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Duggal A, Conrad SA, Barrett NA, Saad M, Cheema T, Pannu S, Romero RS, Brochard L, Nava S, Ranieri VM, May A, Brodie D, Hill NS. Extracorporeal Carbon Dioxide Removal to Avoid Invasive Ventilation During Exacerbations of Chronic Obstructive Pulmonary Disease: VENT-AVOID Trial - A Randomized Clinical Trial. Am J Respir Crit Care Med 2024; 209:529-542. [PMID: 38261630 DOI: 10.1164/rccm.202311-2060oc] [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: 11/10/2023] [Accepted: 01/23/2024] [Indexed: 01/25/2024] Open
Abstract
Rationale: It is unclear whether extracorporeal CO2 removal (ECCO2R) can reduce the rate of intubation or the total time on invasive mechanical ventilation (IMV) in adults experiencing an exacerbation of chronic obstructive pulmonary disease (COPD). Objectives: To determine whether ECCO2R increases the number of ventilator-free days within the first 5 days postrandomization (VFD-5) in exacerbation of COPD in patients who are either failing noninvasive ventilation (NIV) or who are failing to wean from IMV. Methods: This randomized clinical trial was conducted in 41 U.S. institutions (2018-2022) (ClinicalTrials.gov ID: NCT03255057). Subjects were randomized to receive either standard care with venovenous ECCO2R (NIV stratum: n = 26; IMV stratum: n = 32) or standard care alone (NIV stratum: n = 22; IMV stratum: n = 33). Measurements and Main Results: The trial was stopped early because of slow enrollment and enrolled 113 subjects of the planned sample size of 180. There was no significant difference in the median VFD-5 between the arms controlled by strata (P = 0.36). In the NIV stratum, the median VFD-5 for both arms was 5 days (median shift = 0.0; 95% confidence interval [CI]: 0.0-0.0). In the IMV stratum, the median VFD-5 in the standard care and ECCO2R arms were 0.25 and 2 days, respectively; median shift = 0.00 (95% confidence interval: 0.00-1.25). In the NIV stratum, all-cause in-hospital mortality was significantly higher in the ECCO2R arm (22% vs. 0%, P = 0.02) with no difference in the IMV stratum (17% vs. 15%, P = 0.73). Conclusions: In subjects with exacerbation of COPD, the use of ECCO2R compared with standard care did not improve VFD-5. Clinical trial registered with www.clinicaltrials.gov (NCT03255057).
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Affiliation(s)
- Abhijit Duggal
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Steven A Conrad
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - Nicholas A Barrett
- Department of Critical Care, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
- Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Mohamed Saad
- Division of Pulmonary, Critical Care and Sleep Disorders Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Tariq Cheema
- Division of Pulmonary Critical Care, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Sonal Pannu
- Division of Pulmonary Critical Care and Sleep, Department of Medicine, Ohio State University, Columbus, Ohio
| | - Ramiro Saavedra Romero
- Department of Critical Care Medicine, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Laurent Brochard
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stefano Nava
- Respiratory and Critical Care Unit, IRCCS Azienda Hospital, University of Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - V Marco Ranieri
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
- Anesthesia and Intensive Care Medicine, IRCCS Azienda Hospital, University of Bologna, Bologna, Italy
| | - Alexandra May
- ALung Technologies, LivaNova PLC, Pittsburgh, Pennsylvania
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland; and
| | - Nicholas S Hill
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, Boston, Massachusetts
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Abi Abdallah G, Diop S, Jamme M, Legriel S, Ferré A. Respiratory Infection Triggering Severe Acute Exacerbations of Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2024; 19:555-565. [PMID: 38440747 PMCID: PMC10909653 DOI: 10.2147/copd.s447162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/15/2024] [Indexed: 03/06/2024] Open
Abstract
Background Data are scarce on respiratory infections during severe acute exacerbation of chronic obstructive pulmonary disease (COPD). This study aimed to investigate respiratory infection patterns in the intensive care unit (ICU) and identify variables associated with infection type and patient outcome. Methods A retrospective, single-centre cohort study. All patients admitted (2015-2021) to our ICU for severe acute exacerbation of COPD were included. Logistic multivariable regression analysis was performed to predict factors associated with infection and assess the association between infection and outcome. Results We included 473 patients: 288 (60.9%) had respiratory infection and 139 (29.4%) required invasive mechanical ventilation. Eighty-nine (30.9%) had viral, 81 (28.1%) bacterial, 34 (11.8%) mixed, and 84 (29.2%) undocumented infections. Forty-seven (9.9%) patients died in the ICU and 67 (14.2%) in hospital. Factors associated with respiratory infection were temperature (odds ratio [+1°C]=1.43, P=0.008) and blood neutrophils (1.07, P=0.002). Male sex (2.21, P=0.02) and blood neutrophils were associated with bacterial infection (1.06, P=0.04). In a multivariable analysis, pneumonia (cause-specific hazard=1.75, P=0.005), respiratory rate (1.17, P=0.04), arterial partial pressure of carbon-dioxide (1.08, P=0.04), and lactate (1.14, P=0.02) were associated with the need for invasive MV. Age (1.03, P=0.03), immunodeficiency (1.96, P=0.02), and altered performance status (1.78, P=0.002) were associated with hospital mortality. Conclusions Respiratory infections, 39.9% of which were bacterial, were the main cause of severe acute exacerbation of COPD. Body temperature and blood neutrophils were single markers of infection. Pneumonia was associated with the need for invasive mechanical ventilation but not with hospital mortality, as opposed to age, immunodeficiency, and altered performance status.
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Affiliation(s)
| | - Sylvain Diop
- Cardiothoracic Intensive Care Unit, Department of Anesthesiology, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Matthieu Jamme
- Service de Réanimation Polyvalente, Hôpital Privé de l’Ouest Parisien, Ramsay-Générale de Santé, Trappes, France
- CESP, INSERM U1018, Equipe Epidémiologie Clinique, Villejuif, France
| | - Stéphane Legriel
- Intensive Care Unit, Versailles Hospital, Le Chesnay, France
- University Paris-Saclay, UVSQ, INSERM, CESP, Team ”PsyDev”, Villejuif, France
| | - Alexis Ferré
- Intensive Care Unit, Versailles Hospital, Le Chesnay, France
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Westhoff M, Neumann P, Geiseler J, Bickenbach J, Arzt M, Bachmann M, Braune S, Delis S, Dellweg D, Dreher M, Dubb R, Fuchs H, Hämäläinen N, Heppner H, Kluge S, Kochanek M, Lepper PM, Meyer FJ, Neumann B, Putensen C, Schimandl D, Schönhofer B, Schreiter D, Walterspacher S, Windisch W. [Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]. Pneumologie 2023. [PMID: 37832578 DOI: 10.1055/a-2148-3323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.
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Affiliation(s)
- Michael Westhoff
- Klinik für Pneumologie, Lungenklinik Hemer - Zentrum für Pneumologie und Thoraxchirurgie, Hemer
| | - Peter Neumann
- Abteilung für Klinische Anästhesiologie und Operative Intensivmedizin, Evangelisches Krankenhaus Göttingen-Weende gGmbH
| | - Jens Geiseler
- Medizinische Klinik IV - Pneumologie, Beatmungs- und Schlafmedizin, Paracelsus-Klinik Marl, Marl
| | - Johannes Bickenbach
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen
| | - Michael Arzt
- Schlafmedizinisches Zentrum der Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg
| | - Martin Bachmann
- Klinik für Atemwegs-, Lungen- und Thoraxmedizin, Beatmungszentrum Hamburg-Harburg, Asklepios Klinikum Harburg, Hamburg
| | - Stephan Braune
- IV. Medizinische Klinik: Akut-, Notfall- und Intensivmedizin, St. Franziskus-Hospital, Münster
| | - Sandra Delis
- Klinik für Pneumologie, Palliativmedizin und Geriatrie, Helios Klinikum Emil von Behring GmbH, Berlin
| | - Dominic Dellweg
- Klinik für Innere Medizin, Pneumologie und Gastroenterologie, Pius-Hospital Oldenburg, Universitätsmedizin Oldenburg
| | - Michael Dreher
- Klinik für Pneumologie und Internistische Intensivmedizin, Uniklinik RWTH Aachen
| | - Rolf Dubb
- Akademie der Kreiskliniken Reutlingen GmbH, Reutlingen
| | - Hans Fuchs
- Zentrum für Kinder- und Jugendmedizin, Neonatologie und pädiatrische Intensivmedizin, Universitätsklinikum Freiburg
| | | | - Hans Heppner
- Klinik für Geriatrie und Geriatrische Tagesklinik Klinikum Bayreuth, Medizincampus Oberfranken Friedrich-Alexander-Universität Erlangen-Nürnberg, Bayreuth
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Matthias Kochanek
- Klinik I für Innere Medizin, Hämatologie und Onkologie, Universitätsklinikum Köln, Köln
| | - Philipp M Lepper
- Klinik für Innere Medizin V - Pneumologie, Allergologie und Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg
| | - F Joachim Meyer
- Lungenzentrum München - Bogenhausen-Harlaching) München Klinik gGmbH, München
| | - Bernhard Neumann
- Klinik für Neurologie, Donauisar Klinikum Deggendorf, und Klinik für Neurologie der Universitätsklinik Regensburg am BKH Regensburg, Regensburg
| | - Christian Putensen
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Bonn
| | - Dorit Schimandl
- Klinik für Pneumologie, Beatmungszentrum, Zentralklinik Bad Berka GmbH, Bad Berka
| | - Bernd Schönhofer
- Klinik für Innere Medizin, Pneumologie und Intensivmedizin, Evangelisches Klinikum Bethel, Universitätsklinikum Ost Westphalen-Lippe, Bielefeld
| | | | - Stephan Walterspacher
- Medizinische Klinik - Sektion Pneumologie, Klinikum Konstanz und Lehrstuhl für Pneumologie, Universität Witten-Herdecke, Witten
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Lehrstuhl für Pneumologie Universität Witten/Herdecke, Köln
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Krishnan A, Ellis P, Antoine-Pitterson P, Oakes A, Jones B, Turner A, Mukherjee R. Long-Term Mortality following Acute Noninvasive Ventilation for Obesity-Related Respiratory Failure: A Retrospective Single-Centre Study. Can Respir J 2023; 2023:5370197. [PMID: 37868785 PMCID: PMC10586910 DOI: 10.1155/2023/5370197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 08/25/2023] [Accepted: 10/05/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction Determinants of long-term mortality following acute hypercapnic respiratory failure have been extensively studied in patients with chronic obstructive pulmonary disease. However, respiratory failure due to obesity has not been studied to the same extent. This retrospective survey aims to identify whether admission pH is associated with long-term mortality in patients requiring acute noninvasive ventilation (NIV) for obesity-related respiratory failure (ORRF). Methods Records from April 2013 to March 2020 were accessed from a NIV quality database at an acute teaching hospital. Adults with hypercapnic ORRF requiring acute NIV were included. pH data were grouped by threshold (pH≤ and >7.25) and correlated with time from presentation to death; multivariable analysis was performed using Cox proportional hazards. Results A total of 277 acute NIV episodes were included. Two-year mortality was similar for patients in both pH categories. Univariable analysis identified pH ≤ 7.25 to increase risk of two-year mortality by 43%. However, multivariable analysis identified that pH was not a significant determinant of long-term mortality, although male sex, older age, and higher admission pCO2 increased the risk of death at two years by 76%, 3% per year of age, and 16% per 1 kPa of pCO2 increase, respectively. Conclusion Severity of hypercapnia on admission, male sex, and older age are associated with worse two-year mortality in patients requiring acute NIV for ORRF. There is scope for further analyses including investigating the role of domiciliary NIV in ORRF patients.
