-invasive Ventilation Unit, Thorax Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal; ISAMB, Instituto de Saúde Ambiental da Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal.
| | | | | | | | | | | | - Domingo Pascual-Figal
- Cardiology Department, Virgen de la Arrixaca Hospital, Ctra. Madrid-Cartagena, Murcia, Spain
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Mosier JM, Tidswell M, Wang HE. Noninvasive respiratory support in the emergency department: Controversies and state-of-the-art recommendations. J Am Coll Emerg Physicians Open 2024; 5:e13118. [PMID: 38464331 PMCID: PMC10920951 DOI: 10.1002/emp2.13118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/21/2024] [Accepted: 01/26/2024] [Indexed: 03/12/2024] Open
Abstract
Acute respiratory failure is a common reason for emergency department visits and hospital admissions. Diverse underlying physiologic abnormalities lead to unique aspects about the most common causes of acute respiratory failure: acute decompensated heart failure, acute exacerbation of chronic obstructive pulmonary disease, and acute de novo hypoxemic respiratory failure. Noninvasive respiratory support strategies are increasingly used methods to support work of breathing and improve gas exchange abnormalities to improve outcomes relative to conventional oxygen therapy or invasive mechanical ventilation. Noninvasive respiratory support includes noninvasive positive pressure ventilation and nasal high flow, each with unique physiologic mechanisms. This paper will review the physiology of respiratory failure and noninvasive respiratory support modalities and offer data and guideline-driven recommendations in the context of key clinical controversies.
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Affiliation(s)
- Jarrod M. Mosier
- Department of Emergency MedicineThe University of Arizona College of MedicineTucsonArizonaUSA
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Department of MedicineThe University of Arizona College of MedicineTucsonArizonaUSA
| | - Mark Tidswell
- Division of Pulmonary and Critical Care, Department of MedicineUniversity of Massachusetts Chan Medical School – Baystate Medical CenterSpringfieldMassachusettsUSA
| | - Henry E. Wang
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
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Wang J, Duan J, Zhou L. Incidence of noninvasive ventilation failure and mortality in patients with acute respiratory distress syndrome: a systematic review and proportion meta-analysis. BMC Pulm Med 2024; 24:48. [PMID: 38254064 PMCID: PMC10802073 DOI: 10.1186/s12890-024-02839-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 01/01/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Noninvasive ventilation (NIV) is commonly used in patients with acute respiratory distress syndrome (ARDS). However, the incidence and distribution of treatment failure are unclear. METHODS A comprehensive online search was conducted to select potentially eligible studies with reports of the rate of NIV failure in patients with ARDS. A manual search was also performed to identify additional studies. Data were extracted to calculate the pooled incidences of NIV failure and mortality. Based on oxygenation, the severity of the disease was classified as mild, moderate, or severe ARDS. Based on etiologies, ARDS was defined as being of pulmonary origin or extrapulmonary origin. RESULTS We enrolled 90 studies in this meta-analysis, involving 98 study arms. The pooled incidence of NIV failure was 48% (n = 5847, 95% confidence interval [CI]: 43-52%). The pooled incidence of ICU mortality was 29% (n = 2363, 95%CI: 22-36%), and that of hospital mortality was 33% (n = 2927, 95%CI: 27-40%). In patients with mild, moderate, and severe ARDS, the pooled incidence of NIV failure was 30% (n = 819, 95%CI: 21-39%), 51% (n = 1332, 95%CI: 43-60%), and 71% (n = 525, 95%CI: 62-79%), respectively. In patients with pulmonary ARDS, it was 45% (n = 2687, 95%CI: 39-51%). However, it was 30% (n = 802, 95%CI: 21-38%) in those with extrapulmonary ARDS. In patients with immunosuppression, the incidence of NIV failure was 62% (n = 806, 95%CI: 50-74%). However, it was 46% (n = 5041, 95%CI: 41-50%) in those without immunosuppression. CONCLUSIONS Nearly half of patients with ARDS experience NIV failure. The incidence of NIV failure increases with increasing ARDS severity. Pulmonary ARDS seems to have a higher rate of NIV failure than extrapulmonary ARDS. ARDS patients with immunosuppression have the highest rate of NIV failure.
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Affiliation(s)
- Jie Wang
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, 400016, Chongqing, China
| | - Jun Duan
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, 400016, Chongqing, China.
| | - Ling Zhou
- Department of Medical Laboratory, Song Shan Hospital of Chongqing, 69 Renhe Xingguang Avenue, Yubei District, 401121, Chongqing, China.
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Wang X, Chen Y, Ai H, Li P, Zhu C, Yuan J. Study on the therapeutic effects and prognosis evaluation of non-invasive ventilation in patients with chronic obstructive pulmonary disease with lung cancer. Technol Health Care 2024; 32:1915-1923. [PMID: 37980585 PMCID: PMC11091655 DOI: 10.3233/thc-231063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 09/23/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a prevalent respiratory complication among the elderly, and its severity can escalate to respiratory failure as the disease progresses. OBJECTIVE To evaluate the application value of non-invasive ventilation in the clinical treatment of patients with COPD and lung cancer. This study assesses its therapeutic effects and its impact on patients' quality of life (QoL) as measured by the Functional Assessment of Cancer Therapy-Lung (FACT-L) scale. METHODS A retrospective analysis was conducted on clinical data from 102 patients with COPD and lung cancer. Patients were divided into two groups: the control group (n= 48), who received conventional treatment, and the observation group (n= 54), who received non-invasive positive pressure ventilation (NIPPV) in addition to conventional treatment. Relevant indicators of curative effect, including blood gas indices, incidence of dyspnoea, improvements in mental health and appetite, and FACT-L QoL scores, were analysed at 2 weeks, 1 month, and 6 months post-treatment. RESULTS At 2 weeks post-treatment, the observation group who had used NIPPV showed significant improvements in blood gas indices, dyspnoea, mental state and self-care ability compared with the control group (p< 0.05). At 1 month, these benefits persisted and included improved maintenance of body weight (p< 0.05). By 6 months, the observation group had a lower incidence of pulmonary encephalopathy (p< 0.05), and QoL, as measured by the FACT-L scale, improved significantly in the observation group but declined in the control group (p< 0.05). CONCLUSION NIPPV demonstrates significant efficacy in treating COPD patients with lung cancer, particularly in enhancing curative effects and improving patients' QoL.
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Affiliation(s)
- Xiangyun Wang
- Department of Respiratory Medicine, Kongjiang Hospital, Shanghai, China
| | - Yuanjing Chen
- Department of Respiratory Medicine, Kongjiang Hospital, Shanghai, China
| | - Hongjun Ai
- Department of Respiratory Medicine, Kongjiang Hospital, Shanghai, China
| | - Panpan Li
- Department of Respiratory Medicine, Kongjiang Hospital, Shanghai, China
| | - Chengjie Zhu
- Department of Respiratory Medicine, The First Hospital Affiliated to Naval Medical University, Shanghai, China
| | - Jiaying Yuan
- Department of Respiratory Medicine, The First Hospital Affiliated to Naval Medical University, Shanghai, China
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9
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Watson A, Yadollahi S, Fahmy A, Mahar S, Fritche D, Beecham R, Saeed K, Dushianthan A. Non-Invasive Ventilation for Community-Acquired Pneumonia: Outcomes and Predictors of Failure from an ICU Cohort. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:81. [PMID: 38256342 PMCID: PMC10821344 DOI: 10.3390/medicina60010081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: The use of non-invasive ventilation (NIV) for community-acquired pneumonia (CAP) remains controversial. NIV failure in the setting of acute hypoxemic respiratory failure is associated with increased mortality, highlighting the need for careful patient selection. Methods and Methods: This is a retrospective observational cohort study. We included 140 patients with severe CAP, treated with either NIV or invasive mechanical ventilation (IMV) as their primary oxygenation strategy. Results: The median PaO2/FiO2 ratio and SOFA score upon ICU admission were 151 mmHg and 6, respectively. We managed 76% of patients with NIV initially and report an NIV success rate of 59%. Overall, the 28-day mortality was 25%, whilst for patients with NIV success, the mortality was significantly lower at 13%. In the univariate analysis, NIV failure was associated with the SOFA score (OR 1.33), the HACOR score (OR 1.14) and the presence of septic shock (OR 3.99). The SOFA score has an AUC of 0.75 for NIV failure upon ICU admission, whilst HACOR has an AUC of 0.76 after 2 h of NIV. Conclusions: Our results suggest that a SOFA ≤ 4 and an HACOR ≤ 5 are reasonable thresholds to identify patients with severe CAP likely to benefit from NIV.
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Affiliation(s)
- Adam Watson
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (A.W.); (S.M.); (R.B.)
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK; (D.F.); (K.S.)
| | - Sina Yadollahi
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (A.W.); (S.M.); (R.B.)
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK; (D.F.); (K.S.)
| | - Alexander Fahmy
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (A.W.); (S.M.); (R.B.)
| | - Sania Mahar
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (A.W.); (S.M.); (R.B.)
| | - Dominic Fritche
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK; (D.F.); (K.S.)
| | - Ryan Beecham
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (A.W.); (S.M.); (R.B.)
| | - Kordo Saeed
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK; (D.F.); (K.S.)
- Department of Microbiology, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Ahilanandan Dushianthan
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (A.W.); (S.M.); (R.B.)
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK; (D.F.); (K.S.)
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
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10
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Mosier JM, Subbian V, Pungitore S, Prabhudesai D, Essay P, Bedrick EJ, Stocking JC, Fisher JM. Noninvasive vs Invasive Respiratory Support for Patients with Acute Hypoxemic Respiratory Failure. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.12.23.23300368. [PMID: 38234784 PMCID: PMC10793521 DOI: 10.1101/2023.12.23.23300368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Rationale Noninvasive respiratory support modalities are common alternatives to mechanical ventilation for patients with early acute hypoxemic respiratory failure. These modalities include noninvasive positive pressure ventilation, using either continuous or bilevel positive airway pressure, and nasal high flow using a high flow nasal cannula system. However, outcomes data historically compare noninvasive respiratory support to conventional oxygen rather than to mechanical ventilation. Objectives The goal of this study was to compare the outcomes of in-hospital death and alive discharge in patients with acute hypoxemic respiratory failure when treated initially with noninvasive respiratory support compared to patients treated initially with invasive mechanical ventilation. Methods We used a validated phenotyping algorithm to classify all patients with eligible International Classification of Diseases codes at a large healthcare network between January 1, 2018 and December 31, 2019 into noninvasive respiratory support and invasive mechanical ventilation cohorts. The primary outcome was time-to-in-hospital death analyzed using an inverse probability of treatment weighted Cox model adjusted for potential confounders, with estimated cumulative incidence curves. Secondary outcomes included time-to-hospital discharge alive. A secondary analysis was conducted to examine potential differences between noninvasive positive pressure ventilation and nasal high flow. Results During the study period, 3177 patients met inclusion criteria (40% invasive mechanical ventilation, 60% noninvasive respiratory support). Initial noninvasive respiratory support was not associated with a decreased hazard of in-hospital death (HR: 0.65, 95% CI: 0.35 - 1.2), but was associated with an increased hazard of discharge alive (HR: 2.26, 95% CI: 1.92 - 2.67). In-hospital death varied between the nasal high flow (HR 3.27, 95% CI: 1.43 - 7.45) and noninvasive positive pressure ventilation (HR 0.52, 95% CI 0.25 - 1.07), but both were associated with increased likelihood of discharge alive (nasal high flow HR 2.12, 95 CI: 1.25 - 3.57; noninvasive positive pressure ventilation HR 2.29, 95% CI: 1.92 - 2.74). Conclusion These observational data from a large healthcare network show that noninvasive respiratory support is not associated with reduced hazards of in-hospital death but is associated with hospital discharge alive. There are also potential differences between the noninvasive respiratory support modalities.
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11
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Kheir M, Dong V, Roselli V, Mina B. The role of ultrasound in predicting non-invasive ventilation outcomes: a systematic review. Front Med (Lausanne) 2023; 10:1233518. [PMID: 38020158 PMCID: PMC10644356 DOI: 10.3389/fmed.2023.1233518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/12/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose To systematically review and compare ultrasonographic methods and their utility in predicting non-invasive ventilation (NIV) outcomes. Methods A systematic review was performed using the PubMed, Medline, Embase, and Cochrane databases from January 2015 to March 2023. The search terms included the following: ultrasound, diaphragm, lung, prediction, non-invasive, ventilation, and outcomes. The inclusion criteria were prospective cohort studies on adult patients requiring non-invasive ventilation in the emergency department or inpatient setting. Results Fifteen studies were analyzed, which comprised of 1,307 patients (n = 942 for lung ultrasound score studies; n = 365 patients for diaphragm dysfunction studies). Lung ultrasound scores (LUS) greater than 18 were associated with NIV failure with a sensitivity 62-90.5% and specificity 60-91.9%. Similarly, a diaphragm thickening fraction (DTF) of less than 20% was also associated with NIV failure with a sensitivity 80-84.6% and specificity 76.3-91.5%. Conclusion Predicting NIV failure can be difficult by routine initial clinical impression and diagnostic work up. This systematic review emphasizes the importance of using lung and diaphragm ultrasound, in particular the lung ultrasound score and diaphragm thickening fraction respectively, to accurately predict NIV failure, including the need for ICU-level of care, requiring invasive mechanical ventilation, and resulting in higher rates of mortality.