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Affiliation(s)
- Aditya Krishnan
- Institute of Applied Health Research, University of Birmingham, Birmingham, ENG, UK
| | - Paul Ellis
- Institute of Applied Health Research, University of Birmingham, Birmingham, ENG, UK
| | - Pearlene Antoine-Pitterson
- Department of Respiratory Medicine, Heartlands Hospital (Part of University Hospitals Birmingham), Birmingham, ENG, UK
| | - Amy Oakes
- Department of Respiratory Medicine, Heartlands Hospital (Part of University Hospitals Birmingham), Birmingham, ENG, UK
| | - Bethany Jones
- Department of Respiratory Medicine, Heartlands Hospital (Part of University Hospitals Birmingham), Birmingham, ENG, UK
| | - Alice Turner
- Institute of Applied Health Research, University of Birmingham, Birmingham, ENG, UK
- Department of Respiratory Medicine, Heartlands Hospital (Part of University Hospitals Birmingham), Birmingham, ENG, UK
| | - Rahul Mukherjee
- Department of Respiratory Medicine, Heartlands Hospital (Part of University Hospitals Birmingham), Birmingham, ENG, UK
- Institute of Clinical Sciences, University of Birmingham, Birmingham, ENG, UK
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5
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Feng X, Wang D, Pan Q, Yan M, Liu X, Shen Y, Fang L, Cai G, Ning G. Reinforcement Learning Model for Managing Noninvasive Ventilation Switching Policy. IEEE J Biomed Health Inform 2023; 27:4120-4130. [PMID: 37159312 DOI: 10.1109/jbhi.2023.3274568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Noninvasive ventilation (NIV) has been recognized as a first-line treatment for respiratory failure in patients with chronic obstructive pulmonary disease (COPD) and hypercapnia respiratory failure, which can reduce mortality and burden of intubation. However, during the long-term NIV process, failure to respond to NIV may cause overtreatment or delayed intubation, which is associated with increased mortality or costs. Optimal strategies for switching regime in the course of NIV treatment remain to be explored.For the goal of reducing 28-day mortality of the patients undergoing NIV, Double Dueling Deep Q Network (D3QN) of offline-reinforcement learning algorithm was adopted to develop an optimal regime model for making treatment decisions of discontinuing ventilation, continuing NIV, or intubation. The model was trained and tested using the data from Multi-Parameter Intelligent Monitoring in Intensive Care III (MIMIC-III) and evaluated by the practical strategies. Furthermore, the applicability of the model in majority disease subgroups (Catalogued by International Classification of Diseases, ICD) was investigated. Compared with physician's strategies, the proposed model achieved a higher expected return score (4.25 vs. 2.68) and its recommended treatments reduced the expected mortality from 27.82% to 25.44% in all NIV cases. In particular, for these patients finally received intubation in practice, if the model also supported the regime, it would warn of switching to intubation 13.36 hours earlier than clinicians (8.64 vs. 22 hours after the NIV treatment), granting a 21.7% reduction in estimated mortality. In addition, the model was applicable across various disease groups with distinguished achievement in dealing with respiratory disorders. The proposed model is promising to dynamically provide personalized optimal NIV switching regime for patients undergoing NIV with the potential of improving treatment outcomes.
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Schroeder T, Kruse JM, Piper SK, Goettfried K, Karaivanov S, Marcy F. The use of high-flow versus conventional oxygen therapy in addition to noninvasive ventilation in exacerbated COPD patients in the ICU: A retrospective cohort study in 351 patients. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2023. [DOI: 10.1016/j.tacc.2023.101228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
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Duan J, Yang J, Jiang L, Bai L, Hu W, Shu W, Wang K, Yang F. Prediction of noninvasive ventilation failure using the ROX index in patients with de novo acute respiratory failure. Ann Intensive Care 2022; 12:110. [PMID: 36469159 PMCID: PMC9723095 DOI: 10.1186/s13613-022-01085-7] [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: 08/22/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The ratio of SpO2/FiO2 to respiratory rate (ROX) index is commonly used to predict the failure of high-flow nasal cannula. However, its predictive power for noninvasive ventilation (NIV) failure is unclear. METHODS This was a secondary analysis of a multicenter prospective observational study, intended to update risk scoring. Patients with de novo acute respiratory failure were enrolled, but hypercapnic patients were excluded. The ROX index was calculated before treatment and after 1-2, 12, and 24 h NIV. Differences in predictive power for NIV failure using the ROX index, PaO2/FiO2, and PaO2/FiO2/respiratory rate were tested. RESULTS A total of 1286 patients with de novo acute respiratory failure were enrolled. Of these, 568 (44%) experienced NIV failure. Patients with NIV failure had a lower ROX index than those with NIV success. The rates of NIV failure were 92.3%, 70.5%, 55.3%, 41.1%, 35.1%, and 29.5% in patients with ROX index values calculated before NIV of ≤ 2, 2-4, 4-6, 6-8, 8-10, and > 10, respectively. Similar results were found when the ROX index was assessed after 1-2, 12, and 24 h NIV. The area under the receiver operating characteristics curve was 0.64 (95% CI 0.61-0.67) when the ROX index was used to predict NIV failure before NIV. It increased to 0.71 (95% CI 0.68-0.74), 0.74 (0.71-0.77), and 0.77 (0.74-0.80) after 1-2, 12, and 24 h NIV, respectively. The predictive power for NIV failure was similar for the ROX index and for the PaO2/FiO2. Likewise, no difference was found between the ROX index and the PaO2/FiO2/respiratory rate, except at the time point of 1-2 h NIV. CONCLUSIONS The ROX index has moderate predictive power for NIV failure in patients with de novo acute respiratory failure.
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Affiliation(s)
- Jun Duan
- grid.452206.70000 0004 1758 417XDepartment of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016 China
| | - Juhua Yang
- Department of Respiratory and Critical Care Medicine, The Chongqing Western Hospital, Chongqing, 400051 China
| | - Lei Jiang
- grid.452206.70000 0004 1758 417XDepartment of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016 China
| | - Linfu Bai
- grid.452206.70000 0004 1758 417XDepartment of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016 China
| | - Wenhui Hu
- grid.452206.70000 0004 1758 417XDepartment of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016 China
| | - Weiwei Shu
- grid.203458.80000 0000 8653 0555Department of Critical Care Medicine, Yongchuan Hospital of Chongqing Medical University, Yongchuan, Chongqing, 402160 China
| | - Ke Wang
- grid.412461.40000 0004 9334 6536Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010 China
| | - Fuxun Yang
- grid.54549.390000 0004 0369 4060Department of ICU, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, 32# W. Sec 2, 1st Ring Rd, Chengdu, 610072 China
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Duan J, Chen L, Liu X, Bozbay S, Liu Y, Wang K, Esquinas AM, Shu W, Yang F, He D, Chen Q, Wei B, Chen B, Li L, Tang M, Yuan G, Ding F, Huang T, Zhang Z, Tang Z, Han X, Jiang L, Bai L, Hu W, Zhang R, Mina B. An updated HACOR score for predicting the failure of noninvasive ventilation: a multicenter prospective observational study. Crit Care 2022; 26:196. [PMID: 35786223 PMCID: PMC9250742 DOI: 10.1186/s13054-022-04060-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 06/05/2022] [Indexed: 12/11/2022] Open
Abstract
Background Heart rate, acidosis, consciousness, oxygenation, and respiratory rate (HACOR) have been used to predict noninvasive ventilation (NIV) failure. However, the HACOR score fails to consider baseline data. Here, we aimed to update the HACOR score to take into account baseline data and test its predictive power for NIV failure primarily after 1–2 h of NIV. Methods A multicenter prospective observational study was performed in 18 hospitals in China and Turkey. Patients who received NIV because of hypoxemic respiratory failure were enrolled. In Chongqing, China, 1451 patients were enrolled in the training cohort. Outside of Chongqing, another 728 patients were enrolled in the external validation cohort. Results Before NIV, the presence of pneumonia, cardiogenic pulmonary edema, pulmonary ARDS, immunosuppression, or septic shock and the SOFA score were strongly associated with NIV failure. These six variables as baseline data were added to the original HACOR score. The AUCs for predicting NIV failure were 0.85 (95% CI 0.84–0.87) and 0.78 (0.75–0.81) tested with the updated HACOR score assessed after 1–2 h of NIV in the training and validation cohorts, respectively. A higher AUC was observed when it was tested with the updated HACOR score compared to the original HACOR score in the training cohort (0.85 vs. 0.80, 0.86 vs. 0.81, and 0.85 vs. 0.82 after 1–2, 12, and 24 h of NIV, respectively; all p values < 0.01). Similar results were found in the validation cohort (0.78 vs. 0.71, 0.79 vs. 0.74, and 0.81 vs. 0.76, respectively; all p values < 0.01). When 7, 10.5, and 14 points of the updated HACOR score were used as cutoff values, the probability of NIV failure was 25%, 50%, and 75%, respectively. Among patients with updated HACOR scores of ≤ 7, 7.5–10.5, 11–14, and > 14 after 1–2 h of NIV, the rate of NIV failure was 12.4%, 38.2%, 67.1%, and 83.7%, respectively. Conclusions The updated HACOR score has high predictive power for NIV failure in patients with hypoxemic respiratory failure. It can be used to help in decision-making when NIV is used. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04060-7.
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Affiliation(s)
- Jun Duan
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, China.
| | - Lijuan Chen
- Department of Respiratory and Critical Care Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaoyi Liu
- Department of Critical Care Medicine, Dazhou Central Hospital, Dazhou, Shichuan, China
| | - Suha Bozbay
- Intensive Care, Istanbul University Cerrahpasa-Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Yuliang Liu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, China
| | - Ke Wang
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | | | - Weiwei Shu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, China.,Department of Critical Care Medicine, Yongchuan Hospital of Chongqing Medical University, Yongchuan, Chongqing, China
| | - Fuxun Yang
- Department of ICU, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Dehua He
- Department of Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Qimin Chen
- Department of Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Bilin Wei
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Baixu Chen
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Liucun Li
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Manyun Tang
- Department of Traditional Medicine and Rehabilitation, The Chest Hospital of Xi'an, Xi'an, China
| | - Guodan Yuan
- Department of Critical Care Medicine, Chonqing Public Health Medical Center, Chongqing, China
| | - Fei Ding
- Department of Respiratory and Critical Care Medicine, Bishan Hospital of Chongqing Medical University, Chongqing, China
| | - Tao Huang
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhongxing Zhang
- Department of Respiratory and Critical Care Medicine, Affiliated Hospital of Chongqing Three Gorges Medical College, Chongqing, China
| | - ZhiJun Tang
- Department of Respiratory and Critical Care Medicine, The People's Hospital of Nanchuan, Chongqing, China
| | - Xiaoli Han
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, China
| | - Lei Jiang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, 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, 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, China
| | - Rui Zhang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, China
| | - Bushra Mina
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Northwell Health, Lenox Hill Hospital, New York, NY, USA
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9
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Farhadi N, Varpaei HA, Fattah Ghazi S, Amoozadeh L, Mohammadi M. Deciding When to Intubate a COVID-19 Patient. Anesth Pain Med 2022; 12:e123350. [PMID: 36818481 PMCID: PMC9923339 DOI: 10.5812/aapm-123350] [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: 02/17/2022] [Revised: 03/29/2022] [Accepted: 04/16/2022] [Indexed: 11/16/2022] Open
Abstract
Background The SARS-CoV-2 pandemic is one of the most significant challenges for healthcare providers, particularly in the critical care setting. The timing of intubation in COVID-19 patients seems to be challenging. Therefore, we aimed to investigate how it may have a survival benefit, and we determined which clinical characteristics were associated with outcomes. Methods This cross-sectional study was conducted in the Imam Khomeini Hospital Complex. We randomly selected patients admitted to intensive care units and, based on intubation status, categorized them into three subgroups (early, late, and not intubated). Early intubation is defined as intubation within 48 hours of ICU admission, and late intubation is defined as intubation after 48 hours of ICU admission. Results Early-intubated patients were more likely to have dyspnea than late-intubated patients, and late-intubated patients had a higher mean heart rate than early-intubated patients. The neutrophil/lymphocyte ratio was significantly (P < 0.05) lower in not-intubated patients than in other patients. There was no difference in NLR between early- and late-intubated patients. Mean serum creatine phosphokinase and troponin I levels were higher in late-intubated patients than in early- and not-intubated patients. Early-intubated patients had a lower ROX index than late-intubated patients. Patients with higher scores of APACHE 2, respiratory rates, and neutrophil to lymphocyte ratio were more likely to be intubated. Increasing APACHE and SOFA scores were associated with decreased odds of survival. Conclusions There were no statistically significant differences in total mortality between early- and late-intubated patients. APACHE 2 scores, NLR, RR, and history of ischemic heart disease are some of the appropriate predictors of intubation. Higher respiratory rates (tachypnea) can be an indicator of early intubation. The ROX index is one of the most sensitive and capable tools for predicting intubation. Intubation status is a potent predictor of in-hospital mortality.
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Affiliation(s)
| | - Hesam Aldin Varpaei
- Department of Nursing and Midwifery, Islamic Azad University Tehran Medical Sciences, Tehran, Iran
- Department of Surgical Nursing, Faculty of Nursing, Near East University, Nicosia, Cyprus
| | - Samrand Fattah Ghazi
- Department of Anesthesiology and Critical Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Laya Amoozadeh
- Department of Anesthesiology and Critical Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Mohammadi
- Department of Anesthesiology and Critical Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
- Corresponding Author: General ICU, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.
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10
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Elsayed AA, Neanaa EHM, Beshey BN. Diaphragmatic impairment as a predictor of invasive ventilation in acute exacerbation of chronic obstructive pulmonary disease patients. EGYPTIAN JOURNAL OF ANAESTHESIA 2022. [DOI: 10.1080/11101849.2022.2085975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Amr Abdalla Elsayed
- Critical Care Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | - Bassem Nashaat Beshey
- Critical Care Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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11
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Carrillo-Aleman L, Carrasco-Gónzalez E, Araújo MJ, Guia M, Alonso-Fernández N, Renedo-Villarroya A, López-Gómez L, Higon-Cañigral A, Sanchez-Nieto JM, Carrillo-Alcaraz A. Is hypocapnia a risk factor for non-invasive ventilation failure in cardiogenic acute pulmonary edema? J Crit Care 2022; 69:153991. [DOI: 10.1016/j.jcrc.2022.153991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 01/02/2022] [Accepted: 01/14/2022] [Indexed: 11/26/2022]
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12
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Physiological effects of high-intensity versus low-intensity noninvasive positive pressure ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease: a randomised controlled trial. Ann Intensive Care 2022; 12:41. [PMID: 35587843 PMCID: PMC9120318 DOI: 10.1186/s13613-022-01018-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 05/06/2022] [Indexed: 11/22/2022] Open
Abstract
Background High-intensity noninvasive positive pressure ventilation (NPPV) is a novel ventilatory approach to maximally decreasing elevated arterial carbon dioxide tension (PaCO2) toward normocapnia with stepwise up-titration of pressure support. We tested whether high-intensity NPPV is more effective than low-intensity NPPV at decreasing PaCO2, reducing inspiratory effort, alleviating dyspnoea, improving consciousness, and improving NPPV tolerance in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Methods In this physiological, randomised controlled trial, we assigned 24 AECOPD patients to undergo either high-intensity NPPV (n = 12) or low-intensity NPPV (n = 12). The primary outcome was PaCO2 24 h after randomisation. Secondary outcomes included gas exchange other than PaCO2 24 h after randomisation, inspiratory effort, dyspnoea, consciousness, NPPV tolerance, patient–ventilator asynchrony, cardiac function, ventilator-induced lung injury (VILI), and NPPV-related adverse events. Results Inspiratory positive airway pressure 24 h after randomisation was significantly higher (28.0 [26.0–28.0] vs. 15.5 [15.0–17.5] cmH2O; p = 0.000) and NPPV duration within the first 24 h was significantly longer (21.8 ± 2.1 vs. 15.3 ± 4.7 h; p = 0.001) in the high-intensity NPPV group. PaCO2 24 h after randomisation decreased to 54.0 ± 11.6 mmHg in the high-intensity NPPV group but only decreased to 67.4 ± 10.6 mmHg in the low-intensity NPPV group (p = 0.008). Inspiratory oesophageal pressure swing, oesophageal pressure–time product (PTPes)/breath, PTPes/min, and PTPes/L were significantly lower in the high-intensity group. Accessory muscle use and dyspnoea score 24 h after randomisation were also significantly lower in that group. No significant between-groups differences were observed in consciousness, NPPV tolerance, patient–ventilator asynchrony, cardiac function, VILI, or NPPV-related adverse events. Conclusions High-intensity NPPV is more effective than low-intensity NPPV at decreasing elevated PaCO2, reducing inspiratory effort, and alleviating dyspnoea in AECOPD patients. Trial registration: ClinicalTrials.gov (NCT04044625; registered 5 August 2019). Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01018-4.
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13
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Kumle B, Michael M, Wermke A, Schmitz C, Hammer N, Kümpers P, Pin M, Bernhard M. ["B problems" in non-traumatic resuscitation room management]. Notf Rett Med 2022; 26:4-14. [PMID: 35287271 PMCID: PMC8908747 DOI: 10.1007/s10049-022-00990-5] [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] [Accepted: 01/25/2022] [Indexed: 02/02/2023]
Abstract
In the primary survey of resuscitation room management in critically ill nontrauma patients, the ABCDE (airway, breathing, circulation, disability, exposure) approach is used for immediate recognition and treatment of life-threatening conditions. "B problems" are associated with respiratory failure and require immediate treatment. The pathogenesis is diverse, especially in the nontrauma resuscitation room. Clinical examination, emergency sonography and knowledge of oxygenation techniques and ventilation are important components of diagnosis and therapy. Standardized procedures and regular training in the emergency room are of fundamental importance.