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Affiliation(s)
- Matthew Kheir
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Lenox Hill Hospital - Northwell Health, New York, NY, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Vincent Dong
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Department of Medicine, Lenox Hill Hospital - Northwell Health, New York, NY, United States
| | - Victoria Roselli
- Office of Clinical Research, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Bushra Mina
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Lenox Hill Hospital - Northwell Health, New York, NY, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
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12
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Saunders H, Khadka S, Shrestha R, Balavenkataraman A, Hochwald A, Ball C, Helgeson SA. The Association between Non-Invasive Ventilation and the Rate of Ventilator-Associated Pneumonia. Diseases 2023; 11:151. [PMID: 37987262 PMCID: PMC10660719 DOI: 10.3390/diseases11040151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/17/2023] [Accepted: 10/25/2023] [Indexed: 11/22/2023] Open
Abstract
Ventilator-associated pneumonia (VAP) has significant effects on patient outcomes, including prolonging the duration of both mechanical ventilation and stay in the intensive care unit (ICU). The aim of this study was to assess the association between non-invasive ventilation/oxygenation (NIVO) prior to intubation and the rate of subsequent VAP. This was a multicenter retrospective cohort study of adult patients who were admitted to the medical ICU from three tertiary care academic centers in three distinct regions. NIVO was defined as continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), or high-flow nasal cannula (HFNC) for any duration during the hospitalization prior to intubation. The primary outcome variable was VAP association with NIVO. A total of 17,302 patients were included. VAP developed in 2.6% of the patients (444/17,302), 2.3% (285/12,518) of patients among those who did not have NIVO, 1.6% (30/1879) of patients who had CPAP, 2.5% (17/690) of patients who had HFNC, 8.1% (16/197) of patients who had BiPAP, and 4.8% (96/2018) of patients who had a combination of NIVO types. Compared to those who did not have NIVO, VAP was more likely to develop among those who had BiPAP (adj OR 3.11, 95% CI 1.80-5.37, p < 0.001) or a combination of NIVO types (adj OR 1.91, 95% CI 1.49-2.44, p < 0.001) after adjusting for patient demographics and comorbidities. The use of BiPAP or a combination of NIVO types significantly increases the odds of developing VAP once receiving IMV.
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Affiliation(s)
- Hollie Saunders
- Department of Pulmonary and Critical Care, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA; (S.K.); (R.S.); (A.B.)
| | - Subekshya Khadka
- Department of Pulmonary and Critical Care, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA; (S.K.); (R.S.); (A.B.)
| | - Rabi Shrestha
- Department of Pulmonary and Critical Care, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA; (S.K.); (R.S.); (A.B.)
| | - Arvind Balavenkataraman
- Department of Pulmonary and Critical Care, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA; (S.K.); (R.S.); (A.B.)
| | - Alexander Hochwald
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Colleen Ball
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Scott A. Helgeson
- Department of Pulmonary and Critical Care, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA; (S.K.); (R.S.); (A.B.)
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13
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Elkins MR. Physiotherapy management of rib fractures. J Physiother 2023; 69:211-219. [PMID: 37714770 DOI: 10.1016/j.jphys.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 08/30/2023] [Indexed: 09/17/2023] Open
Affiliation(s)
- Mark R Elkins
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
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14
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Milesi C, Baleine J, Mortamet G, Apert J, Gavotto A, Cambonie G. Noninvasive Ventilation in Pediatric Acute Respiratory Distress Syndrome: "Another Dogma Bites the Dust". Pediatr Crit Care Med 2023; 24:783-785. [PMID: 37668500 DOI: 10.1097/pcc.0000000000003299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Affiliation(s)
- Christophe Milesi
- Pediatric Intensive Care Unit, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Julien Baleine
- Pediatric Intensive Care Unit, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, Grenoble-Alps University Hospital, Grenoble, France
| | - Juliette Apert
- Pediatric Intensive Care Unit, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Arthur Gavotto
- Pediatric Intensive Care Unit, Montpellier University Hospital, University of Montpellier, Montpellier, France
- PhyMedExp, CNRS, INSERM, University of Montpellier, Montpellier, France
| | - Gilles Cambonie
- Pediatric Intensive Care Unit, Montpellier University Hospital, University of Montpellier, Montpellier, France
- Pathogenesis and Control of Chronic Infection, INSERM UMR 1058, University of Montpellier, Montpellier, France
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15
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Ai T, Zhang Z, Tan Z, Shi Z, Li H, Zhang S, Zhao X, Yao Y, Li W, Gao Y, Zhu M. Modified Respiratory Rate Oxygenation Index: An Early Warning Index for the Need of Intubation in COVID-19 Patients with High-Flow Nasal Cannula Therapy. J Emerg Med 2023; 65:e93-e100. [PMID: 37479639 PMCID: PMC10212589 DOI: 10.1016/j.jemermed.2023.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND High-flow nasal cannula oxygen therapy (HFNC) is recommended for patients with COVID-19. However, the increasing use of HFNC brings a risk of delayed intubation. The optimal timing of switching from HFNC to invasive mechanical ventilation (IMV) remains unclear. An effective predictor is needed to assist in deciding on the timing of intubation. Respiratory rate and oxygenation (ROX) index, defined as (SpO2/FiO2) / respiratory rate, has already shown good diagnostic accuracy. Modified ROX (mROX) index, defined as (PaO2 /FiO2) / respiratory rate, might be better than the ROX index in predicting HFNC failure. OBJECTIVE The aim was to evaluate the predictive value of mROX for HFNC failure in patients with COVID-19. METHODS Severe or critical patients with COVID-19 treated with HFNC were enrolled in two clinical centers. Laboratory indicators, respiratory parameters, and mROX index at 0 h and 2 h after initial HFNC were collected. Based on the need for IMV after HFNC initiation, the patients were divided into an HFNC failure group and an HFNC success group. The predictive value of mROX index for IMV was evaluated by the area under the receiver operating characteristic curve (AUROC) and logistic regression analysis. We performed Kaplan-Meier survival analysis using the log-rank test. RESULTS Sixty patients with COVID-19 (mean ± SD age, 62.8 ± 14.1 years; 42 patients were male) receiving HFNC were evaluated, including 18 critical and 42 severe cases. A total of 33 patients had hypertension; 14 had diabetes; 17 had chronic cardiac disease; 11 had chronic lung disease; 13 had chronic kidney disease; and 17 had a history of stroke. The AUROC of mROX index at 2 h was superior to that of other respiratory parameters to predict the need for IMV (0.959; p < 0.001). At the mROX index cutoff point of 4.45, predicting HFNC failure reached the optimal threshold, with specificity of 94% and sensitivity of 92%. Logistic regression analysis showed that 2-h mROX index < 4.45 was a protective factor for IMV (odd radio 0.18; 95% CI 0.05-0.64; p = 0.008). In the HFNC failure group, the median time from HFNC to IMV was 22.5 h. The 28-day mortality of the late intubation patients (≥ 22.5 h) was higher than that of the early intubation patients (< 22.5 h) (53.8% vs. 8.3%; p = 0.023). CONCLUSIONS mROX at 2 h is a good early warning index of the need for IMV in patients with COVID-19 after HFNC initiation. Early intubation may lead to better survival in patients with 2-h mROX index < 4.45.
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Affiliation(s)
- Tianyi Ai
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhiyun Zhang
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhangjun Tan
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhiqiang Shi
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hui Li
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Shuyi Zhang
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xianyuan Zhao
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yulong Yao
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wen Li
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuan Gao
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
| | - Mingli Zhu
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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16
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Santus P, Radovanovic D, Saad M, Zilianti C, Coppola S, Chiumello DA, Pecchiari M. Acute dyspnea in the emergency department: a clinical review. Intern Emerg Med 2023; 18:1491-1507. [PMID: 37266791 PMCID: PMC10235852 DOI: 10.1007/s11739-023-03322-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/22/2023] [Indexed: 06/03/2023]
Abstract
Acute dyspnea represents one of the most frequent symptoms leading to emergency room evaluation. Its significant prognostic value warrants a careful evaluation. The differential diagnosis of dyspnea is complex due to the lack of specificity and the loose association between its intensity and the severity of the underlying pathological condition. The initial assessment of dyspnea calls for prompt diagnostic evaluation and identification of optimal monitoring strategy and provides information useful to allocate the patient to the most appropriate setting of care. In recent years, accumulating evidence indicated that lung ultrasound, along with echocardiography, represents the first rapid and non-invasive line of assessment that accurately differentiates heart, lung or extra-pulmonary involvement in patients with dyspnea. Moreover, non-invasive respiratory support modalities such as high-flow nasal oxygen and continuous positive airway pressure have aroused major clinical interest, in light of their efficacy and practicality to treat patients with dyspnea requiring ventilatory support, without using invasive mechanical ventilation. This clinical review is focused on the pathophysiology of acute dyspnea, on its clinical presentation and evaluation, including ultrasound-based diagnostic workup, and on available non-invasive modalities of respiratory support that may be required in patients with acute dyspnea secondary or associated with respiratory failure.
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Affiliation(s)
- Pierachille Santus
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milan, Italy.
- Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milan, Italy.
| | - Dejan Radovanovic
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milan, Italy
- Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milan, Italy
| | - Marina Saad
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milan, Italy
| | - Camilla Zilianti
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
| | - Silvia Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, Ospedale Universitario San Paolo, Milan, Italy
| | - Davide Alberto Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, Ospedale Universitario San Paolo, Milan, Italy
- Department of Health Sciences, Università Degli Studi Di Milano, Milan, Italy
- Coordinated Research Center On Respiratory Failure, Università Degli Studi Di Milano, Milan, Italy
| | - Matteo Pecchiari
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
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17
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Spinazzola G, Ferrone G, Costa R, Piastra M, Maresca G, Rossi M, Antonelli M, Conti G. Comparative evaluation of three total full-face masks for delivering Non-Invasive Positive Pressure Ventilation (NPPV): a bench study. BMC Pulm Med 2023; 23:189. [PMID: 37259052 DOI: 10.1186/s12890-023-02489-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/23/2023] [Indexed: 06/02/2023] Open
Abstract
Historically, the oro-nasal mask has been the preferred interface to deliver Non-Invasive Positive Pressure Ventilation (NPPV) in critically ill patients. To overcome the problems related to air leaks and discomfort, Total Full-face masks have been designed. No study has comparatively evaluated the performance of the total Full-face masks available.The aim of this bench study was to evaluate the influence of three largely diffuse models of total Full -face masks on patient-ventilator synchrony and performance during pressure support ventilation. NPPV was applied to a mannequin, connected to an active test lung through three largely diffuse Full-face masks: Dimar Full-face mask (DFFM), Performax Full-face mask (RFFM) and Pulmodyne Full-face mask (PFFM).The performance analysis showed that the ΔPtrigger was significantly lower with PFFM (p < 0.05) at 20 breaths/min (RRsim) at both pressure support (iPS) levels applied, while, at RRsim 30, DFFM had the longest ΔPtrigger compared to the other 2 total full face masks (p < 0.05). At all ventilator settings, the PTP200 was significantly shorter with DFFM than with the other two total full-face masks (p < 0.05). In terms of PTP500 ideal index (%), we did not observe significant differences between the interfaces tested.The PFFM demonstrated the best performance and synchrony at low respiratory rates, but when the respiratory rate increased, no difference between all tested total full-face masks was reported.
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Affiliation(s)
- Giorgia Spinazzola
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Francesco Vito N 8, 00168, Rome, Italy.
- Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore, Largo Francesco Vito 8, Rome, Italy.
| | - Giuliano Ferrone
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Francesco Vito N 8, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore, Largo Francesco Vito 8, Rome, Italy
| | - Roberta Costa
- Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore, Largo Francesco Vito 8, Rome, Italy
| | - Marco Piastra
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Francesco Vito N 8, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore, Largo Francesco Vito 8, Rome, Italy
| | - Gianmarco Maresca
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Francesco Vito N 8, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore, Largo Francesco Vito 8, Rome, Italy
| | - Marco Rossi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Francesco Vito N 8, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore, Largo Francesco Vito 8, Rome, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Francesco Vito N 8, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore, Largo Francesco Vito 8, Rome, Italy
| | - Giorgio Conti
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Francesco Vito N 8, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore, Largo Francesco Vito 8, Rome, Italy
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Herzberg J, Guraya SY, Merkle D, Strate T, Honarpisheh H. The role of prophylactic administration of CPAP in general surgical wards after open visceral surgery in reducing postoperative pneumonia-a retrospective cohort study. Langenbecks Arch Surg 2023; 408:167. [PMID: 37120478 PMCID: PMC10148695 DOI: 10.1007/s00423-023-02899-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 04/14/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND Postoperative pneumonia is a main adverse event that causes increased postoperative morbidity and prolonged length of hospital stay leading to high postoperative mortality. Continuous positive airway pressure (CPAP) is a type of non-invasive ventilation for the delivery of a positive airway pressure during respiration. In this study, we evaluated the impact of postoperative prophylactic CPAP on prevention of pneumonia in patients after open visceral surgery. METHODS In this observational cohort study, we compared the rates of postoperative pneumonia in patients who underwent open major visceral surgery from January 2018 till August 2020 in the study and control group. The study group had postoperative prophylactic sessions of CPAP for 15 min, 3-5 times a day and a repeated spirometer training was also performed in the general surgical ward. The control group received only the postoperative spirometer training as a prophylactic measure against postoperative pneumonia. The chi-square test was used to measure the relationships between categorical variables, and a binary regression analysis determined the correlation between independent and dependent variables. RESULTS A total of 258 patients met the inclusion criteria who had open visceral surgery for various clinical illnesses. There were 146 men (56.6%) and 112 women with a mean age of 68.62 years. As many as 142 patients received prophylactic CPAP and they were grouped into the study group, whereas 116 patients without prophylactic CPAP were placed in the control group. Overall, the rate of postoperative pneumonia was significantly less in the study group (5.6% vs. 25.9% in the control group; p-value < 0.0001), which could be confirmed by the regression analysis (OR 0.118, CI 95% 0.047-0.295, p < 0.001). CONCLUSION Postoperative intermittent CPAP after open visceral surgery can be performed in a general surgical ward. Our study showed a significant association with a low rate of postoperative pneumonia, especially in high-risk patients. This leads to a significantly shorter postoperative hospital stay especially in high-risk patients after upper gastrointestinal surgery. TRIAL REGISTRATION NUMBER DRKS00028988, 04.05.2022, retrospectively registered.