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Affiliation(s)
- Bernhard Kumle
- Klinik für Akut- und Notfallmedizin, Schwarzwald-Baar Klinikum, Klinikstr. 11, 78052 Villingen-Schwenningen, Deutschland
- Medical Life Science, Campus Schwenningen, Furtwangen University, Schwenningen, Deutschland
| | - Mark Michael
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
| | - Andreas Wermke
- Klinik für Akut- und Notfallmedizin, Schwarzwald-Baar Klinikum, Klinikstr. 11, 78052 Villingen-Schwenningen, Deutschland
| | - Christoph Schmitz
- Interdisziplinäres Notfallzentrum, Kantonsspital Schaffhausen, Schaffhausen, Schweiz
| | - Niels Hammer
- Institut für Klinische und Makroskopische Anatomie, Medizinische Universität Graz, Graz, Österreich
- Klinik für Orthopädie und Unfallchirurgie, Universität Leipzig, Leipzig, Deutschland
- Abteilung Medizintechnik, Fraunhofer-Institut für Werkstoff- und Umformtechnik, Dresden, Deutschland
| | - Philipp Kümpers
- Medizinische Klinik D, Allgemeine Innere Medizin und Notaufnahme sowie Nieren- und Hochdruckkrankheiten und Rheumatologie, Universitätsklinikum Münster, Münster, Deutschland
| | - Martin Pin
- Zentrale Notaufnahme, Florence-Nightingale-Krankenhaus, Düsseldorf, Deutschland
| | - Michael Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
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14
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Park S. Treatment of acute respiratory failure: noninvasive mechanical ventilation. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2022. [DOI: 10.5124/jkma.2022.65.3.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Noninvasive ventilation (NIV) has been an important strategy to support patients with respiratory failure, while preventing complications assorted with invasive mechanical ventilation. Physicians need to be aware of the various roles of NIV and the challenges encountered in clinical practice.Current Concepts: Traditionally, the application of NIV has been well-known to be associated with reduced mortality in patients with chronic obstructive pulmonary disease (COPD) or acute pulmonary edema and those suffering from acute respiratory failure. However, despite some positive results of NIV treatment in patients with de novo hypoxemic respiratory failure such as acute pneumonia or acute respiratory distress syndrome, NIV failure (or delayed intubation) can have deleterious effects on patients outcomes. Besides, the aggravation of lung injury should also be taken into consideration when applied to patients exhibiting high respiratory drive. Nonetheless, NIV has potential for wide applications in various clinical situations such as facilitation of ventilator weaning, post-operative respiratory failure, or palliative treatment.Discussion and Conclusion: In addition to the strong evidence in patients with acute respiratory failure due to COPD or acute pulmonary edema, the NIV treatment can be potentially used for various clinical conditions. However, compared to European countries, the prevalence of NIV use continues to remain lower in South Korea. Nevertheless, when applied in appropriately selected patients in a timely manner, NIV treatment can be associated with improved patient outcomes.
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15
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Liang N, Wang C, Duan J, Xie X, Wang Y. Efficacy prediction of noninvasive ventilation failure based on the stacking ensemble algorithm and autoencoder. BMC Med Inform Decis Mak 2022; 22:27. [PMID: 35101003 PMCID: PMC8805397 DOI: 10.1186/s12911-022-01767-z] [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: 08/02/2021] [Accepted: 01/25/2022] [Indexed: 11/21/2022] Open
Abstract
Background Early prediction of noninvasive ventilation failure is of great significance for critically ill ICU patients to escalate or change treatment. Because clinically collected data are highly time-series correlated and have imbalanced classes, it is difficult to accurately predict the efficacy of noninvasive ventilation for severe patients. This paper aims to precisely predict the failure probability of noninvasive ventilation before or in the early stage (1–2 h) of using it on patients and to explain the correlation of the predicted results. Methods In this paper, we proposed a SMSN model (stacking and modified SMOTE algorithm of prediction of noninvasive ventilation failure). In the feature generation stage, we used an autoencoder algorithm based on long short-term memory (LSTM) to automatically extract time series features. In the modelling stage, we adopted a modified SMOTE algorithm to address imbalanced classes, and three classifiers (logistic regression, random forests, and Catboost) were combined with the stacking ensemble algorithm to achieve high prediction accuracy. Results Data from 2495 patients were used to train the SMSN model. Among them, 80% of 2495 patients (1996 patients) were randomly selected as the training set, and 20% of these patients (499 patients) were chosen as the testing set. The F1 of the proposed SMSN model was 79.4%, and the accuracy was 88.2%. Compared with the traditional logistic regression algorithm, the F1 and accuracy were improved by 4.7% and 1.3%, respectively. Conclusions Through SHAP analysis, oxygenation index, pH and H1FIO2 collected after 1 h of noninvasive ventilation were the most relevant features affecting the prediction.
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Affiliation(s)
- Na Liang
- College of Computer Science, Chongqing University, Chongqing, 400000, People's Republic of China
| | - Chengliang Wang
- College of Computer Science, Chongqing University, Chongqing, 400000, People's Republic of China.
| | - Jun Duan
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People's Republic of China.
| | - Xin Xie
- College of Computer Science, Chongqing University, Chongqing, 400000, People's Republic of China
| | - Yu Wang
- Chongqing Health Statistics Information Center, Chongqing, 401120, People's Republic of China
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16
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Bräunlich J, Köppe-Bauernfeind N, Petroff D, Franke A, Wirtz H. Nasal high-flow compared to non-invasive ventilation in treatment of acute acidotic hypercapnic exacerbation of chronic obstructive pulmonary disease-protocol for a randomized controlled noninferiority trial (ELVIS). Trials 2022; 23:28. [PMID: 35012620 PMCID: PMC8744018 DOI: 10.1186/s13063-021-05978-z] [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: 05/19/2021] [Accepted: 12/23/2021] [Indexed: 11/29/2022] Open
Abstract
Background Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) have a major negative impact on health status, rates of hospitalization, readmission, disease progression and mortality. Non-invasive ventilation (NIV) is the standard therapy for hypercapnic acidotic respiratory failure in AECOPD. Despite its beneficial effects, NIV is often poorly tolerated (11–34 % failure rate). An increasing number of studies have documented a beneficial effect of nasal high-flow (NHF) in acute hypercapnia. We designed a prospective, randomized, multi-centre, open label, non-inferiority trial to compare treatment failure in nasal NHF vs NIV in patients with acidotic hypercapnic AECOPD. Methods The study will be conducted in about 35 sites in Germany. Patients with hypercapnic AECOPD with respiratory acidosis (pH < 7.35) will be randomized 1:1 to NIV or NHF. The primary outcome is the combined endpoint of intubation, treatment failure or death at 72 h. The switch from one to the other device marks a device failure but acts as a rescue treatment in absence of intubation criteria. A sample size of 720 was calculated to have 80% power for showing that NHF is non-inferior to NIV with a margin of 8 percentage points. Linear regression will be used for the confirmatory analysis. Discussion If NHF is shown to be non-inferior to NIV in acidotic hypercapnic AECOPD, it could become an important alternative treatment. Trial registration ClinicalTrials.gov, NCT04881409, Registered on May 11, 2021 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05978-z.
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Affiliation(s)
- Jens Bräunlich
- University of Leipzig, Leipzig, Germany. .,Hospital Emden, Bolardusstrasse 20, 26721, Emden, Germany.
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17
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Azzi M, Aboab J, Alviset S, Ushmorova D, Ferreira L, Ioos V, Memain N, Issoufaly T, Lermuzeaux M, Laine L, Serbouti R, Silva D. Extracorporeal CO 2 removal in acute exacerbation of COPD unresponsive to non-invasive ventilation. BMJ Open Respir Res 2021; 8:8/1/e001089. [PMID: 34893522 PMCID: PMC8666884 DOI: 10.1136/bmjresp-2021-001089] [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: 08/25/2021] [Accepted: 11/02/2021] [Indexed: 11/05/2022] Open
Abstract
Background The gold-standard treatment for acute exacerbation of chronic obstructive pulmonary disease (ae-COPD) is non-invasive ventilation (NIV). However, NIV failures may be observed, and invasive mechanical ventilation (IMV) is required. Extracorporeal CO₂ removal (ECCO₂R) devices can be an alternative to intubation. The aim of the study was to assess ECCO₂R effectiveness and safety. Methods Patients with consecutive ae-COPD who experienced NIV failure were retrospectively assessed over two periods of time: before and after ECCO₂R device implementation in our ICU in 2015 (Xenios AG). Results Both groups (ECCO₂R: n=26, control group: n=25) were comparable at baseline, except for BMI, which was significantly higher in the ECCO₂R group (30 kg/m² vs 25 kg/m²). pH and PaCO₂ significantly improved in both groups. The mean time on ECCO₂R was 5.4 days versus 27 days for IMV in the control group. Four patients required IMV in the ECCO₂R group, of whom three received IMV after ECCO₂R weaning. Seven major bleeding events were observed with ECCO₂R, but only three led to premature discontinuation of ECCO₂R. Eight cases of ventilator-associated pneumonia were observed in the control group. Mean time spent in the ICU and mean hospital stay in the ECCO₂R and control groups were, respectively, 18 vs 30 days, 29 vs 49 days, and the 90-day mortality rates were 15% vs 28%. Conclusions ECCO₂R was associated with significant improvement of pH and PaCO₂ in patients with ae-COPD failing NIV therapy. It also led to avoiding intubation in 85% of cases, with low complication rates. Trial registration number ClinicalTrials.gov, NCT04882410. Date of registration 12 May 2021, retrospectively registered. https://www.clinicaltrials.gov/ct2/show/NCT04882410.
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Affiliation(s)
- Mathilde Azzi
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Jerome Aboab
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Sophie Alviset
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Daria Ushmorova
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Luis Ferreira
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Vincent Ioos
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Nathalie Memain
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Tazime Issoufaly
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Mathilde Lermuzeaux
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Laurent Laine
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Rita Serbouti
- Medical Affairs, Fresenius Medical Care France SAS, Fresnes, Île-de-France, France
| | - Daniel Silva
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
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Tonetti T, Pisani L, Cavalli I, Vega ML, Maietti E, Filippini C, Nava S, Ranieri VM. Extracorporeal carbon dioxide removal for treatment of exacerbated chronic obstructive pulmonary disease (ORION): study protocol for a randomised controlled trial. Trials 2021; 22:718. [PMID: 34666820 PMCID: PMC8524839 DOI: 10.1186/s13063-021-05692-w] [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: 04/12/2021] [Accepted: 10/07/2021] [Indexed: 02/08/2023] Open
Abstract
Background Hypercapnic exacerbations are severe complications of chronic obstructive pulmonary disease (COPD), characterized by negative impact on prognosis, quality of life and healthcare costs. The present standard of care for acute exacerbations of COPD is non-invasive ventilation; when it fails, the use of invasive mechanical ventilation is inevitable, but is associated with extremely poor prognosis. Extracorporeal circuits designed to remove CO2 (ECCO2R) may enhance the efficacy of NIV to remove CO2 and avoid the worsening of respiratory acidosis, which inevitably leads to failure of non-invasive ventilation. Although the use of ECCO2R for acute exacerbations of COPD is steadily increasing, solid evidence on its efficacy and safety is scarce, thus the need for a randomized controlled trial. Methods multicenter randomized controlled unblinded clinical trial including 284 (142 per arm) patients with acute hypercapnic respiratory failure caused by exacerbation of COPD, requiring respiratory support with NIV. The primary outcome is event free survival at 28 days, a composite outcome defined by survival in absence of prolonged mechanical ventilation, severe hypoxemia, septic shock and second episode of COPD exacerbation. Secondary outcomes are incidence of endotracheal intubation and tracheostomy, intensive care and hospital length-of-stay and 90-day mortality. Discussion Acute exacerbations of COPD represent a significant burden in terms of prognosis, quality of life and healthcare costs. Lack definite evidence despite increasing use of ECCO2R justifies a randomized trial to evaluate whether patients with acute hypercapnic acidosis not responsive to NIV should undergo invasive mechanical ventilation (with all serious related risks) or be treated with ECCO2R to avoid invasive ventilation but be exposed to possible adverse events of ECCO2R. Owing to its pragmatic nature, sample size and composite primary outcome, this trial aims at providing valuable answers to relevant questions for clinical treatment of acute exacerbations of COPD. Trial registration ClinicalTrials.gov, NCT04582799. Registered 12 October 2020, . Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05692-w.
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Affiliation(s)
- Tommaso Tonetti
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy.,Anesthesia and Intensive Care Medicine, Sant'Orsola Research Hospital, Bologna, Italy
| | - Lara Pisani
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum - University of Bologna, Bologna, Italy.,Pneumology and Respiratory Critical Care, Sant'Orsola Research Hospital, Bologna, Italy
| | - Irene Cavalli
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy.,Anesthesia and Intensive Care Medicine, Sant'Orsola Research Hospital, Bologna, Italy
| | - Maria Laura Vega
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum - University of Bologna, Bologna, Italy.,Pneumology and Respiratory Critical Care, Sant'Orsola Research Hospital, Bologna, Italy
| | - Elisa Maietti
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Claudia Filippini
- Dipartimento di Scienze Chirurgiche, Università di Torino, Torino, Italy
| | - Stefano Nava
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum - University of Bologna, Bologna, Italy.,Pneumology and Respiratory Critical Care, Sant'Orsola Research Hospital, Bologna, Italy
| | - V Marco Ranieri
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy. .,Anesthesia and Intensive Care Medicine, Sant'Orsola Research Hospital, Bologna, Italy.
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19
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Söyler Y, Akın Kabalak P, Saral Öztürk Z, Uğurman F. Comparing effectiveness of intelligent volume-assured pressure support (iVAPS) vs bi-level positive airway pressure spontaneous/timed (BPAP S/T) for hypercapnic respiratory failure in chronic obstructive pulmonary disease. Int J Clin Pract 2021; 75:e14595. [PMID: 34228853 DOI: 10.1111/ijcp.14595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/01/2021] [Accepted: 06/10/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND AIM Intelligent volume-assured pressure support (iVAPS) is a relatively new hybrid mode of non-invasive ventilation (NIV). There is still limited evidence for iVAPS. The aim of this study was to compare the effectiveness of iVAPS to that of bi-level positive airway pressure spontaneous/timed (BPAP S/T) in patients with acute hypercapnic respiratory failure or acute-on-chronic hypercapnic respiratory failure caused by acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in the emergency department. MATERIAL AND METHODS This was an observational, retrospective study. Eighty-two patients with hypercapnic respiratory failure caused by AECOPD, who were admitted to our emergency department, were analysed. Arterial blood gas (ABG) parameters, length of hospital stay and rate of intensive care unit (ICU) admission were compared between iVAPS and BPAP S/T. RESULTS A total of 82 patients (26 females, 56 males, mean age 68.26 ± 11.63 years) who were treated with iVAPS (N = 26) or BPAP S/T (N = 56) were enrolled. There were no significant differences between two modes with respect to demographics such as age, gender, presence of comorbidity, usage of long-term oxygen therapy or NIV, and the baseline ABG parameters. The presence of pneumonia was significantly higher in BPAP S/T (P = .01). The rate of ICU admission was 26.9% in iVAPS vs 25% in BPAP S/T. The mean length of hospital stay was 11.5 ± 12.3 days in iVAPS and 9.7 ± 7.4 days in BPAP S/T (P = .53). The mean values of ABG parameters at the 1st and 24th hours of NIV therapy did not differ in both groups. CONCLUSION Both modes were similarly effective in the management of appropriately selected patients with hypercapnic respiratory failure caused by AECOPD. Hence, we underline that NIV mode selection in the emergency department should be performed in line with experiences of clinicians/institutions and accessibility of ventilator devices/modes.
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Affiliation(s)
- Yasemin Söyler
- Chest Diseases Department, Ankara Atatürk Chest Diseases and Thoracic Surgery Research and Training Hospital, Ankara, Turkey
| | - Pınar Akın Kabalak
- Chest Diseases Department, Ankara Atatürk Chest Diseases and Thoracic Surgery Research and Training Hospital, Ankara, Turkey
| | - Zeynep Saral Öztürk
- Emergency Medicine Department, Ankara Atatürk Chest Diseases and Thoracic Surgery Research and Training Hospital, Ankara, Turkey
| | - Feza Uğurman
- Chest Diseases Department, Ankara Atatürk Chest Diseases and Thoracic Surgery Research and Training Hospital, Ankara, Turkey
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20
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Loued L, Saad AB, Migaou A, Fahem N, Kaddoussi R, Joobeur S, Mhamed SC, Rouatbi N. [Factors predicting the need for invasive mechanical ventilation in patients with chronic obstructive pulmonary disease (COPD)]. Pan Afr Med J 2021; 39:119. [PMID: 34512855 PMCID: PMC8396382 DOI: 10.11604/pamj.2021.39.119.27514] [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: 12/20/2020] [Accepted: 05/15/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction the use of invasive mechanical ventilation (IMV) in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) constitutes a negative turning point in the progression of the disease. The purpose of this study is to determine factors predicting the need for IMV in AECOPD. Methods we conducted a retrospective study by reviewing the medical records of patients with AECOPD hospitalized in our Department over a 18-year period (2000-2017). We compared 2 groups: G1: patients with AECOPD undergoing at least one IMV and G2: patients who had never undergone IMV following AECOPD. Results the study included 1152 patients with COPD: 133 in the G1 group (11.5%), and 1019 in the G2 group (88.5%). G1 patients were more symptomatic (p < 0.001), with more severe bronchial obstruction (p < 0.001). G1 patients had more exacerbations (p < 0.001), more hospitalizations and a higher need for non-invasive ventilation (NIV) (p < 0.001). Similarly, G1 patients more often developed chronic respiratory failure (p < 0.001) and had significantly lower survival rates. Independent risk factors associated with IMV were hypercapnia and decreased pH (in patients with severe AECOPD), a history of NIV, and chronic respiratory failure (CRF). Conclusion respiratory function impairment, the severity of exacerbation and the need for NIV in a previous episode are factors predicting the need for IMV and poor outcomes.