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Affiliation(s)
- Jonas Herzberg
- Department of Surgery, Division of General, Abdominal and Thoracic Surgery, Krankenhaus Reinbek St. Adolf-Stift, Hamburger Strasse 41, 21465, Reinbek, Germany.
| | - Salman Yousuf Guraya
- Clinical Sciences Department, College of Medicine, University of Sharjah, P. O. Box 27272, Sharjah, United Arab Emirates
| | - Daniel Merkle
- Department of Surgery, Division of General, Abdominal and Thoracic Surgery, Krankenhaus Reinbek St. Adolf-Stift, Hamburger Strasse 41, 21465, Reinbek, Germany
| | - Tim Strate
- Department of Surgery, Division of General, Abdominal and Thoracic Surgery, Krankenhaus Reinbek St. Adolf-Stift, Hamburger Strasse 41, 21465, Reinbek, Germany
| | - Human Honarpisheh
- Department of Surgery, Division of General, Abdominal and Thoracic Surgery, Krankenhaus Reinbek St. Adolf-Stift, Hamburger Strasse 41, 21465, Reinbek, Germany
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Carrié C, Rieu B, Benard A, Trin K, Petit L, Massri A, Jurcison I, Rousseau G, Tran Van D, Reynaud Salard M, Bourenne J, Levrat A, Muller L, Marie D, Dahyot-Fizelier C, Pottecher J, David JS, Godet T, Biais M. Early non-invasive ventilation and high-flow nasal oxygen therapy for preventing endotracheal intubation in hypoxemic blunt chest trauma patients: the OptiTHO randomized trial. Crit Care 2023; 27:163. [PMID: 37101272 PMCID: PMC10131545 DOI: 10.1186/s13054-023-04429-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/04/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND The benefit-risk ratio of prophylactic non-invasive ventilation (NIV) and high-flow nasal oxygen therapy (HFNC-O2) during the early stage of blunt chest trauma remains controversial because of limited data. The main objective of this study was to compare the rate of endotracheal intubation between two NIV strategies in high-risk blunt chest trauma patients. METHODS The OptiTHO trial was a randomized, open-label, multicenter trial over a two-year period. Every adult patients admitted in intensive care unit within 48 h after a high-risk blunt chest trauma (Thoracic Trauma Severity Score ≥ 8), an estimated PaO2/FiO2 ratio < 300 and no evidence of acute respiratory failure were eligible for study enrollment (Clinical Trial Registration: NCT03943914). The primary objective was to compare the rate of endotracheal intubation for delayed respiratory failure between two NIV strategies: i) a prompt association of HFNC-O2 and "early" NIV in every patient for at least 48 h with vs. ii) the standard of care associating COT and "late" NIV, indicated in patients with respiratory deterioration and/or PaO2/FiO2 ratio ≤ 200 mmHg. Secondary outcomes were the occurrence of chest trauma-related complications (pulmonary infection, delayed hemothorax or moderate-to-severe ARDS). RESULTS Study enrollment was stopped for futility after a 2-year study period and randomization of 141 patients. Overall, 11 patients (7.8%) required endotracheal intubation for delayed respiratory failure. The rate of endotracheal intubation was not significantly lower in patients treated with the experimental strategy (7% [5/71]) when compared to the control group (8.6% [6/70]), with an adjusted OR = 0.72 (95%IC: 0.20-2.43), p = 0.60. The occurrence of pulmonary infection, delayed hemothorax or delayed ARDS was not significantly lower in patients treated by the experimental strategy (adjusted OR = 1.99 [95%IC: 0.73-5.89], p = 0.18, 0.85 [95%IC: 0.33-2.20], p = 0.74 and 2.14 [95%IC: 0.36-20.77], p = 0.41, respectively). CONCLUSION A prompt association of HFNC-O2 with preventive NIV did not reduce the rate of endotracheal intubation or secondary respiratory complications when compared to COT and late NIV in high-risk blunt chest trauma patients with non-severe hypoxemia and no sign of acute respiratory failure. CLINICAL TRIAL REGISTRATION NCT03943914, Registered 7 May 2019.
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Affiliation(s)
- Cédric Carrié
- Surgical and Trauma Intensive Care Unit, Anesthesiology and Critical Care Department, Hôpital Pellegrin, CHU Bordeaux, Bordeaux University Hospital, Place Amélie Raba Léon, 33076, Bordeaux Cedex, France.
| | - Benjamin Rieu
- Anesthesiology and Critical Care Department, Clermont - Ferrand University Hospital, Clermont - Ferrand, France
| | - Antoine Benard
- Pôle de Santé Publique, Service d'information Médicale, Clinical Epidemiology Unit (USMR), CHU Bordeaux, Bordeaux, France
| | - Kilian Trin
- Pôle de Santé Publique, Service d'information Médicale, Clinical Epidemiology Unit (USMR), CHU Bordeaux, Bordeaux, France
| | - Laurent Petit
- Surgical and Trauma Intensive Care Unit, Anesthesiology and Critical Care Department, Hôpital Pellegrin, CHU Bordeaux, Bordeaux University Hospital, Place Amélie Raba Léon, 33076, Bordeaux Cedex, France
| | - Alexandre Massri
- Anesthesiology and Critical Care Department, Pau Hospital, Pau, France
| | - Igor Jurcison
- Anesthesiology and Critical Care Department, Beaujon University Hospital, Paris, France
| | - Guillaume Rousseau
- Anesthesiology and Critical Care Department, Beaujon University Hospital, Paris, France
| | - David Tran Van
- Anesthesiology and Critical Care Department, Robert Picqué Hospital, Bordeaux, France
| | - Marie Reynaud Salard
- Anesthesiology and Critical Care Department, Saint Etienne University Hospital, Saint Etienne, France
| | - Jeremy Bourenne
- Emergency and Critical Care Department, Hôpital de La Timone, Marseille University Hospital, Marseille, France
| | - Albrice Levrat
- Anesthesiology and Critical Care Department, Annecy Hospital, Annecy, France
| | - Laurent Muller
- Anesthesiology and Critical Care Department, Nimes University Hospital, Nimes, France
| | - Damien Marie
- Anesthesiology and Critical Care Department, Poitiers University Hospital, Poitiers, France
| | - Claire Dahyot-Fizelier
- Anesthesiology and Critical Care Department, Poitiers University Hospital, Poitiers, France
| | - Julien Pottecher
- Anesthesiology and Critical Care Department, Strasbourg University Hospital, Strasbourg, France
| | - Jean-Stéphane David
- Department of Anesthesia and Intensive Care, Groupe Hospitalier Sud, Hospices Civils de Lyon (HCL), Lyon, France
- Research On Healthcare Performance (RESHAPE), INSERM U1290, University Claude Bernard Lyon 1, Lyon, France
| | - Thomas Godet
- Anesthesiology and Critical Care Department, Clermont - Ferrand University Hospital, Clermont - Ferrand, France
| | - Matthieu Biais
- Surgical and Trauma Intensive Care Unit, Anesthesiology and Critical Care Department, Hôpital Pellegrin, CHU Bordeaux, Bordeaux University Hospital, Place Amélie Raba Léon, 33076, Bordeaux Cedex, France
- INSERM U1034, Biology of Cardiovascular Diseases, Bordeaux University, Pessac, France
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Buell KG, Patel BK. Helmet noninvasive ventilation in acute hypoxic respiratory failure. Curr Opin Crit Care 2023; 29:8-13. [PMID: 36580369 PMCID: PMC9830589 DOI: 10.1097/mcc.0000000000001008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW Invasive mechanical ventilation is a lifesaving intervention for patients with severe acute hypoxic respiratory failure (AHRF), but it is associated with neuromuscular, cognitive, and infectious complications. Noninvasive ventilation (NIV) may provide sufficient respiratory support without these complications. The helmet interface for NIV could address concerns raised for the use of NIV as first-line therapy in AHRF. This review will summarize and appraise the current evidence for helmet NIV in AHRF. RECENT FINDINGS There are only six randomized controlled trials comparing helmet NIV to standard nasal cannula, facemask NIV, or high-flow nasal oxygen in patients with AHRF. Lower rates of endotracheal intubations and fewer days of mechanical ventilation were reported, with inconsistent findings on patient survival. Facemask NIV may worsen preexisting lung injury, delay intubations, and be inferior at delivering lung protective ventilation strategies compared with mechanical ventilation. The helmet interface could circumvent some of these concerns through the delivery of higher positive end expiratory pressure and more uniform distribution of negative pleural pressure. SUMMARY There is limited evidence to support or refute the use of helmet NIV in AHRF. Further studies investigating the interface of helmet in NIV as a separate clinical entity are needed.
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Affiliation(s)
- Kevin G. Buell
- University of Chicago, Department of Medicine, Section of Pulmonary and Critical Care, Chicago, Illinois
| | - Bhakti K. Patel
- University of Chicago, Department of Medicine, Section of Pulmonary and Critical Care, Chicago, Illinois
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21
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Frat JP, Marchasson L, Arrivé F, Coudroy R. High-flow nasal cannula oxygen therapy in acute hypoxemic respiratory failure and COVID-19-related respiratory failure. JOURNAL OF INTENSIVE MEDICINE 2023; 3:20-26. [PMID: 36756183 PMCID: PMC9534601 DOI: 10.1016/j.jointm.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/19/2022] [Accepted: 07/13/2022] [Indexed: 11/17/2022]
Abstract
Although standard oxygen face masks are first-line therapy for patients with acute hypoxemic respiratory failure, high-flow nasal cannula oxygen therapy has gained major popularity in intensive care units. The physiological effects of high-flow oxygen counterbalance the physiological consequences of acute hypoxemic respiratory failure by lessening the deleterious effects of intense and prolonged inspiratory efforts generated by patients. Its simplicity of application for physicians and nurses and its comfort for patients are other arguments for its use in this setting. Although clinical studies have reported a decreased risk of intubation with high-flow oxygen compared with standard oxygen, its survival benefit is uncertain. A more precise definition of acute hypoxemic respiratory failure, including a classification of severity based on oxygenation levels, is needed to better compare the efficiencies of different non-invasive oxygenation support methods (standard oxygen, high-flow oxygen, and non-invasive ventilation). Additionally, the respective role of each non-invasive oxygenation support method needs to be established through further clinical trials in acute hypoxemic respiratory failure, especially in severe forms.
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Affiliation(s)
- Jean-Pierre Frat
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers 86021, France,Centre d'Investigation Clinique 1402 ALIVE, INSERM, Université de Poitiers, Poitiers 86021, France,Corresponding author: Jean-Pierre Frat, Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers 86021, France
| | - Laura Marchasson
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers 86021, France
| | - François Arrivé
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers 86021, France
| | - Rémi Coudroy
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers 86021, France,Centre d'Investigation Clinique 1402 ALIVE, INSERM, Université de Poitiers, Poitiers 86021, France
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22
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Impact of noninvasive ventilation at a municipal emergency department on ICU admissions. Wien Klin Wochenschr 2023; 135:28-34. [PMID: 36441338 PMCID: PMC9703406 DOI: 10.1007/s00508-022-02111-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 10/17/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND In 2015, the emergency department of a municipal hospital in Vienna began to perform noninvasive ventilation (NIV) on patients admitted for acute respiratory failure, given no intubation criteria were met. The intention of this study was to show to which type of hospital unit patients were transferred after undergoing NIV in the emergency department. Additionally, the impact of the underlying disease, a patient's sex and age and the year of intervention were analyzed. METHODS A single-center retrospective exploratory study was performed on 371 patients. All patients with acute respiratory failure who were noninvasively ventilated at the study center emergency department from 2015 to 2018 were eligible. Relevant data were extracted from the patient's medical records. RESULTS A total of 43.7% (95% confidence interval, CI 38.8-48.5%) of patients were successfully stabilized in the emergency department through NIV and subsequently transferred to a normal care unit or discharged. This nonintensive care admission rate was significantly associated with certain underlying medical conditions, age and year of intervention. A further 19.7% (95% CI 15.6-23.7%) of patients were transferred to an intermediate care unit instead of an intensive care unit. CONCLUSION These findings emphasize the importance of noninvasive ventilation at the emergency department in reducing load on intensive care units and ensuring an efficient hospital workflow. Nonintensive care admission rate appears to be the highest in patients with pulmonary edema, especially in the higher age range and is also associated with the level of staff training. Prospective trials are needed to accurately confirm these correlations.
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23
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Muacevic A, Adler JR, M G N, V C, Gulur H, V H. A Retrospective Analysis of Ventilatory Strategy Comparing Non-invasive Ventilation (NIV) With Invasive Ventilation in Patients Admitted With Severe COVID-19 Pneumonia. Cureus 2023; 15:e34249. [PMID: 36855494 PMCID: PMC9968367 DOI: 10.7759/cureus.34249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2023] [Indexed: 01/28/2023] Open
Abstract
Background The second wave of the COVID-19 pandemic in India saw a sudden upsurge of critically ill patients getting admitted to the ICU. The guidance for respiratory support was unclear in the early phase. But later reports showed lower mortality with non-invasive ventilation (NIV) than with intubation. The aim of this study was to assess the end result of initial methods of ventilation in COVID-19 patients. Methodology Patients admitted to ICU with COVID-19 were categorized as group 1 (IPPV-intubated within 24 hrs of admission), group 2 (NIV -NIV only), group 3 (NIV+ IPPV-intubated after 24 hrs), and group 4 (NRBM - Non-Rebreathing Mask only). All causes in the hospital or 30-day mortality, length of stay in ICU, and incidence of pneumothorax were compared between groups. Logistic regression analysis was done to determine the odds of mortality. Results The overall mortality rate among patients admitted to tertiary care centers was 15% and the rate among patients in ICU was 54.07%. Patients in group 1 and group 3 had significantly high mortality rates of 90.47% and 93.75%, respectively, as compared to 51.28% in group 2 patients. The odds of mortality were high in group 3 (OR 29.57, 95% CI 4.51 and 193.52) and group 1 (OR 8.01, 95% CI 1.35 and 47.48). Conclusion In a resource-limited setting, the use of NIV is associated with higher survival in COVID-19 patients. The prognosis of patients who are intubated early or after a trial of NIV is the same with increased odds of mortality.