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Affiliation(s)
- Lobna Loued
- Service de Pneumologie et d´Allergologie, Hôpital Universitaire Fattouma Bourguiba, Monastir, Rue 1er juin, 5000 Monastir, Monastir, Tunisie
| | - Ahmed Ben Saad
- Service de Pneumologie et d´Allergologie, Hôpital Universitaire Fattouma Bourguiba, Monastir, Rue 1er juin, 5000 Monastir, Monastir, Tunisie
| | - Asma Migaou
- Service de Pneumologie et d´Allergologie, Hôpital Universitaire Fattouma Bourguiba, Monastir, Rue 1er juin, 5000 Monastir, Monastir, Tunisie
| | - Nesrine Fahem
- Service de Pneumologie et d´Allergologie, Hôpital Universitaire Fattouma Bourguiba, Monastir, Rue 1er juin, 5000 Monastir, Monastir, Tunisie
| | - Rania Kaddoussi
- Service de Pneumologie et d´Allergologie, Hôpital Universitaire Fattouma Bourguiba, Monastir, Rue 1er juin, 5000 Monastir, Monastir, Tunisie
| | - Samah Joobeur
- Service de Pneumologie et d´Allergologie, Hôpital Universitaire Fattouma Bourguiba, Monastir, Rue 1er juin, 5000 Monastir, Monastir, Tunisie
| | - Saousen Cheikh Mhamed
- Service de Pneumologie et d´Allergologie, Hôpital Universitaire Fattouma Bourguiba, Monastir, Rue 1er juin, 5000 Monastir, Monastir, Tunisie
| | - Naceur Rouatbi
- Service de Pneumologie et d´Allergologie, Hôpital Universitaire Fattouma Bourguiba, Monastir, Rue 1er juin, 5000 Monastir, Monastir, Tunisie
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21
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Feng X, Pan S, Yan M, Shen Y, Liu X, Cai G, Ning G. Dynamic prediction of late noninvasive ventilation failure in intensive care unit using a time adaptive machine model. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 208:106290. [PMID: 34298473 DOI: 10.1016/j.cmpb.2021.106290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 07/09/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Noninvasive ventilation (NIV) failure is strongly associated with poor prognosis. Nowadays, plenty of mature studies have been proposed to predict early NIV failure (within 48 hours of NIV), however, the prediction for late NIV failure (after 48 hours of NIV) lacks sufficient research. Late NIV failure delays intubation resulting in the increasing mortality of the patients. Therefore, it is of great significance to expeditiously predict the late NIV failure. In order to dynamically predict late NIV failure, we proposed a Time Updated Light Gradient Boosting Machine (TULightGBM) model. MATERIAL AND METHODS In this work, 5653 patients undergoing NIV over 48 hours were extracted from the database of Medical Information Mart for Intensive Care Ⅲ (MIMIC-Ⅲ) for model construction. The TULightGBM model consists of a series of sub-models which learn clinical information from updating data within 48 hours of NIV and integrates the outputs of the sub-models by the dynamic attention mechanism to predict late NIV failure. The performance of the proposed TULightGBM model was assessed by comparison with common models of logistic regression (LR), random forest (RF), LightGBM, eXtreme gradient boosting (XGBoost), artificial neural network (ANN), and long short-term memory (LSTM). RESULTS The TULightGBM model yielded prediction results at 8, 16, 24, 36, and 48 hours after the start of the NIV with dynamic AUC values of 0.8323, 0.8435, 0.8576, 0.8886, and 0.9123, respectively. Furthermore, the sensitivity, specificity, and accuracy of the TULightGBM model were 0.8207, 0.8164, and 0.8184, respectively. The proposed model achieved superior performance over other tested models. CONCLUSIONS The TULightGBM model is able to dynamically predict the late NIV failure with high accuracy and offer potential decision support for clinical practice.
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Affiliation(s)
- Xue Feng
- Department of Biomedical Engineering, Zhejiang University, 38 Zheda Road, Hangzhou 310027, China.
| | - Su Pan
- Department of Biomedical Engineering, Zhejiang University, 38 Zheda Road, Hangzhou 310027, China
| | - Molei Yan
- Department of Intensive Care Unit, Zhejiang Hospital, 12 Lingyin Road, Hangzhou 310013, China
| | - Yanfei Shen
- Department of Intensive Care Unit, Zhejiang Hospital, 12 Lingyin Road, Hangzhou 310013, China
| | - Xiaoqing Liu
- Deepwise AI LAB, 8 Haidian Road, Beijng 100089, China
| | - Guolong Cai
- Department of Intensive Care Unit, Zhejiang Hospital, 12 Lingyin Road, Hangzhou 310013, China.
| | - Gangmin Ning
- Department of Biomedical Engineering, Zhejiang University, 38 Zheda Road, Hangzhou 310027, China.
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22
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Ghazala L, Hatipoğlu U, Devnani T, Covert E, Hanks J, Edwards K, Macmurdo M, Li M, Wang X, Duggal A. Duration of noninvasive ventilation is not a predictor of clinical outcomes in patients with acute exacerbation of COPD and respiratory failure. CANADIAN JOURNAL OF RESPIRATORY THERAPY : CJRT = REVUE CANADIENNE DE LA THERAPIE RESPIRATOIRE : RCTR 2021; 57:113-118. [PMID: 34447880 PMCID: PMC8372872 DOI: 10.29390/cjrt-2021-021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Purpose Acute exacerbation of chronic obstructive pulmonary disease (COPD) is a major cause of mortality and morbidity. Noninvasive ventilation (NIV) is proven to be effective in the majority of patients with acute exacerbation COPD (AECOPD) complicated with respiratory failure. NIV could be lifesaving but also can delay mechanical ventilation if its efficacy is not assessed in a timely manner. In this study, we analyzed potential predictors of NIV failure in AECOPD in a tertiary medical intensive care unit (MICU). In particular, we wondered whether duration of NIV among those who eventually failed was associated with poor outcomes. Methods A retrospective review of consecutive patients with a primary diagnosis of AECOPD requiring NIV admitted to the MICU was conducted for the period between 2012 and 2017. Baseline data included demographics, APACHE III score, albumin level, blood lactate, and blood gas elements. Additional chart review was performed to collect NIV setting parameters on presentation to the MICU. Clinical outcome variables collected included outcome and duration of NIV, duration of invasive mechanical ventilation, MICU length of stay, hospital length of stay, and in-hospital mortality. Multivariate regression analysis was performed to determine independent variables associated with clinical outcomes. Results There were 370 patients who met the inclusion criteria; 53.2% were male. Mean age was 64.7 ± 11.2 years old. Mean baseline FEV1 was 34 ±17% of predicted. Patients had mean pH of 7.20 ± 0.54 and PaCO2 of 70.3 ± 28.7 on presentation; 323 patients (87.3%) were successfully weaned off NIV; 47 patients (12.7%) failed NIV and required invasive mechanical ventilation. APACHE III score was higher among patients who failed NIV (68.3±18.9 versus 48.8± 15.2, P < 0.001). In the subset of 47 patients who failed NIV requiring intubation, duration of NIV was 25.0 ± 58.8 h. Multivariate regression analysis yielded a model consisting of APACHE III score and body mass index as predictive variables for NIV failure (C-statistic = 0.809). Duration of NIV was not associated with worse clinical outcomes among patients who failed NIV. Conclusions NIV is successful in preventing invasive mechanical ventilation in majority of patients with acute respiratory failure due to COPD. Patients with worse clinical status at presentation are more likely to fail NIV and require mechanical ventilation. In the subgroup of patients who failed NIV, duration of NIV prior to intubation was not associated with poor clinical outcomes.
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Affiliation(s)
- Laith Ghazala
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.,Trillium Health Partners, Mississauga, ON, Canada
| | - Umur Hatipoğlu
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tanya Devnani
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Erin Covert
- Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Justin Hanks
- Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | | | - Maeve Macmurdo
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Manshi Li
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Xiaofeng Wang
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Abhijit Duggal
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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23
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Elshof J, Duiverman ML, Wijkstra PJ. The NIVO score: can it help to improve noninvasive ventilation in daily clinical practice? Eur Respir J 2021; 58:58/2/2100336. [PMID: 34385288 DOI: 10.1183/13993003.00336-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 02/03/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Judith Elshof
- Dept of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
| | - Marieke L Duiverman
- Dept of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
| | - Peter J Wijkstra
- Dept of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
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24
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Hartley T, Lane ND, Steer J, Elliott MW, Sovani MP, Curtis HJ, Fuller ER, Murphy PB, Shrikrishna D, Lewis KE, Ward NR, Turnbull CD, Hart N, Bourke SC. The Noninvasive Ventilation Outcomes (NIVO) score: prediction of in-hospital mortality in exacerbations of COPD requiring assisted ventilation. Eur Respir J 2021; 58:13993003.04042-2020. [PMID: 33479109 PMCID: PMC8358235 DOI: 10.1183/13993003.04042-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 12/29/2020] [Indexed: 11/05/2022]
Abstract
Introduction Acute exacerbations of COPD (AECOPD) complicated by acute (acidaemic) hypercapnic respiratory failure (AHRF) requiring ventilation are common. When applied appropriately, ventilation substantially reduces mortality. Despite this, there is evidence of poor practice and prognostic pessimism. A clinical prediction tool could improve decision making regarding ventilation, but none is routinely used. Methods Consecutive patients admitted with AECOPD and AHRF treated with assisted ventilation (principally noninvasive ventilation) were identified in two hospitals serving differing populations. Known and potential prognostic indices were identified a priori. A prediction tool for in-hospital death was derived using multivariable regression analysis. Prospective, external validation was performed in a temporally separate, geographically diverse 10-centre study. The trial methodology adhered to TRIPOD (Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis) recommendations. Results Derivation cohort: n=489, in-hospital mortality 25.4%; validation cohort: n=733, in-hospital mortality 20.1%. Using six simple categorised variables (extended Medical Research Council Dyspnoea score 1–4/5a/5b, time from admission to acidaemia >12 h, pH <7.25, presence of atrial fibrillation, Glasgow coma scale ≤14 and chest radiograph consolidation), a simple scoring system with strong prediction of in-hospital mortality is achieved. The resultant Noninvasive Ventilation Outcomes (NIVO) score had area under the receiver operating curve of 0.79 and offers good calibration and discrimination across stratified risk groups in its validation cohort. Discussion The NIVO score outperformed pre-specified comparator scores. It is validated in a generalisable cohort and works despite the heterogeneity inherent to both this patient group and this intervention. Potential applications include informing discussions with patients and their families, aiding treatment escalation decisions, challenging pessimism and comparing risk-adjusted outcomes across centres. The NIVO score was created to predict in-hospital mortality in exacerbations of COPD requiring assisted ventilation. Prospective validation under real-world conditions in 10 UK hospitals shows it easily outperforms existing alternative scores.https://bit.ly/3oKMZdI
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Affiliation(s)
- Tom Hartley
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Department of Respiratory Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Nicholas D Lane
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Department of Respiratory Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - John Steer
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Department of Respiratory Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Mark W Elliott
- Respiratory Medicine, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Milind P Sovani
- Department of Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Helen Jane Curtis
- Respiratory and Critical Care Medicine, Gateshead Health NHS Foundation Trust, Gateshead, UK
| | - Elizabeth R Fuller
- Department of Respiratory Medicine, South Tyneside and Sunderland NHS Foundation Trust, South Shields, UK.,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Patrick B Murphy
- Lane Fox Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Dinesh Shrikrishna
- Respiratory Medicine, Musgrove Park Hospital, Somerset NHS Foundation Trust, Taunton, UK
| | - Keir E Lewis
- Respiratory Medicine, Hywel Dda University Health Board, Llanelli, UK.,School of Medicine, University of Swansea, Swansea, UK
| | - Neil R Ward
- Respiratory Medicine, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Chris D Turnbull
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicholas Hart
- Lane Fox Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Stephen C Bourke
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Department of Respiratory Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
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25
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Alnajada AA, Blackwood B, Mobrad A, Akhtar A, Pavlov I, Shyamsundar M. High flow nasal oxygen for acute type two respiratory failure: a systematic review. F1000Res 2021; 10:482. [PMID: 34621510 PMCID: PMC8453312 DOI: 10.12688/f1000research.52885.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2021] [Indexed: 04/04/2024] Open
Abstract
Background: Acute type two respiratory failure (AT2RF) is characterized by high carbon dioxide levels (PaCO 2 >6kPa). Non-invasive ventilation (NIV), the current standard of care, has a high failure rate. High flow nasal therapy (HFNT) has potential additional benefits such as CO 2 clearance, the ability to communicate and comfort. The primary aim of this systematic review is to determine whether HFNT in AT2RF improves 1) PaCO 2, 2) clinical and patient-centred outcomes and 3) to assess potential harms. Methods: We searched EMBASE, MEDLINE and CENTRAL (January 1999-January 2021). Randomised controlled trials (RCTs) and cohort studies comparing HFNT with low flow nasal oxygen (LFO) or NIV were included. Two authors independently assessed studies for eligibility, data extraction and risk of bias. We used Cochrane risk of bias tool for RCTs and Ottawa-Newcastle scale for cohort studies. Results: From 727 publications reviewed, four RCTs and one cohort study (n=425) were included. In three trials of HFNT vs NIV, comparing PaCO 2 (kPa) at last follow-up time point, there was a significant reduction at four hours (1 RCT; HFNT median 6.7, IQR 5.6 - 7.7 vs NIV median 7.6, IQR 6.3 - 9.3) and no significant difference at 24-hours or five days. Comparing HFNT with LFO, there was no significant difference at 30-minutes. There was no difference in intubation or mortality. Conclusions: This review identified a small number of studies with low to very low certainty of evidence. A reduction of PaCO 2 at an early time point of four hours post-intervention was demonstrated in one small RCT. Significant limitations of the included studies were lack of adequately powered outcomes and clinically relevant time-points and small sample size. Accordingly, systematic review cannot recommend the use of HFNT as the initial management strategy for AT2RF and trials adequately powered to detect clinical and patient-relevant outcomes are urgently warranted.
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Affiliation(s)
- Asem Abdulaziz Alnajada
- Wellcome-Wolfson Institute For Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute For Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Abdulmajeed Mobrad
- Prince Sultan college for emergency medical services, King Saud University, Riyadh, Saudi Arabia
| | - Adeel Akhtar
- Emergency department, Royal Victoria Hospital, Belfast, Belfast, UK
| | - Ivan Pavlov
- Emergency department, Hôpital de Verdun, Montréal, Canada
| | - Murali Shyamsundar
- Wellcome-Wolfson Institute For Experimental Medicine, Queen's University Belfast, Belfast, UK
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26
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Alnajada AA, Blackwood B, Mobrad A, Akhtar A, Pavlov I, Shyamsundar M. High flow nasal oxygen for acute type two respiratory failure: a systematic review. F1000Res 2021; 10:482. [PMID: 34621510 PMCID: PMC8453312.2 DOI: 10.12688/f1000research.52885.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Acute type two respiratory failure (AT2RF) is characterized by high carbon dioxide levels (PaCO 2 >6kPa). Non-invasive ventilation (NIV), the current standard of care, has a high failure rate. High flow nasal therapy (HFNT) has potential additional benefits such as CO 2 clearance, the ability to communicate and comfort. The primary aim of this systematic review is to determine whether HFNT in AT2RF improves 1) PaCO 2, 2) clinical and patient-centred outcomes and 3) to assess potential harms. Methods: We searched EMBASE, MEDLINE and CENTRAL (January 1999-January 2021). Randomised controlled trials (RCTs) and cohort studies comparing HFNT with low flow nasal oxygen (LFO) or NIV were included. Two authors independently assessed studies for eligibility, data extraction and risk of bias. We used Cochrane risk of bias tool for RCTs and Ottawa-Newcastle scale for cohort studies. Results: From 727 publications reviewed, four RCTs and one cohort study (n=425) were included. In three trials of HFNT vs NIV, comparing PaCO 2 (kPa) at last follow-up time point, there was a significant reduction at four hours (1 RCT; HFNT median 6.7, IQR 5.6 - 7.7 vs NIV median 7.6, IQR 6.3 - 9.3) and no significant difference at 24-hours or five days. Comparing HFNT with LFO, there was no significant difference at 30-minutes. There was no difference in intubation or mortality. Conclusions: This review identified a small number of studies with low to very low certainty of evidence. A reduction of PaCO 2 at an early time point of four hours post-intervention was demonstrated in one small RCT. Significant limitations of the included studies were lack of adequately powered outcomes and clinically relevant time-points and small sample size. Accordingly, systematic review cannot recommend the use of HFNT as the initial management strategy for AT2RF and trials adequately powered to detect clinical and patient-relevant outcomes are urgently warranted.
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Affiliation(s)
- Asem Abdulaziz Alnajada
- Wellcome-Wolfson Institute For Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute For Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Abdulmajeed Mobrad
- Prince Sultan college for emergency medical services, King Saud University, Riyadh, Saudi Arabia
| | - Adeel Akhtar
- Emergency department, Royal Victoria Hospital, Belfast, Belfast, UK
| | - Ivan Pavlov
- Emergency department, Hôpital de Verdun, Montréal, Canada
| | - Murali Shyamsundar
- Wellcome-Wolfson Institute For Experimental Medicine, Queen's University Belfast, Belfast, UK
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27
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MacLeod M, Papi A, Contoli M, Beghé B, Celli BR, Wedzicha JA, Fabbri LM. Chronic obstructive pulmonary disease exacerbation fundamentals: Diagnosis, treatment, prevention and disease impact. Respirology 2021; 26:532-551. [PMID: 33893708 DOI: 10.1111/resp.14041] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In chronic obstructive pulmonary disease (COPD), exacerbations (ECOPD), characterized by an acute deterioration in respiratory symptoms, are fundamental events impacting negatively upon disease progression, comorbidities, wellbeing and mortality. ECOPD also represent the largest component of the socioeconomic burden of COPD. ECOPDs are currently defined as acute worsening of respiratory symptoms that require additional therapy. Definitions that require worsening of dyspnoea and sputum volume/purulence assume that acute infections, especially respiratory viral infections, and/or exposure to pollutants are the main cause of ECOPD. But other factors may contribute to ECOPD, such as the exacerbation of other respiratory diseases and non-respiratory diseases (e.g., heart failure, thromboembolism). The complexity of worsening dyspnoea has suggested a need to improve the definition of ECOPD using objective measurements such as blood counts and C-reactive protein to improve accuracy of diagnosis and a personalized approach to management. There are three time points when we can intervene to improve outcomes: acutely, to attenuate the length and severity of an established exacerbation; in the aftermath, to prevent early recurrence and readmission, which are common, and in the long-term, establishing preventative measures that reduce the risk of future events. Acute management includes interventions such as corticosteroids or antibiotics and measures to support the respiratory system, including non-invasive ventilation (NIV). Current therapies are broad and better understanding of clinical phenotypes and biomarkers may help to establish a more tailored approach, for example in relation to antibiotic prescription. Other unmet needs include effective treatment for viruses, which commonly cause exacerbations. Preventing early recurrence and readmission to hospital is important and the benefits of interventions such as antibiotics or anti-inflammatories in this period are not established. Domiciliary NIV in those patients who are persistently hypercapnic following discharge and pulmonary rehabilitation can have a positive impact. For long-term prevention, inhaled therapy is key. Dual bronchodilators reduce exacerbation frequency but in patients with continuing exacerbations, triple therapy should be considered, especially if blood eosinophils are elevated. Other options include phosphodiesterase inhibitors and macrolide antibiotics. ECOPD are a key component of the assessment of COPD severity and future outcomes (quality of life, hospitalisations, health care resource utilization, mortality) and are a central component in pharmacological management decisions. Targeted therapies directed towards specific pathways of inflammation are being explored in exacerbation prevention, and this is a promising avenue for future research.
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Affiliation(s)
- Mairi MacLeod
- National Heart and Lung Institute, Imperial College, London, UK
| | - Alberto Papi
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Marco Contoli
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Bianca Beghé
- Department of Respiratory Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | | | | | - Leonardo M Fabbri
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy.,Department of Respiratory Diseases, University of Modena and Reggio Emilia, Modena, Italy
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28
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Stefan MS, Priya A, Pekow PS, Steingrub JS, Hill NS, Lagu T, Raghunathan K, Bhat AG, Lindenauer PK. A scoring system derived from electronic health records to identify patients at high risk for noninvasive ventilation failure. BMC Pulm Med 2021; 21:52. [PMID: 33546651 PMCID: PMC7863252 DOI: 10.1186/s12890-021-01421-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/28/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To develop and validate a clinical risk prediction score for noninvasive ventilation (NIV) failure defined as intubation after a trial of NIV in non-surgical patients. DESIGN Retrospective cohort study of a multihospital electronic health record database. PATIENTS Non-surgical adult patients receiving NIV as the first method of ventilation within two days of hospitalization. MEASUREMENT Primary outcome was intubation after a trial of NIV. We used a non-random split of the cohort based on year of admission for model development and validation. We included subjects admitted in years 2010-2014 to develop a risk prediction model and built a parsimonious risk scoring model using multivariable logistic regression. We validated the model in the cohort of subjects hospitalized in 2015 and 2016. MAIN RESULTS Of all the 47,749 patients started on NIV, 11.7% were intubated. Compared with NIV success, those who were intubated had worse mortality (25.2% vs. 8.9%). Strongest independent predictors for intubation were organ failure, principal diagnosis group (substance abuse/psychosis, neurological conditions, pneumonia, and sepsis), use of invasive ventilation in the prior year, low body mass index, and tachypnea. The c-statistic was 0.81, 0.80 and 0.81 respectively, in the derivation, validation and full cohorts. We constructed three risk categories of the scoring system built on the full cohort; the median and interquartile range of risk of intubation was: 2.3% [1.9%-2.8%] for low risk group; 9.3% [6.3%-13.5%] for intermediate risk category; and 35.7% [31.0%-45.8%] for high risk category. CONCLUSIONS In patients started on NIV, we found that in addition to factors known to be associated with intubation, neurological, substance abuse, or psychiatric diagnoses were highly predictive for intubation. The prognostic score that we have developed may provide quantitative guidance for decision-making in patients who are started on NIV.