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Zbiral M, Weber M, König S, Kraft F, Ullrich R, Krenn K. Usefulness and limitations of the acute respiratory distress syndrome definitions in non-intubated patients. A narrative review. Front Med (Lausanne) 2023; 10:1088709. [PMID: 36910485 PMCID: PMC9995400 DOI: 10.3389/fmed.2023.1088709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/07/2023] [Indexed: 02/25/2023] Open
Abstract
According to the Berlin Definition of acute respiratory distress syndrome (ARDS), a positive end-expiratory pressure (PEEP) of at least 5 cmH2O is required to diagnose and grade ARDS. While the Berlin consensus statement specifically acknowledges the role of non-invasive ventilation (NIV) in mild ARDS, this stratification has traditionally presumed a mechanically ventilated patient in the context of moderate to severe ARDS. This may not accurately reflect today's reality of clinical respiratory care. NIV and high-flow nasal cannula oxygen therapy (HFNO) have been used for managing of severe forms of acute hypoxemic respiratory failure with growing frequency, including in patients showing pathophysiological signs of ARDS. This became especially relevant during the COVID-19 pandemic. The levels of PEEP achieved with HFNO have been particularly controversial, and the exact FiO2 it achieves is subject to variability. Pinpointing the presence of ARDS in patients receiving HNFO and the severity in those receiving NIV therefore remains methodically problematic. This narrative review highlights the evolution of the ARDS definition in the context of non-invasive ventilatory support and provides an overview of the parallel development of definitions and ventilatory management of ARDS. It summarizes the methodology applied in clinical trials to classify ARDS in non-intubated patients and the respective consequences on treatment. As ARDS severity has significant therapeutic and prognostic consequences, and earlier treatment in non-intubated patients may be beneficial, closing this knowledge gap may ultimately be a relevant step to improve comparability in clinical trial design and outcomes.
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Affiliation(s)
- Martin Zbiral
- Department of Anesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Maximilian Weber
- Department of Anesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Sebastian König
- Department of Anesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Felix Kraft
- Department of Anesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Roman Ullrich
- Department of Anesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria.,Department of Anesthesiology and Intensive Care Medicine, AUVA Trauma Center Vienna, Vienna, Austria
| | - Katharina Krenn
- Department of Anesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
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25
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Cesarano M, Grieco DL, Michi T, Munshi L, Menga LS, Delle Cese L, Ruggiero E, Rosà T, Natalini D, Sklar MC, Cutuli SL, Bongiovanni F, De Pascale G, Ferreyro BL, Goligher EC, Antonelli M. Helmet noninvasive support for acute hypoxemic respiratory failure: rationale, mechanism of action and bedside application. Ann Intensive Care 2022; 12:94. [PMID: 36241926 PMCID: PMC9568634 DOI: 10.1186/s13613-022-01069-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/29/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Helmet noninvasive support may provide advantages over other noninvasive oxygenation strategies in the management of acute hypoxemic respiratory failure. In this narrative review based on a systematic search of the literature, we summarize the rationale, mechanism of action and technicalities for helmet support in hypoxemic patients. Main results In hypoxemic patients, helmet can facilitate noninvasive application of continuous positive-airway pressure or pressure-support ventilation via a hood interface that seals at the neck and is secured by straps under the arms. Helmet use requires specific settings. Continuous positive-airway pressure is delivered through a high-flow generator or a Venturi system connected to the inspiratory port of the interface, and a positive end-expiratory pressure valve place at the expiratory port of the helmet; alternatively, pressure-support ventilation is delivered by connecting the helmet to a mechanical ventilator through a bi-tube circuit. The helmet interface allows continuous treatments with high positive end-expiratory pressure with good patient comfort. Preliminary data suggest that helmet noninvasive ventilation (NIV) may provide physiological benefits compared to other noninvasive oxygenation strategies (conventional oxygen, facemask NIV, high-flow nasal oxygen) in non-hypercapnic patients with moderate-to-severe hypoxemia (PaO2/FiO2 ≤ 200 mmHg), possibly because higher positive end-expiratory pressure (10–15 cmH2O) can be applied for prolonged periods with good tolerability. This improves oxygenation, limits ventilator inhomogeneities, and may attenuate the potential harm of lung and diaphragm injury caused by vigorous inspiratory effort. The potential superiority of helmet support for reducing the risk of intubation has been hypothesized in small, pilot randomized trials and in a network metanalysis. Conclusions Helmet noninvasive support represents a promising tool for the initial management of patients with severe hypoxemic respiratory failure. Currently, the lack of confidence with this and technique and the absence of conclusive data regarding its efficacy render helmet use limited to specific settings, with expert and trained personnel. As per other noninvasive oxygenation strategies, careful clinical and physiological monitoring during the treatment is essential to early identify treatment failure and avoid delays in intubation.
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Affiliation(s)
- Melania Cesarano
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore Rome, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy
| | - Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. .,Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore Rome, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy.
| | - Teresa Michi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore Rome, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Division of Respirology, University Health Network/Sinai Health System, Toronto, Canada
| | - Luca S Menga
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore Rome, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy
| | - Luca Delle Cese
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore Rome, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy
| | - Ersilia Ruggiero
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore Rome, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy
| | - Tommaso Rosà
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore Rome, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy
| | - Daniele Natalini
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore Rome, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy
| | - Michael C Sklar
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Division of Respirology, University Health Network/Sinai Health System, Toronto, Canada
| | - Salvatore L Cutuli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore Rome, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy
| | - Filippo Bongiovanni
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore Rome, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy
| | - Gennaro De Pascale
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Division of Respirology, University Health Network/Sinai Health System, Toronto, Canada
| | - Bruno L Ferreyro
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Division of Respirology, University Health Network/Sinai Health System, Toronto, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Division of Respirology, University Health Network/Sinai Health System, Toronto, Canada
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto Di Anestesiologia E Rianimazione, Università Cattolica del Sacro Cuore Rome, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy
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Taraxasterol Inhibits Hyperactivation of Macrophages to Alleviate the Sepsis-induced Inflammatory Response of ARDS Rats. Cell Biochem Biophys 2022; 80:763-770. [PMID: 36070121 DOI: 10.1007/s12013-022-01092-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 08/24/2022] [Indexed: 11/03/2022]
Abstract
To explore the effect and mechanism of taraxasterol on sepsis-induced acute respiratory distress syndrome (ARDS). Twenty-four male SD rats were randomly divided into four groups: the control group, model (lipopolysaccharide, LPS) group, lipopolysaccharide+taraxasterol (LPS + TXL) group, and lipopolysaccharide+ulinastatin (LPS + UTI) group. The model of sepsis-induced ARDS was established by intraperitoneal injection of LPS. The lung water content of the rats in each group was determined by the dry/wet ratio. Pathology of rat lung tissue was observed through H&E staining. Wright staining was applied to count the number of neutrophils, macrophages, and total cells. ELISA was utilized to measure the levels of the inflammatory factors TNF-α, IL-1β, and IL-6 in bronchoalveolar lavage fluid (BALF). Biochemical detection was adopted to check the levels of myeloperoxidase (MPO), superoxide dismutase (SOD) and catalase (CAT) in lung tissue. Western blotting was performed to check the protein expression of IL-12, iNOS, Arg-1, and Mrc1 in lung tissue. Compared with the LPS group, both taraxasterol and ulinastatin significantly decreased lung tissue water content, improved lung tissue injury, reduced the number of neutrophils, macrophages and total cells, and decreased the level of inflammatory factors. In addition, taraxasterol and ulinastatin also reduced the content of MPO and the expression of IL-12 and iNOS and increased the activity of SOD and CAT as well as the protein expression of Arg-1 and Mrc1. Taraxasterol can suppress macrophage M1 polarization to alleviate the inflammatory response and oxidative stress, thereby treating sepsis-induced ARDS.
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Tetlow S, Anandanadesan R, Taheri L, Pagkalidou E, De Lavallade H, Metaxa V. High-flow nasal cannula oxygen in patients with haematological malignancy: a retrospective observational study. Ann Hematol 2022; 101:1191-1199. [PMID: 35394147 DOI: 10.1007/s00277-022-04824-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 03/21/2022] [Indexed: 01/05/2023]
Abstract
Patients with haematological malignancies (HM) face high rates of intensive care unit (ICU) admission and mortality. High-flow nasal cannula oxygen (HFNCO) is increasingly used to support HM patients in ward settings, but there is limited evidence on the safety and efficacy of HFNCO in this group. We retrospectively reviewed all HM patients receiving ward-based HFNCO, supervised by a critical care outreach service (CCOS), from January 2014 to January 2019. We included 130 consecutive patients. Forty-three (33.1%) were weaned off HFNCO without ICU admission. Eighty-seven (66.9%) were admitted to ICU, 20 (23.3%) required non-invasive and 34 (39.5%) invasive mechanical ventilation. ICU and hospital mortality were 42% and 55% respectively. Initial FiO2 < 0.4 (OR 0.27, 95% CI 0.09-0.81, p = 0.019) and HFNCO use on the ward > 1 day (OR 0.16, 95% CI 0.04, 0.59, p = 0.006) were associated with reduced likelihood for ICU admission. Invasive ventilation was associated with reduced survival (OR 0.27, 95%CI 0.1-0.7, p = 0.007). No significant adverse events were reported. HM patients receiving ward-based HFNCO have higher rates of ICU admission, but comparable hospital mortality to those requiring CCOS review without respiratory support. Results should be interpreted cautiously, as the model proposed depends on the existence of CCOS.
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Affiliation(s)
- Simon Tetlow
- University College Hospital NHS Foundation Trust, 235 Euston Rd, Bloomsbury, London, NW1 2BU, UK.
| | | | - Leila Taheri
- Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Eirini Pagkalidou
- School of Medicine, Aristotle University of Thessaloniki, University Campus, 54124, Thessaloniki, Greece
| | - Hugues De Lavallade
- Department of Haematological Medicine, King's College Hospital, Denmark Hill, Brixton, London, SE5 9RS, UK
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital, Denmark Hill, Brixton, London, SE5 9RS, UK
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Im DD, Laksana E, Ledbetter DR, Aczon MD, Khemani RG, Wetzel RC. Development of a deep learning model that predicts Bi-level positive airway pressure failure. Sci Rep 2022; 12:8907. [PMID: 35618738 PMCID: PMC9135753 DOI: 10.1038/s41598-022-12984-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 05/16/2022] [Indexed: 11/09/2022] Open
Abstract
Delaying intubation for patients failing Bi-Level Positive Airway Pressure (BIPAP) may be associated with harm. The objective of this study was to develop a deep learning model capable of aiding clinical decision making by predicting Bi-Level Positive Airway Pressure (BIPAP) failure. This was a retrospective cohort study in a tertiary pediatric intensive care unit (PICU) between 2010 and 2020. Three machine learning models were developed to predict BIPAP failure: two logistic regression models and one deep learning model, a recurrent neural network with a Long Short-Term Memory (LSTM-RNN) architecture. Model performance was evaluated in a holdout test set. 175 (27.7%) of 630 total BIPAP sessions were BIPAP failures. Patients in the BIPAP failure group were on BIPAP for a median of 32.8 (9.2-91.3) hours prior to intubation. Late BIPAP failure (intubation after using BIPAP > 24 h) patients had fewer 28-day Ventilator Free Days (13.40 [0.68-20.96]), longer ICU length of stay and more post-extubation BIPAP days compared to those who were intubated ≤ 24 h from BIPAP initiation. An AUROC above 0.5 indicates that a model has extracted new information, potentially valuable to the clinical team, about BIPAP failure. Within 6 h of BIPAP initiation, the LSTM-RNN model predicted which patients were likely to fail BIPAP with an AUROC of 0.81 (0.80, 0.82), superior to all other models. Within 6 h of BIPAP initiation, the LSTM-RNN model would identify nearly 80% of BIPAP failures with a 50% false alarm rate, equal to an NNA of 2. In conclusion, a deep learning method using readily available data from the electronic health record can identify which patients on BIPAP are likely to fail with good discrimination, oftentimes days before they are intubated in usual practice.
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Affiliation(s)
- Daniel D Im
- Department of Pediatrics, Keck School of Medicine, University of Southern California, 2020 Zonal Ave, IRD 114, Los Angeles, CA, 90089, USA.
| | - Eugene Laksana
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA.,Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - David R Ledbetter
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA.,Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Melissa D Aczon
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA.,Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Robinder G Khemani
- Department of Pediatrics, Keck School of Medicine, University of Southern California, 2020 Zonal Ave, IRD 114, Los Angeles, CA, 90089, USA.,Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Randall C Wetzel
- Department of Pediatrics, Keck School of Medicine, University of Southern California, 2020 Zonal Ave, IRD 114, Los Angeles, CA, 90089, USA.,Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA.,Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Children's Hospital Los Angeles, Los Angeles, CA, USA.,Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Jayasimhan D, Martynoga RA, Fairweather SM, Chang CL. Non-invasive ventilation for acute hypoxaemic respiratory failure: a propensity-matched cohort study. BMJ Open Respir Res 2022; 9:9/1/e001149. [PMID: 35580915 PMCID: PMC9114973 DOI: 10.1136/bmjresp-2021-001149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 05/05/2022] [Indexed: 11/22/2022] Open
Abstract
Background Non-invasive ventilation (NIV), although effective in treating hypercapnic respiratory failure, has not demonstrated the same efficacy in treating acute hypoxaemic respiratory failure. We aimed to examine the effect of NIV use on ventilator-free days in patients with acute hypoxaemic respiratory failure admitted to the intensive care unit (ICU). Methods We conducted a retrospective study of patients admitted to the ICU with acute hypoxaemic respiratory failure at Waikato Hospital, New Zealand, from 1 January 2009 to 31 December 2018. Patients treated with NIV as the initial oxygenation strategy were compared with controls treated with early intubation. The two groups were matched using a propensity score based on baseline characteristics. The primary outcome was the number of ventilator-free days at day 28. The secondary outcomes were ICU and hospital length of stay and in-hospital mortality. Results Out of 175 eligible patients, 79 each out of the NIV and early intubation groups were matched using a propensity score. Early NIV was associated with significantly higher median ventilator-free days than early intubation (17 days vs 23 days, p=0.013). There was no significant difference in median ICU length of stay (112.5 hours vs 117.7 hours), hospital length of stay (14 days vs 14 days) or in-hospital mortality (31.6% vs 37.9%) between the NIV and the early intubation group. Conclusion Compared with early intubation, NIV use was associated with more ventilator-free days in patients with hypoxaemic respiratory failure. However, this did not translate into a shorter length of stay or reduced mortality based on our single-centre experience.
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Affiliation(s)
- Dilip Jayasimhan
- Department of Respiratory Medicine and Respiratory Research Unit, Waikato Hospital, Hamilton, New Zealand .,Intensive Care Unit, Waikato Hospital, Hamilton, New Zealand
| | | | - Sarah M Fairweather
- Department of Respiratory Medicine and Respiratory Research Unit, Waikato Hospital, Hamilton, New Zealand
| | - Catherina L Chang
- Department of Respiratory Medicine and Respiratory Research Unit, Waikato Hospital, Hamilton, New Zealand
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30
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Frat JP, Le Pape S, Coudroy R, Thille AW. Noninvasive Oxygenation in Patients with Acute Respiratory Failure: Current Perspectives. Int J Gen Med 2022; 15:3121-3132. [PMID: 35418775 PMCID: PMC9000535 DOI: 10.2147/ijgm.s294906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 02/22/2022] [Indexed: 01/16/2023] Open
Abstract
Purpose of Review High-flow nasal oxygen and noninvasive ventilation are two alternative strategies to standard oxygen in the management of acute respiratory failure. Discussion Although high-flow nasal oxygen has gained major popularity in ICUs due to its simplicity of application, good comfort for patients, efficiency in improving oxygenation and promising results in patients with acute hypoxemic respiratory failure, further large clinical trials are needed to confirm its superiority over standard oxygen. Non-invasive ventilation may have deleterious effects, especially in patients exerting strong inspiratory efforts, and no current recommendations support its use in this setting. Protective non-invasive ventilation using higher levels of positive-end expiratory pressure, more prolonged sessions and other interfaces such as the helmet may have beneficial physiological effects leading to it being proposed as alternative to high-flow nasal oxygen in acute hypoxemic respiratory failure. By contrast, non-invasive ventilation is the first-line strategy of oxygenation in patients with acute exacerbation of chronic lung disease, while high-flow nasal oxygen could be an alternative to non-invasive ventilation after partial reversal of respiratory acidosis. Questions remain about the target populations and non-invasive oxygen strategy representing the best alternative to standard oxygen in acute hypoxemic respiratory failure. As concerns acute on-chronic-respiratory failure, the place of high-flow nasal oxygen remains to be evaluated.
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Affiliation(s)
- Jean-Pierre Frat
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers, France
- Centre d’Investigation Clinique 1402 ALIVE, INSERM, Université de Poitiers, Poitiers, France
| | - Sylvain Le Pape
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers, France
| | - Rémi Coudroy
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers, France
- Centre d’Investigation Clinique 1402 ALIVE, INSERM, Université de Poitiers, Poitiers, France
| | - Arnaud W Thille
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers, France
- Centre d’Investigation Clinique 1402 ALIVE, INSERM, Université de Poitiers, Poitiers, France
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31
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Cammarota G, Simonte R, De Robertis E. Comfort During Non-invasive Ventilation. Front Med (Lausanne) 2022; 9:874250. [PMID: 35402465 PMCID: PMC8988041 DOI: 10.3389/fmed.2022.874250] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/28/2022] [Indexed: 01/03/2023] Open
Abstract
Non-invasive ventilation (NIV) has been shown to be effective in avoiding intubation and improving survival in patients with acute hypoxemic respiratory failure (ARF) when compared to conventional oxygen therapy. However, NIV is associated with high failure rates due, in most cases, to patient discomfort. Therefore, increasing attention has been paid to all those interventions aimed at enhancing patient's tolerance to NIV. Several practical aspects have been considered to improve patient adaptation. In particular, the choice of the interface and the ventilatory setting adopted for NIV play a key role in the success of respiratory assistance. Among the different NIV interfaces, tolerance is poorest for the nasal and oronasal masks, while helmet appears to be better tolerated, resulting in longer use and lower NIV failure rates. The choice of fixing system also significantly affects patient comfort due to pain and possible pressure ulcers related to the device. The ventilatory setting adopted for NIV is associated with varying degrees of patient comfort: patients are more comfortable with pressure-support ventilation (PSV) than controlled ventilation. Furthermore, the use of electrical activity of the diaphragm (EADi)-driven ventilation has been demonstrated to improve patient comfort when compared to PSV, while reducing neural drive and effort. If non-pharmacological remedies fail, sedation can be employed to improve patient's tolerance to NIV. Sedation facilitates ventilation, reduces anxiety, promotes sleep, and modulates physiological responses to stress. Judicious use of sedation may be an option to increase the chances of success in some patients at risk for intubation because of NIV intolerance consequent to pain, discomfort, claustrophobia, or agitation. During the Coronavirus Disease-19 (COVID-19) pandemic, NIV has been extensively employed to face off the massive request for ventilatory assistance. Prone positioning in non-intubated awake COVID-19 patients may improve oxygenation, reduce work of breathing, and, possibly, prevent intubation. Despite these advantages, maintaining prone position can be particularly challenging because poor comfort has been described as the main cause of prone position discontinuation. In conclusion, comfort is one of the major determinants of NIV success. All the strategies aimed to increase comfort during NIV should be pursued.
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Monitoring respiratory mechanics by oscillometry in COVID-19 patients receiving non-invasive respiratory support. PLoS One 2022; 17:e0265202. [PMID: 35312682 PMCID: PMC8936489 DOI: 10.1371/journal.pone.0265202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 02/28/2022] [Indexed: 01/08/2023] Open
Abstract
Background Non-invasive ventilation (NIV) has been increasingly used in COVID-19 patients. The limited physiological monitoring and the unavailability of respiratory mechanic measures, usually obtainable during invasive ventilation, is a limitation of NIV for ARDS and COVID-19 patients management. Objectives This pilot study was aimed to evaluate the feasibility of non-invasively monitoring respiratory mechanics by oscillometry in COVID-19 patients with moderate-severe acute respiratory distress syndrome (ARDS) receiving NIV. Method 15 COVID-19 patients affected by moderate-severe ARDS at the RICU (Respiratory Intensive Care Unit) of the University hospital of Cattinara, Trieste, Italy were recruited. Patients underwent oscillometry tests during short periods of spontaneous breathing between NIV sessions. Results Oscillometry proved to be feasible, reproducible and well-tolerated by patients. At admission, 8 of the 15 patients showed oscillometry parameters within the normal range which further slightly improved before discharge. At discharge, four patients had still abnormal respiratory mechanics, not exclusively linked to pre-existing respiratory comorbidities. Lung mechanics parameters were not correlated with oxygenation. Conclusions Our results suggest that lung mechanics provide complementary information for improving patients phenotyping and personalisation of treatments during NIV in COVID 19 patients, especially in the presence of respiratory comorbidities where deterioration of lung mechanics may be less coupled with changes in oxygenation and more difficult to identify. Oscillometry may provide a valuable tool for monitoring lung mechanics in COVID 19 patients receiving NIV.
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Paiva DN, Wagner LE, Dos Santos Marinho SE, Dornelles CFD, de Souza Barbosa JF, de Melo Marinho PÉ. Effectiveness of an adapted diving mask (Owner mask) for non-invasive ventilation in the COVID-19 pandemic scenario: study protocol for a randomized clinical trial. Trials 2022; 23:218. [PMID: 35303958 PMCID: PMC8931183 DOI: 10.1186/s13063-022-06133-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 02/28/2022] [Indexed: 12/15/2022] Open
Abstract
Background Non-invasive ventilation (NIV) is indicated to avoid orotracheal intubation (OTI) to reduce hospital stay and mortality. Patients infected by SARS-CoV2 can progress to respiratory failure (RF); however, in the initial phase, they can be submitted to oxygen therapy and NIV. Such resources can produce aerosol and can cause a high risk of contagion to health professionals. Safe NIV strategies are sought, and therefore, the authors adapted diving masks to be used as NIV masks (called an Owner mask). Objective To assess the Owner mask safety and effectiveness regarding conventional orofacial mask for patients in respiratory failure with and without confirmation or suspicion of COVID-19. Methods A Brazilian multicentric study to assess patients admitted to the intensive care unit regarding their clinical, sociodemographic and anthropometric data. The primary outcome will be the rate of tracheal intubation, and secondary outcomes will include in-hospital mortality, the difference in PaO2/FiO2 ratio and PaCO2 levels, time in the intensive care unit and hospitalization time, adverse effects, degree of comfort and level of satisfaction of the mask use, success rate of NIV (not progressing to OTI), and behavior of the ventilatory variables obtained in NIV with an Owner mask and with a conventional face mask. Patients with COVID-19 and clinical signs indicative of RF will be submitted to NIV with an Owner mask [NIV Owner COVID Group (n = 63)] or with a conventional orofacial mask [NIV orofacial COVID Group (n = 63)], and those patients in RF due to causes not related to COVID-19 will be allocated into the NIV Owner Non-COVID Group (n = 97) or to the NIV Orofacial Non-COVID Group (n = 97) in a randomized way, which will total 383 patients, admitting 20% for loss to follow-up. Discussion This is the first randomized and controlled trial during the COVID-19 pandemic about the safety and effectiveness of the Owner mask compared to the conventional orofacial mask. Experimental studies have shown that the Owner mask enables adequate sealing on the patient’s face and the present study is relevant as it aims to minimize the aerosolization of the virus in the environment and improve the safety of health professionals. Trial registration Brazilian Registry of Clinical Trials (ReBEC): RBR – 7xmbgsz. Registered on 15 April 2021.
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Affiliation(s)
- Dulciane Nunes Paiva
- Post-Graduate Program in Health Promotion, Universidade de Santa Cruz do Sul, Santa Cruz do Sul, RS, Brazil.
| | - Litiele Evelin Wagner
- Multiprofessional Residency Health Program, Hospital Santa Cruz, Santa Cruz do Sul, RS, Brazil
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Long B, Gottlieb M. Dexmedetomidine in critically ill adults requiring noninvasive ventilation. Acad Emerg Med 2022; 29:384-386. [PMID: 34374168 DOI: 10.1111/acem.14368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/02/2021] [Accepted: 08/05/2021] [Indexed: 11/29/2022]
Abstract
Noninvasive ventilation (NIV) is an effective therapy for hypercapnic and hypoxemic respiratory failure and can reduce the need for intubation and mechanical ventilation.1 It may also reduce intensive care unit (ICU) length of stay, pneumonia, and mortality.2-6 However, NIV can be uncomfortable for patients due to the mask interface and respiratory pressures delivered, and over one-third of patients placed on NIV will experience agitation.7,8 Intolerance to NIV typically requires intubation. A variety of interventions can be utilized to improve compliance with NIV, including medications such as dexmedetomidine, an α-2 agonist with sedative and analgesic effects.9 Current guidelines recommend the use of a non-benzodiazepine sedative such as propofol or dexmedetomidine in critically ill, mechanically ventilated adults, as these medications may improve delirium, ICU length of stay, and duration of mechanical ventilation.10.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine Brooke Army Medical Center Fort Sam Houston Texas USA
| | - Michael Gottlieb
- Department of Emergency Medicine Rush University Medical Center Chicago Illinois USA
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Junhai Z, Jing Y, Beibei C, Li L. The value of ROX index in predicting the outcome of high flow nasal cannula: a systematic review and meta-analysis. Respir Res 2022; 23:33. [PMID: 35177091 PMCID: PMC8851822 DOI: 10.1186/s12931-022-01951-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 02/03/2022] [Indexed: 12/01/2022] Open
Abstract
Background High flow nasal cannula (HFNC) therapy is widely employed in acute hypoxemic respiratory failure (AHRF) patients. However, the techniques for predicting HFNC outcome remain scarce. Methods PubMed, EMBASE, and Cochrane Library were searched until April 20, 2021. We included the studies that evaluated the potential predictive value of ROX (respiratory rate-oxygenation) index for HFNC outcome. This meta-analysis determined sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic score, diagnostic odds ratio (DOR), and pooled area under the summary receiver operating characteristic (SROC) curve. Results We assessed nine studies with 1933 patients, of which 745 patients experienced HFNC failure. This meta-analysis found that sensitivity, specificity, PLR, NLR, diagnostic score, and DOR of ROX index in predicting HFNC failure were 0.67 (95% CI 0.57–0.76), 0.72 (95% CI 0.65–0.78), 2.4 (95% CI 2.0–2.8), 0.46 (95% CI 0.37–0.58), 1.65(95% CI 1.37–1.93), and 5.0 (95% CI 4.0–7.0), respectively. In addition, SROC was 0.75 (95% CI 0.71–0.79). Besides, our subgroup analyses revealed that ROX index had higher sensitivity and specificity for predicting HFNC failure in COVID-19 patients, use the cut-off value > 5, and the acquisition time of other times after receiving HFNC had a greater sensitivity and specificity when compared to 6 h. Conclusions This study demonstrated that ROX index could function as a novel potential marker to identify patients with a higher risk of HFNC failure. However, the prediction efficiency was moderate, and additional research is required to determine the optimal cut-off value and propel acquisition time of ROX index in the future. PROSPERO registration number: CRD42021240607.
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Affiliation(s)
- Zhen Junhai
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, 310013, Zhejiang, China
| | - Yan Jing
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, 310013, Zhejiang, China
| | - Cao Beibei
- Department of Pathology, Zhejiang Hospital, Hangzhou, 310013, Zhejiang, China
| | - Li Li
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, 310013, Zhejiang, China.
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Sullivan ZP, Zazzeron L, Berra L, Hess DR, Bittner EA, Chang MG. Noninvasive respiratory support for COVID-19 patients: when, for whom, and how? J Intensive Care 2022; 10:3. [PMID: 35033204 PMCID: PMC8760575 DOI: 10.1186/s40560-021-00593-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/26/2021] [Indexed: 12/14/2022] Open
Abstract
The significant mortality rate and prolonged ventilator days associated with invasive mechanical ventilation (IMV) in patients with severe COVID-19 have incited a debate surrounding the use of noninvasive respiratory support (NIRS) (i.e., HFNC, CPAP, NIV) as a potential treatment strategy. Central to this debate is the role of NIRS in preventing intubation in patients with mild respiratory disease and the potential beneficial effects on both patient outcome and resource utilization. However, there remains valid concern that use of NIRS may prolong time to intubation and lung protective ventilation in patients with more advanced disease, thereby worsening respiratory mechanics via self-inflicted lung injury. In addition, the risk of aerosolization with the use of NIRS has the potential to increase healthcare worker (HCW) exposure to the virus. We review the existing literature with a focus on rationale, patient selection and outcomes associated with the use of NIRS in COVID-19 and prior pandemics, as well as in patients with acute respiratory failure due to different etiologies (i.e., COPD, cardiogenic pulmonary edema, etc.) to understand the potential role of NIRS in COVID-19 patients. Based on this analysis we suggest an algorithm for NIRS in COVID-19 patients which includes indications and contraindications for use, monitoring recommendations, systems-based practices to reduce HCW exposure, and predictors of NIRS failure. We also discuss future research priorities for addressing unanswered questions regarding NIRS use in COVID-19 with the goal of improving patient outcomes.
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Affiliation(s)
- Zachary P Sullivan
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, MA, Boston, USA
| | - Luca Zazzeron
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, MA, Boston, USA
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, MA, Boston, USA
| | - Dean R Hess
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, MA, Boston, USA
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, MA, Boston, USA
| | - Marvin G Chang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, MA, Boston, USA.
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Lauria MJ, Root CW, Gottula AL, Braude DA. Management of Respiratory Distress and Failure in Morbidly and Super Obese Patients During Critical Care Transport. Air Med J 2022; 41:133-140. [PMID: 35248332 DOI: 10.1016/j.amj.2021.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 08/24/2021] [Accepted: 09/21/2021] [Indexed: 06/14/2023]
Abstract
Morbidly and super obese patients are a unique patient population that presents critical care transport providers with unique clinical and logistical challenges in the setting of respiratory distress and failure. These patients are more likely to have chronic respiratory issues at baseline, unique anatomic and physiologic abnormalities, and other comorbidities that leave them poorly able to tolerate respiratory illness or injury. This requires specialized understanding of their respiratory mechanics as well as how to tailor standard treatment modalities, such as noninvasive ventilation, to meet their needs. Also, careful and deliberate planning is required to address the specific anatomic and physiologic characteristics of this population if intubation and mechanical ventilation are needed. Finally, their dimensions and weight also have distinct consequences on transport vehicle considerations. This article reviews the pathophysiology, management, and critical care transport considerations for this unique patient population in respiratory distress and failure.
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Affiliation(s)
- Michael J Lauria
- Lifeguard Air Emergency Services, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM.
| | - Christopher W Root
- Lifeguard Air Emergency Services, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | - Adam L Gottula
- Department of Anesthesiology, Division of Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Darren A Braude
- Lifeguard Air Emergency Services, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico, Albuquerque, NM
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Şık N, Şenol HB, Çağlar A, Yılmaz D, Duman M. Early application of non-invasive ventilation for children with pulmonary edema after drowning. Pediatr Int 2022; 64:e14858. [PMID: 34057774 DOI: 10.1111/ped.14858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/15/2021] [Accepted: 05/27/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND The present study aimed to assess the efficacy of non-invasive ventilation (NIV) on the clinical course, oxygenation, need for invasive mechanical ventilation (IMV), and outcomes for children with pulmonary edema after drowning. METHODS We conducted a retrospective chart review. Children who were referred to the pediatric emergency department due to drowning-related pulmonary edema and underwent NIV between May 2014 and October 2020 were included. Demographics, vital signs, clinical findings, and results of laboratory and radiologic investigations were recorded. Patients were divided into six groups using the Szpilman classification system. The need for IMV, the need for pediatric intensive care unit admission, and the length of NIV treatment and stay in the pediatric intensive care unit were recorded for each patient. RESULTS Twenty-five patients were enrolled. According to the Szpilman classification, 13 (52.0%) patients were evaluated as grade 3 and 12 (48.0%) as grade 4. All patients were treated with bi-level positive airway pressure in the spontaneous / timed mode. A significant increase in oxygen saturation (SpO₂) and SpO₂/fraction of inspired oxygen ratios was observed from the beginning of NIV treatment and this increase was also observed for the second and fourth hours. There was a decrease in respiratory rate at the fourth hour of NIV treatment. No patient subsequently deteriorated to require IMV. CONCLUSIONS We have reported a favorable clinical course of drowning patients who underwent early use of NIV in the pediatric emergency department. Management of drowning patients with pulmonary edema by NIV with close follow-up can be successfully applied in selected cases.
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Affiliation(s)
- Nihan Şık
- Division of Pediatric Emergency Care, Department of Pediatrics, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Hüseyin Bahadır Şenol
- Department of Pediatrics, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Aykut Çağlar
- Division of Pediatric Emergency Care, Department of Pediatrics, Faculty of Medicine, Adnan Menderes University, Aydın, Turkey
| | - Durgül Yılmaz
- Division of Pediatric Emergency Care, Department of Pediatrics, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Murat Duman
- Division of Pediatric Emergency Care, Department of Pediatrics, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
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Jiang L, Wan Q, Ma H. Management strategy for hematological malignancy patients with acute respiratory failure. Eur J Med Res 2021; 26:108. [PMID: 34535193 PMCID: PMC8447613 DOI: 10.1186/s40001-021-00579-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 09/06/2021] [Indexed: 02/08/2023] Open
Abstract
Acute respiratory failure (ARF) is still the major cause of intensive care unit (ICU) admission for hematological malignancy (HM) patients although the advance in hematology and supportive care has greatly improved the prognosis. Clinicians have to make decisions whether the HM patients with ARF should be sent to ICU and which ventilation support should be administered. Based on the reported investigations related to management of HM patients with ARF, we propose a selection procedure to manage this population and recommend hematological ICU as the optimal setting to recuse these patients, where hematologists and intensivists can collaborate closely and improve the outcomes. Moreover, noninvasive ventilation (NIV) still has its own place for selected HM patients with ARF who have mild hypoxemia and reversible causes. It is also crucial to monitor the efficacy of NIV closely and switch to invasive mechanical ventilation at appropriate timing when NIV shows no apparent improvement. Otherwise, early IMV should be initiated to HM with ARF who have moderate and severe hypoxemia, adult respiratory distress syndrome, multiple organ dysfunction, and unstable hemodynamic. More studies are needed to elucidate the predictors of ICU mortality and ventilatory mode for HM patients with ARF.
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Affiliation(s)
- Li Jiang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Qunfang Wan
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Hongbing Ma
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, China.
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Intermittent Abdominal Pressure Ventilation: An Alternative for Respiratory Support. Can Respir J 2021; 2021:5554765. [PMID: 34471441 PMCID: PMC8405303 DOI: 10.1155/2021/5554765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/21/2021] [Accepted: 08/16/2021] [Indexed: 12/04/2022] Open
Abstract
Intermittent abdominal pressure ventilation is a positive pressure ventilation technique that works with abdominal compressions. It has been known since 1938; however, for many years, it was out of production. In recent years, a new device has been produced that has captured the attention to this old respiratory support technique. We considered eight patients with respiratory failure secondary to a neuromuscular disease (congenital myopathy, Duchenne dystrophy, and amyotrophic lateral sclerosis) intolerant to daytime noninvasive ventilation (NIV). IAPV was proposed as an alternative to NIV. We performed baseline and post-IAPV respiratory function assessment. All patients, two years later, are still using intermittent abdominal ventilation. Intermittent positive abdominal mechanical ventilation can be a valid alternative to noninvasive mechanical ventilation with a nasal or face mask. It improves gas exchange, symptoms, and quality of life, decreases the incidence of pneumonia, and can avert the need for intubation and tracheotomy.
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41
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Lanza A, Sommariva M, Mariani S, Ferreyra G, Stagni GE, Tombini V, Oppizzi A, Pontiggia C, Bellone A. Prolonged non-invasive respiratory support in a COVID-19 patient with severe acute hypoxemic respiratory failure. Monaldi Arch Chest Dis 2021; 92. [PMID: 34461700 DOI: 10.4081/monaldi.2021.1783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/07/2021] [Indexed: 11/23/2022] Open
Abstract
A pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus 2 was declared in 2020. Severe cases were characterized by the development of acute hypoxemic respiratory failure (AHRF) requiring advanced respiratory support. However, intensive care units (ICU) were saturated, and many patients had to be treated out of ICU. This case describes a 75-year-old man affected by AHRF due to Coronavirus Disease 2019 (COVID-19), hospitalized in a high-dependency unit, with PaO2/FiO2 <100 for 28 consecutive days. An experienced team with respiratory physiotherapists was in charge of the noninvasive ventilatory support (NIVS). The patient required permanent NIVS with continuous positive airway pressure, non-invasive ventilation, high flow nasal oxygen and body positioning. He was weaned from NIVS after 37 days and started exercise training afterwards. The patient was discharged at home with low-flow oxygen therapy. This case represents an example of a successful treatment of AHRF with the still controversial noninvasive respiratory support in one patient with COVID-19.
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Affiliation(s)
- Andrea Lanza
- Respiratory Physiotherapists Equipe, ASST Grande Ospedale Metropolitano Niguarda, Milan.
| | - Maurizio Sommariva
- Respiratory Physiotherapists Equipe, ASST Grande Ospedale Metropolitano Niguarda, Milan.
| | - Sara Mariani
- Respiratory Physiotherapists Equipe, ASST Grande Ospedale Metropolitano Niguarda, Milan.
| | - Gabriela Ferreyra
- Department of Surgical Science, Anesthesia and Critical Care, University of Turin.
| | - Giuliana Enrica Stagni
- Respiratory Physiotherapists Equipe, ASST Grande Ospedale Metropolitano Niguarda, Milan.
| | - Valeria Tombini
- Emergency Department, ASST Grande Ospedale Metropolitano Niguarda, Milan.
| | - Angela Oppizzi
- Emergency Department, ASST Grande Ospedale Metropolitano Niguarda, Milan.
| | - Catia Pontiggia
- Emergency Department, ASST Grande Ospedale Metropolitano Niguarda, Milan.
| | - Andrea Bellone
- Emergency Department, ASST Grande Ospedale Metropolitano Niguarda, Milan.
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42
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Grieco DL, Maggiore SM, Roca O, Spinelli E, Patel BK, Thille AW, Barbas CSV, de Acilu MG, Cutuli SL, Bongiovanni F, Amato M, Frat JP, Mauri T, Kress JP, Mancebo J, Antonelli M. Non-invasive ventilatory support and high-flow nasal oxygen as first-line treatment of acute hypoxemic respiratory failure and ARDS. Intensive Care Med 2021; 47:851-866. [PMID: 34232336 PMCID: PMC8261815 DOI: 10.1007/s00134-021-06459-2] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/09/2021] [Indexed: 12/21/2022]
Abstract
The role of non-invasive respiratory support (high-flow nasal oxygen and noninvasive ventilation) in the management of acute hypoxemic respiratory failure and acute respiratory distress syndrome is debated. The oxygenation improvement coupled with lung and diaphragm protection produced by non-invasive support may help to avoid endotracheal intubation, which prevents the complications of sedation and invasive mechanical ventilation. However, spontaneous breathing in patients with lung injury carries the risk that vigorous inspiratory effort, combined or not with mechanical increases in inspiratory airway pressure, produces high transpulmonary pressure swings and local lung overstretch. This ultimately results in additional lung damage (patient self-inflicted lung injury), so that patients intubated after a trial of noninvasive support are burdened by increased mortality. Reducing inspiratory effort by high-flow nasal oxygen or delivery of sustained positive end-expiratory pressure through the helmet interface may reduce these risks. In this physiology-to-bedside review, we provide an updated overview about the role of noninvasive respiratory support strategies as early treatment of hypoxemic respiratory failure in the intensive care unit. Noninvasive strategies appear safe and effective in mild-to-moderate hypoxemia (PaO2/FiO2 > 150 mmHg), while they can yield delayed intubation with increased mortality in a significant proportion of moderate-to-severe (PaO2/FiO2 ≤ 150 mmHg) cases. High-flow nasal oxygen and helmet noninvasive ventilation represent the most promising techniques for first-line treatment of severe patients. However, no conclusive evidence allows to recommend a single approach over the others in case of moderate-to-severe hypoxemia. During any treatment, strict physiological monitoring remains of paramount importance to promptly detect the need for endotracheal intubation and not delay protective ventilation.
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Affiliation(s)
- Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. .,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy.
| | - Salvatore Maurizio Maggiore
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy.,University Department of Innovative Technologies in Medicine and Dentistry, Gabriele D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Oriol Roca
- Servei de Medicina Intensiva, Hospital Universitari Vall D'Hebron, Institut de Recerca Vall D'Hebron, Barcelona, Spain.,Ciber Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Maggiore Policlinico Hospital, Milan, Italy
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Arnaud W Thille
- Centre Hospitalier Universitaire (CHU) de Poitiers, Médecine Intensive Réanimation, Poitiers, France.,Centre D'Investigation Clinique 1402, ALIVE, INSERM, Université de Poitiers, Poitiers, France
| | - Carmen Sílvia V Barbas
- Division of Pulmonary and Critical Care, University of São Paulo, São Paulo, Brazil.,Intensive Care Unit, Albert Einstein Hospital, São Paulo, Brazil
| | - Marina Garcia de Acilu
- Servei de Medicina Intensiva, Hospital Universitari Vall D'Hebron, Institut de Recerca Vall D'Hebron, Barcelona, Spain.,Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Salvatore Lucio Cutuli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy
| | - Filippo Bongiovanni
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy
| | - Marcelo Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Jean-Pierre Frat
- Centre Hospitalier Universitaire (CHU) de Poitiers, Médecine Intensive Réanimation, Poitiers, France.,Centre D'Investigation Clinique 1402, ALIVE, INSERM, Université de Poitiers, Poitiers, France
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Maggiore Policlinico Hospital, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - John P Kress
- Department of Anesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Maggiore Policlinico Hospital, Milan, Italy
| | - Jordi Mancebo
- Servei de Medicina Intensiva, Hospital Universitari de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy
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43
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Dunand A, Beysard N, Maudet L, Carron PN, Dami F, Piquilloud L, Caillet-Bois D, Pasquier M. Management of respiratory distress following prehospital implementation of noninvasive ventilation in a physician-staffed emergency medical service: a single-center retrospective study. Scand J Trauma Resusc Emerg Med 2021; 29:85. [PMID: 34187538 PMCID: PMC8240431 DOI: 10.1186/s13049-021-00900-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/11/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Noninvasive ventilation (NIV) is recognized as first line ventilatory support for the management of acute pulmonary edema (APE) and chronic obstructive pulmonary disease (COPD) exacerbations. We aimed to study the prehospital management of patients in acute respiratory distress with an indication for NIV and whether they received it or not. METHODS This retrospective study included patients ≥18 years old who were cared for acute respiratory distress in a prehospital setting. Indications for NIV were oxygen saturation (SpO2) <90% and/or respiratory rate (RR) >25/min with a presumptive diagnosis of APE or COPD exacerbation. Study population characteristics, initial and at hospital vital signs, presumptive and definitive diagnosis were analyzed. For patients who received NIV, dyspnea level was evaluated with a dyspnea verbal ordinal scale (D-VOS, 0-10) and arterial blood gas (ABG) values were obtained at hospital arrival. RESULTS Among the 187 consecutive patients included in the study, most (n = 105, 56%) had experienced APE or COPD exacerbation, and 56 (30%) received NIV. In comparison with patients without NIV, those treated with NIV had a higher initial RR (35 ± 8/min vs 29 ± 10/min, p < 0.0001) and a lower SpO2 (79 ± 10 vs 88 ± 11, p < 0.0001). The level of dyspnea was significantly reduced for patients treated with NIV (on-scene D-VOS 8.4 ± 1.7 vs 4.4 ± 1.8 at admission, p < 0.0001). Among the 131 patients not treated with NIV, 41 (31%) had an indication. In the latter group, initial SpO2 was 80 ± 10% in the NIV group versus 86 ± 11% in the non-NIV group (p = 0.0006). NIV was interrupted in 9 (16%) patients due to either discomfort (n = 5), technical problem (n = 2), persistent desaturation (n = 1), or vomiting (n = 1). CONCLUSIONS The results of this study contribute to a better understanding of the prehospital management of patients who present with acute respiratory distress and an indication for NIV. NIV was started on clinically more severe patients, even if predefined criteria to start NIV were present. NIV allows to improve vital signs and D-VOS in those patients. A prospective study could further elucidate why patients with a suspected diagnosis of APE and COPD are not treated with NIV, as well as the clinical impact of the different strategies. TRIAL REGISTRATION The study was approved by our institutional ethical committee ( CER-VD 2020-01363 ).
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Affiliation(s)
- Adeline Dunand
- Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 21, 1011, Lausanne, Switzerland.,Department of Emergency Medicine, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Nicolas Beysard
- Department of Emergency Medicine, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Ludovic Maudet
- Department of Emergency Medicine, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Pierre-Nicolas Carron
- Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 21, 1011, Lausanne, Switzerland.,Department of Emergency Medicine, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Fabrice Dami
- Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 21, 1011, Lausanne, Switzerland.,Department of Emergency Medicine, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Lise Piquilloud
- Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 21, 1011, Lausanne, Switzerland.,Adult Intensive Care Unit, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - David Caillet-Bois
- Department of Emergency Medicine, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Mathieu Pasquier
- Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 21, 1011, Lausanne, Switzerland. .,Department of Emergency Medicine, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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44
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Mercurio G, D'Arrigo S, Moroni R, Grieco DL, Menga LS, Romano A, Annetta MG, Bocci MG, Eleuteri D, Bello G, Montini L, Pennisi MA, Conti G, Antonelli M. Diaphragm thickening fraction predicts noninvasive ventilation outcome: a preliminary physiological study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:219. [PMID: 34174903 PMCID: PMC8233594 DOI: 10.1186/s13054-021-03638-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/09/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND A correlation between unsuccessful noninvasive ventilation (NIV) and poor outcome has been suggested in de-novo Acute Respiratory Failure (ARF) patients. Consequently, it is of paramount importance to identify accurate predictors of NIV outcome. The aim of our preliminary study is to evaluate the Diaphragmatic Thickening Fraction (DTF) and the respiratory rate/DTF ratio as predictors of NIV outcome in de-novo ARF patients. METHODS Over 36 months, we studied patients admitted to the emergency department with a diagnosis of de-novo ARF and requiring NIV treatment. DTF and respiratory rate/DTF ratio were measured by 2 trained operators at baseline, at 1, 4, 12, 24, 48, 72 and 96 h of NIV treatment and/or until NIV discontinuation or intubation. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the ability of DTF and respiratory rate/DTF ratio to distinguish between patients who were successfully weaned and those who failed. RESULTS Eighteen patients were included. We found overall good repeatability of DTF assessment, with Intra-class Correlation Coefficient (ICC) of 0.82 (95% confidence interval 0.72-0.88). The cut-off values of DTF for prediction of NIV failure were < 36.3% and < 37.1% for the operator 1 and 2 (p < 0.0001), respectively. The cut-off value of respiratory rate/DTF ratio for prediction of NIV failure was > 0.6 for both operators (p < 0.0001). CONCLUSION DTF and respiratory rate/DTF ratio may both represent valid, feasible and noninvasive tools to predict NIV outcome in patients with de-novo ARF. Trial registration ClinicalTrials.gov Identifier: NCT02976233, registered 26 November 2016.
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Affiliation(s)
- Giovanna Mercurio
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy.
| | - Sonia D'Arrigo
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Rossana Moroni
- Biostatistics, Office of the Scientific Director, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Domenico Luca Grieco
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Luca Salvatore Menga
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Anna Romano
- Institute of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - Maria Giuseppina Annetta
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Maria Grazia Bocci
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Davide Eleuteri
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Giuseppe Bello
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Luca Montini
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy.,Institute of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - Mariano Alberto Pennisi
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy.,Institute of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - Giorgio Conti
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy.,Institute of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - Massimo Antonelli
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy.,Institute of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy
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45
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Kang NM, Zhang N, Luo BJ, Wu ED, Shi JQ, Li L, Jiang L. Sequential non-invasive following short-term invasive mechanical ventilation in the treatment of tuberculosis with respiratory failure: a randomized controlled study. BMC Pulm Med 2021; 21:203. [PMID: 34162374 PMCID: PMC8220117 DOI: 10.1186/s12890-021-01563-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 06/08/2021] [Indexed: 11/23/2022] Open
Abstract
Background Invasive and non-invasive mechanical ventilation (MV) have been combined as sequential MV in the treatment of respiratory failure. However, the effectiveness remains unclear. Here, we performed a randomized controlled study to assess the efficacy and safety of sequential MV in the treatment of tuberculosis with respiratory failure. Methods Forty-four tuberculosis patients diagnosed with respiratory failure were randomly divided into sequential MV group (n = 24) and conventional MV group (n = 20). Initially, the patients in both groups received invasive positive pressure ventilation. When the patients' conditions were relieved, the ventilation modality in sequential MV group was switched to oronasal face mask continuous positive airway pressure until weaning. Results After treatment, the patients in sequential MV group had similar respiratory rate, heart rate, oxygenation index, alveolo-arterial oxygen partial pressure difference (A-aDO2), blood pH, PaCO2 to those in conventional MV group (all P value > 0.05). There was no significant difference in ventilation time and ICU stay between the two groups (P > 0.05), but sequential MV group significantly reduced the time of invasive ventilation (mean difference (MD): − 36.2 h, 95% confidence interval (CI) − 53.6, − 18.8 h, P < 0.001). Sequential MV group also reduced the incidence of ventilator-associated pneumonia (VAP; relative risk (RR): 0.44, 95% CI 0.24, 0.83, P = 0.006) and atelectasis (RR:0.49, 95% CI 0.24,1.00, P = 0.040). Conclusions Sequential MV was effective in treating tuberculosis with respiratory failure. It showed advantages in reducing invasive ventilation time and ventilator-associated adverse events. Registration number for clinical trial Chinese Clinical Trial Registry ChiCTR2000032311, April 21st, 2020
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Affiliation(s)
- Nai-Min Kang
- Department of ICU, Beijing Chest Hospital, Capital Medical University, 9 Beiguan Street, Tongzhou District, Beijing, 101149, China
| | - Nan Zhang
- Department of ICU, Beijing Chest Hospital, Capital Medical University, 9 Beiguan Street, Tongzhou District, Beijing, 101149, China
| | - Bao-Jian Luo
- Department of ICU, Beijing Chest Hospital, Capital Medical University, 9 Beiguan Street, Tongzhou District, Beijing, 101149, China
| | - En-Dong Wu
- Department of ICU, Beijing Chest Hospital, Capital Medical University, 9 Beiguan Street, Tongzhou District, Beijing, 101149, China
| | - Jian-Quan Shi
- Department of ICU, Beijing Chest Hospital, Capital Medical University, 9 Beiguan Street, Tongzhou District, Beijing, 101149, China
| | - Liang Li
- Department of ICU, Beijing Chest Hospital, Capital Medical University, 9 Beiguan Street, Tongzhou District, Beijing, 101149, China.
| | - Li Jiang
- Department of Intensive Care Unit, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.
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46
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Cornillon A, Balbo J, Coffinet J, Floch T, Bard M, Giordano-Orsini G, Malinovsky JM, Kanagaratnam L, Michelet D, Legros V. The ROX index as a predictor of standard oxygen therapy outcomes in thoracic trauma. Scand J Trauma Resusc Emerg Med 2021; 29:81. [PMID: 34154631 PMCID: PMC8215800 DOI: 10.1186/s13049-021-00876-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Thoracic trauma is commonplace and accounts for 50-70% of the injuries found in severe trauma. Little information is available in the literature as to timing of endotracheal intubation. The main objective of this study was to assess the accuracy of the ROX index in predicting successful standard oxygen (SO) therapy outcomes, and in pre-empting intubation. METHODS Patient selection included all thoracic trauma patients treated with standard oxygen who were admitted to a Level I trauma center between January 1, 2013 and April 30, 2020. Successful standard SO outcomes were defined as non-requirement of invasive mechanical ventilation within the 7 first days after thoracic trauma. RESULTS One hundred seventy one patients were studied, 49 of whom required endotracheal intubation for acute respiratory distress (28.6%). A ROX index score ≤ 12.85 yielded an area under the ROC curve of 0.88 with a 95% CI [0.80-0.94], 81.63sensitivity, 95%CI [0.69-0.91] and 88.52 specificity, 95%CI [0.82-0.94] involving a Youden index of 0.70. Patients with a median ROX index greater than 12.85 within the initial 24 h were less likely to require mechanical ventilation within the initial 7 days of thoracic trauma. CONCLUSION We have shown that a ROX index greater than 12.85 at 24 h was linked to successful standard oxygen therapy outcomes in critical thoracic trauma patients. It is our belief that an early low ROX index in the initial phase of trauma should heighten vigilance on the part of the attending intensivist, who has a duty to optimize management.
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Affiliation(s)
- Adrien Cornillon
- Department of Anesthesiology and critical care, Reims University Hospital, Reims, France
| | - Juliette Balbo
- Department of Anesthesiology and critical care, Reims University Hospital, Reims, France
| | - Julien Coffinet
- Department of Anesthesiology and critical care, Reims University Hospital, Reims, France
| | - Thierry Floch
- Surgical and Trauma Intensive Care Unit, Reims University Hospital, 45 rue Cognacq Jay, 51092, Reims Cedex, France
| | - Mathieu Bard
- Surgical and Trauma Intensive Care Unit, Reims University Hospital, 45 rue Cognacq Jay, 51092, Reims Cedex, France.,University of Reims Champagne Ardennes, Reims, France
| | - Guillaume Giordano-Orsini
- University of Reims Champagne Ardennes, Reims, France.,Department of Emergency Medicine, Reims University Hospital, Reims, France
| | - Jean-Marc Malinovsky
- Department of Anesthesiology and critical care, Reims University Hospital, Reims, France.,University of Reims Champagne Ardennes, Reims, France
| | - Lukshe Kanagaratnam
- University of Reims Champagne Ardennes, Reims, France.,Clinical Research Unit, Reims University Hospital, Reims, France
| | - Daphne Michelet
- Department of Anesthesiology and critical care, Reims University Hospital, Reims, France
| | - Vincent Legros
- Surgical and Trauma Intensive Care Unit, Reims University Hospital, 45 rue Cognacq Jay, 51092, Reims Cedex, France.
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47
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Rowan CM, Fitzgerald JC, Agulnik A, Zinter MS, Sharron MP, Slaven JE, Kreml EM, Bajwa RPS, Mahadeo KM, Moffet J, Tarquinio KM, Steiner ME. Risk Factors for Noninvasive Ventilation Failure in Children Post-Hematopoietic Cell Transplant. Front Oncol 2021; 11:653607. [PMID: 34123807 PMCID: PMC8190382 DOI: 10.3389/fonc.2021.653607] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/29/2021] [Indexed: 11/13/2022] Open
Abstract
Rationale Little is known on the use of noninvasive ventilation (NIPPV) in pediatric hematopoietic cell transplant (HCT) patients. Objective We sought to describe the landscape of NIPPV use and to identify risk factors for failure to inform future investigation or quality improvement. Methods This is a multicenter, retrospective observational cohort of 153 consecutive children post-HCT requiring NIPPV from 2010-2016. Results 97 (63%) failed NIPPV. Factors associated with failure on univariate analysis included: longer oxygen use prior to NIPPV (p=0.04), vasoactive agent use (p<0.001), and higher respiratory rate at multiple hours of NIPPV use (1hr p=0.02, 2hr p=0.04, 4hr p=0.008, 8hr p=0.002). Using respiratory rate at 4 hours a multivariable model was constructed. This model demonstrated high ability to discriminate NIPPV failure (AUC=0.794) with the following results: respiratory rate >40 at 4 hours [aOR=6.3 9(95% CI: 2.4, 16.4), p<0.001] and vasoactive use [aOR=4.9 (95% CI: 1.9, 13.1), p=0.001]. Of note, 11 patients had a cardiac arrest during intubation (11%) and 3 others arrested prior to intubation. These 14 patients were closer to HCT [14 days (IQR:4, 73) vs 54 (IQR:21,117), p<0.01] and there was a trend toward beginning NIPPV outside of the PICU and arrest during/prior to intubation (p=0.056). Conclusions In this cohort respiratory rate at 4 hours and vasoactive use are independent risk factors of NIPPV failure. An objective model to predict which children may benefit from a trial of NIPPV, may also inform the timing of both NIPPV initiation and uncomplicated intubation.
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Affiliation(s)
- Courtney M Rowan
- Department of Pediatrics, Division of Critical Care, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Asya Agulnik
- Department of Global Pediatric Medicine, Division of Critical Care, St. Jude's Children's Research Hospital, Memphis, TN, United States
| | - Matt S Zinter
- Department of Pediatrics, Division of Critical Care, University of California San Francisco, San Francisco, CA, United States
| | - Matthew P Sharron
- Department of Pediatrics, Division of Critical Care, George Washington University School of Medicine and Health Sciences, Children's National, Washington, DC, United States
| | - James E Slaven
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Erin M Kreml
- Critical Care Medicine, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Rajinder P S Bajwa
- Division of Heme/Onc/Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, OH, United States
| | - Kris M Mahadeo
- Department of Pediatrics, Division of Pediatric Stem Cell Transplant and Cellular Therapy, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - Jerelyn Moffet
- Department of Pediatrics, Division of Blood and Marrow Transplant, Duke Children's Hospital, Duke University, Durham, NC, United States
| | - Keiko M Tarquinio
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Marie E Steiner
- Department of Pediatrics, Division of Critical Care and Division of Hematology, Masonic Children's Hospital, University of Minnesota, Minneapolis, MN, United States
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Bertaina M, Nuñez-Gil IJ, Franchin L, Fernández Rozas I, Arroyo-Espliguero R, Viana-Llamas MC, Romero R, Maroun Eid C, Uribarri A, Becerra-Muñoz VM, Huang J, Alfonso E, Marmol-Mosquera F, Ugo F, Cerrato E, Fernandez-Presa L, Raposeiras Roubin S, Feltes Guzman G, Gonzalez A, Abumayyaleh M, Fernandez-Ortiz A, Macaya C, Estrada V. Non-invasive ventilation for SARS-CoV-2 acute respiratory failure: a subanalysis from the HOPE COVID-19 registry. Emerg Med J 2021; 38:359-365. [PMID: 33727235 PMCID: PMC7970657 DOI: 10.1136/emermed-2020-210411] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 01/26/2021] [Accepted: 02/01/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND The COVID-19 pandemic has seriously challenged worldwide healthcare systems and limited intensive care facilities, leading to physicians considering the use of non-invasive ventilation (NIV) for managing SARS-CoV-2-related acute respiratory failure (ARF). METHODS We conducted an interim analysis of the international, multicentre HOPE COVID-19 registry including patients admitted for a confirmed or highly suspected SARS-CoV-2 infection until 18 April 2020. Those treated with NIV were considered. The primary endpoint was a composite of death or need for intubation. The components of the composite endpoint were the secondary outcomes. Unadjusted and adjusted predictors of the primary endpoint within those initially treated with NIV were investigated. RESULTS 1933 patients who were included in the registry during the study period had data on oxygen support type. Among them, 390 patients (20%) were treated with NIV. Compared with those receiving other non-invasive oxygen strategy, patients receiving NIV showed significantly worse clinical and laboratory signs of ARF at presentation. Of the 390 patients treated with NIV, 173 patients (44.4%) met the composite endpoint. In-hospital death was the main determinant (147, 37.7%), while 62 patients (15.9%) needed invasive ventilation. Those requiring invasive ventilation had the lowest survival rate (41.9%). After adjustment, age (adjusted OR (adj(OR)) for 5-year increase: 1.37, 95% CI 1.15 to 1.63, p<0.001), hypertension (adj(OR) 2.95, 95% CI 1.14 to 7.61, p=0.03), room air O2 saturation <92% at presentation (adj(OR) 3.05, 95% CI 1.28 to 7.28, p=0.01), lymphocytopenia (adj(OR) 3.55, 95% CI 1.16 to 10.85, p=0.03) and in-hospital use of antibiotic therapy (adj(OR) 4.91, 95% CI 1.69 to 14.26, p=0.003) were independently associated with the composite endpoint. CONCLUSION NIV was used in a significant proportion of patients within our cohort, and more than half of these patients survived without the need for intubation. NIV may represent a viable strategy particularly in case of overcrowded and limited intensive care resources, but prompt identification of failure is mandatory to avoid harm. Further studies are required to better clarify our hypothesis. TRIAL REGISTRATION NUMBERS NCT04334291/EUPAS34399.
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Affiliation(s)
- Maurizio Bertaina
- Department of Cardiology, San Giovanni Bosco Hospital, Turin, Piemonte, Italy
- Emergency Medicine Department, Martini Hospital Centre, Torino, Piemonte, Italy
| | - Ivan J Nuñez-Gil
- Cardiovascular Institute, Hospital Clinico San Carlos, Madrid, Community of Madrid, Spain
| | - Luca Franchin
- Emergency Medicine Department, Martini Hospital Centre, Torino, Piemonte, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, University Hospital Città della Salute e della Scienza, Turin, Italy
| | | | - Ramón Arroyo-Espliguero
- Department of Cardiology, General University Hospital of Guadalajara, Guadalajara, Castilla-La Mancha, Spain
| | - María C Viana-Llamas
- Department of Cardiology, General University Hospital of Guadalajara, Guadalajara, Castilla-La Mancha, Spain
| | - Rodolfo Romero
- Servicio de Urgencias, Getafe University Hospital, Getafe, Community of Madrid, Spain
| | | | - Aitor Uribarri
- Division of Cardiology, Valladolid University Clinical Hospital, Valladolid, Castilla y León, Spain
| | | | - Jia Huang
- Department of Critical Care Medicine, Shenzhen Second People's Hospital, Shenzhen, Guangdong, China
| | - Emilio Alfonso
- Division of Cardiology, Institute of Cardiology and Cardiovascular Surgery, Havana, Cuba
| | - Fernando Marmol-Mosquera
- Internal Medicine Department, Hospital General del norte de Guayaquil IESS Los Ceibos, Guayaquil, Ecuador
| | - Fabrizio Ugo
- Division of Cardiology, Sant'Andrea di Vercelli Hospital, Vercelli, Piedmont, Italy
| | - Enrico Cerrato
- Division of Cardiology, San Luigi Gonzaga University Hospital, Orbassano, Italy
| | | | | | - Gisela Feltes Guzman
- Division of Cardiology, Hospital Nuestra Señora de América Madrid, Madrid, Spain
| | - Adelina Gonzalez
- Infanta Sofia University Hospital, San Sebastian de los Reyes, Community of Madrid, Spain
| | | | | | - Carlos Macaya
- Cardiovascular Institute, Hospital Clinico San Carlos, Madrid, Community of Madrid, Spain
| | - Vicente Estrada
- Cardiovascular Institute, Hospital Clinico San Carlos, Madrid, Community of Madrid, Spain
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49
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López J, Pons-Òdena M, Medina A, Molinos-Norniella C, Palanca-Arias D, Demirkol D, León-González JS, López-Fernández YM, Perez-Baena L, López-Herce J. Early factors related to mortality in children treated with bi-level noninvasive ventilation and CPAP. Pediatr Pulmonol 2021; 56:1237-1244. [PMID: 33382190 DOI: 10.1002/ppul.25246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 11/26/2020] [Accepted: 12/19/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To describe and analyze the characteristics and the early risk factors for mortality of noninvasive ventilation (NIV) in critically ill children. STUDY DESIGN A multicenter, prospective, observational 2-year study carried out with critically ill patients (1 month - 18 years of age) who needed NIV. Clinical data and NIV parameters during the first 12 h of admission were collected. A multilevel mixed-effects logistic regression was performed to identify mortality risk factors. RESULTS A total of 781 patients (44.2 ± 57.7 months) were studied (57.8% male). Of them, 53.7% had an underlying condition, and 47.1% needed NIV for lower airway respiratory pathologies. Bi-level NIV was the initial support in 78.2% of the patients. Continuous positive airway pressure (CPAP) was used more in younger patients (33.7%) than in older ones (9.7%; p < .001). About 16.7% had to be intubated and 6.2% died. The risk factors for mortality were immunodeficiency (odds ratio [OR] = 11.79; 95% confidence interval [CI] = 2.95-47.13); cerebral palsy (OR = 5.86; 95% CI = 1.94-17.65); presence of apneas on admission (OR = 5.57; 95% CI = 2.13-14.58); tachypnea 6 h after NIV onset (OR = 2.59; 95% CI = 1.30-6.94); and NIV failure (OR = 6.54; 95% CI = 2.79-15.34). CONCLUSION NIV is used with great variability in types of support. Younger children receive CPAP more frequently than older children. Immunodeficiency, cerebral palsy, apneas on admission, tachypnea 6 h after NIV onset, and NIV failure are the early factors associated with mortality.
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Affiliation(s)
- Jorge López
- Department of Pediatric Intensive Care, Gregorio Marañón General University Hospital, Madrid, Spain.,School of Medicine, Complutense University of Madrid, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain.,Mother-Child Health and Development Network (RedSAMID) of Carlos III Health Institute, Madrid, Spain
| | - Martí Pons-Òdena
- Department of Pediatric Intensive and Intermediate Care, Sant Joan de Déu University Hospital, Universitat de Barcelona, Esplugues de Llobregat, Spain.,Critical Care Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain
| | - Alberto Medina
- Pediatric Intensive Care Unit, CIBERes, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Daniel Palanca-Arias
- Pediatric Intensive Care Unit, Miguel Servet University Hospital, Zaragoza, Spain
| | - Demet Demirkol
- Pediatric Intensive Care Unit, Koç University School of Medicine, Istanbul, Turkey
| | - José S León-González
- Pediatric Intensive Care Unit, Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, Spain
| | | | - Luis Perez-Baena
- Pediatric Intensive Care Unit, Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, Spain
| | - Jesús López-Herce
- Department of Pediatric Intensive Care, Gregorio Marañón General University Hospital, Madrid, Spain.,School of Medicine, Complutense University of Madrid, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain.,Mother-Child Health and Development Network (RedSAMID) of Carlos III Health Institute, Madrid, Spain
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50
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Nishikimi M, Nishida K, Shindo Y, Shoaib M, Kasugai D, Yasuda Y, Higashi M, Numaguchi A, Yamamoto T, Matsui S, Matsuda N. Failure of non-invasive respiratory support after 6 hours from initiation is associated with ICU mortality. PLoS One 2021; 16:e0251030. [PMID: 33930089 PMCID: PMC8087003 DOI: 10.1371/journal.pone.0251030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/19/2021] [Indexed: 12/28/2022] Open
Abstract
A previous study has shown that late failure (> 48 hours) of high-flow nasal cannula (HFNC) was associated with intensive care unit (ICU) mortality. The aim of this study was to investigate whether failure of non-invasive respiratory support, including HFNC and non-invasive positive pressure ventilation (NPPV), was also associated with the risk of mortality even if it occurs in the earlier phase. We retrospectively analyzed 59 intubated patients for acute respiratory failure due to lung diseases between April 2014 and June 2018. We divided the patients into 2 groups according to the time from starting non-invasive ventilatory support until their intubation: ≤ 6 hours failure and > 6 hours failure group. We evaluated the differences in the ICU mortality between these two groups. The multivariate logistic regression analysis showed the highest mortality in the > 6 hours failure group as compared to the ≤ 6 hours failure group, with a statistically significant difference (p < 0.01). It was also associated with a statistically significant increased 30-day mortality and decreased ventilator weaning rate. The ICU mortality in patients with acute respiratory failure caused by lung diseases was increased if the time until failure of HFNC and NPPV was more than 6 hours.
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Affiliation(s)
- Mitsuaki Nishikimi
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Department of Emergency Medicine, Northwell Health, NY, NY, United States of America
- Laboratory for Critical Care Physiology at the Feinstein Institutes for Medical Research, Northwell Health, NY, NY, United States of America
- * E-mail:
| | - Kazuki Nishida
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuichiro Shindo
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Muhammad Shoaib
- Laboratory for Critical Care Physiology at the Feinstein Institutes for Medical Research, Northwell Health, NY, NY, United States of America
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States of America
| | - Daisuke Kasugai
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuma Yasuda
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Michiko Higashi
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Atsushi Numaguchi
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takanori Yamamoto
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shigeyuki Matsui
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoyuki Matsuda
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
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