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Affiliation(s)
- Mihaela S Stefan
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.
- Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.
| | - Aruna Priya
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Penelope S Pekow
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
- School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA, USA
| | - Jay S Steingrub
- Division of Pulmonary and Critical Care, Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Nicholas S Hill
- Division of Pulmonary and Critical Care, Tufts University School of Medicine, Boston, MA, USA
| | - Tara Lagu
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
- Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Karthik Raghunathan
- Division of Veterans Affairs, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Anusha G Bhat
- Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
- Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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Sprooten RTM, Rohde GGU, Janssen MTHF, Cobben NAM, Wouters EFM, Franssen FME. Predictors for long-term mortality in COPD patients requiring non-invasive positive pressure ventilation for the treatment of acute respiratory failure. THE CLINICAL RESPIRATORY JOURNAL 2020; 14:1144-1152. [PMID: 32780940 PMCID: PMC7756413 DOI: 10.1111/crj.13251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 03/31/2020] [Accepted: 08/05/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The effectiveness of non-invasive mechanical ventilation (NIV) in the management of COPD patients suffering from acute respiratory failure (ARF) as a consequence of exacerbation of the disease, is well established. However, data on long-term outcomes and their predictors, including the individual response to NIV, are scarce. OBJECTIVES To investigate predictors for short- and long-term mortality in this study population. METHODS A retrospective cohort study was performed including all patients admitted to the Medium Respiratory Care Unit of Maastricht University Medical Center in Maastricht, the Netherlands, with hospitalized exacerbation of COPD (H-ECOPD) with ARF requiring NIV for the first time between January 2009 and December 2011. An extensive number of potential predictors of outcomes, including the response to NIV, were determined on admission and during hospitalization. Univariate and multivariate logistic regression was used for statistical analysis. RESULTS Seventy-eight consecutive patients with moderate to severe COPD (mean age 71.0 ± 10.7 years; 48.7% males) were included; In-hospital, 1-year and 2-year mortality rates were 14.1%, 43.6% and 56.4%, respectively. Independent risk factors for 2-year mortality were: advanced age (odds ratio(OR) 1.025; confidence interval (CI) 1.002-1.049; P = 0.037), prolonged NIV use more than 8 days (OR:1.054;CI:1.006-1.104; P = 0.027) and no successful response to NIV (OR:2.392;CI:1.297-4.413; P = 0.005). CONCLUSION Patients with an H-ECOPD requiring NIV for the first time, constitute a severely ill patient group with high in-hospital and 2-year mortality. This study identified advanced age, NIV use more than 8 days and unsuccessful response to NIV as clinical important independent predictors for long-term mortality.
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Affiliation(s)
- Roy T. M. Sprooten
- Department of Respiratory MedicineMaastricht University Medical CenterMaastrichtThe Netherlands
- NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtThe Netherlands
| | - Gernot G. U. Rohde
- Department of Respiratory Medicine, Medical Clinic 1University HospitalFrankfurtGermany
| | - Marlou T. H. F. Janssen
- Department of Respiratory MedicineMaastricht University Medical CenterMaastrichtThe Netherlands
| | - Nicolle A. M. Cobben
- Department of Respiratory MedicineMaastricht University Medical CenterMaastrichtThe Netherlands
| | - Emiel F. M. Wouters
- Department of Respiratory MedicineMaastricht University Medical CenterMaastrichtThe Netherlands
- NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtThe Netherlands
- CIROHornThe Netherlands
| | - Frits M. E. Franssen
- Department of Respiratory MedicineMaastricht University Medical CenterMaastrichtThe Netherlands
- NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtThe Netherlands
- CIROHornThe Netherlands
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Risk Factors Associated with Late Failure of Noninvasive Ventilation in Patients with Chronic Obstructive Pulmonary Disease. Can Respir J 2020; 2020:8885464. [PMID: 33123301 PMCID: PMC7582075 DOI: 10.1155/2020/8885464] [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: 08/19/2020] [Revised: 09/25/2020] [Accepted: 09/29/2020] [Indexed: 11/26/2022] Open
Abstract
Background Risk factors for noninvasive ventilation (NIV) failure after initial success are not fully clear in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). Methods Patients who received NIV beyond 48 h due to acute exacerbation of COPD were enrolled. However, we excluded those whose pH was higher than 7.35 or PaCO2 was less than 45 mmHg which was measured before NIV. Late failure of NIV was defined as patients required intubation or died during NIV after initial success. Results We enrolled 291 patients in this study. Of them, 48 (16%) patients experienced late NIV failure (45 received intubation and 3 died during NIV). The median time from initiation of NIV to intubation was 4.8 days (IQR: 3.4–8.1). Compared with the data collected at initiation of NIV, the heart rate, respiratory rate, pH, and PaCO2 significantly improved after 1–2 h of NIV both in the NIV success and late failure of NIV groups. Nosocomial pneumonia (odds ratio (OR) = 75, 95% confidence interval (CI): 11–537), heart rate at initiation of NIV (1.04, 1.01–1.06 beat per min), and pH at 1–2 h of NIV (2.06, 1.41–3.00 per decrease of 0.05 from 7.35) were independent risk factors for late failure of NIV. In addition, the Glasgow coma scale (OR = 0.50, 95% CI: 0.34–0.73 per one unit increase) and PaO2/FiO2 (0.992, 0.986–0.998 per one unit increase) were independent protective factors for late failure of NIV. In addition, patients with late failure of NIV had longer ICU stay (median 9.5 vs. 6.6 days) and higher hospital mortality (92% vs. 3%) compared with those with NIV success. Conclusions Nosocomial pneumonia; heart rate at initiation of NIV; and consciousness, acidosis, and oxygenation at 1–2 h of NIV were associated with late failure of NIV in patients with COPD exacerbation. And, late failure of NIV was associated with increased hospital mortality.
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Liengswangwong W, Yuksen C, Thepkong T, Nakasint P, Jenpanitpong C. Early detection of non-invasive ventilation failure among acute respiratory failure patients in the emergency department. BMC Emerg Med 2020; 20:80. [PMID: 33028230 PMCID: PMC7542761 DOI: 10.1186/s12873-020-00376-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 10/01/2020] [Indexed: 11/24/2022] Open
Abstract
Background Non-invasive mechanical ventilation (NIV) has become an alternative to an invasive artificial airway for the management of acute respiratory failure (ARF). NIV failure causes delayed intubation, which eventually has been associated with increased morbidity and mortality. This study aimed to develop the clinical scoring system of NIV failure in ARF patients. Methods This study was a diagnostic, retrospectively cross-sectional, and exploratory model at the Emergency Medicine Department in Ramathibodi Hospital between February 2017 and December 2017. We included all of the acute respiratory failure patients aged > 18 years and received non-invasive ventilation (NIV). Clinical factors associated with NIV failure were recorded. The predictive model and prediction score for NIV failure were developed by multivariable logistic regression analysis. Result A total of 329 acute respiratory failure patients have received NIV success (N = 237) and failure (N = 92). This study showed that NIV failure was associated with heart rate > 110 bpm, systolic BP < 110 mmHg, SpO2 < 90%, arterial pH < 7.30 and serum lactate. The clinical scores were classified into three groups: low, moderate, and high. Conclusion We suggested that the novel clinical scoring of the NIV failure in this study may use as a good predictor for NIV failure in the emergency room.
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Affiliation(s)
- W Liengswangwong
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270, Rama 6 Road, Phayathai, Ratchathewi, Bangkok, 10400, Thailand
| | - C Yuksen
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270, Rama 6 Road, Phayathai, Ratchathewi, Bangkok, 10400, Thailand.
| | - T Thepkong
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270, Rama 6 Road, Phayathai, Ratchathewi, Bangkok, 10400, Thailand
| | - P Nakasint
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270, Rama 6 Road, Phayathai, Ratchathewi, Bangkok, 10400, Thailand
| | - C Jenpanitpong
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270, Rama 6 Road, Phayathai, Ratchathewi, Bangkok, 10400, Thailand
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Heili-Frades S, Minguez P, Mahillo Fernández I, Jiménez Hiscock L, Santos A, Heili Frades D, Carballosa de Miguel MDP, Fernández Ormaechea I, Álvarez Suárez L, Naya Prieto A, González Mangado N, Peces-Barba Romero G. Patient Management Assisted by a Neural Network Reduces Mortality in an Intermediate Care Unit. Arch Bronconeumol 2020; 56:564-570. [DOI: 10.1016/j.arbres.2019.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/24/2019] [Accepted: 11/03/2019] [Indexed: 10/25/2022]
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Oxygen Therapy and Noninvasive Ventilation in Chronic Obstructive Pulmonary Disease. Clin Chest Med 2020; 41:529-545. [DOI: 10.1016/j.ccm.2020.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Gungor S, Mocin OY, Tuncay E, Aksoy E, Goksenoglu NC, Ocakli B, Irmak I, Salturk C, Adiguzel N, Karakurt Z. Risk factors of unfavorable outcomes in chronic obstructive pulmonary disease patients treated with noninvasive ventilation for acute hypercapnic respiratory failure. CLINICAL RESPIRATORY JOURNAL 2020; 14:1083-1089. [PMID: 32762016 DOI: 10.1111/crj.13245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 07/03/2020] [Accepted: 07/31/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND-AIM Noninvasive mechanical ventilation (NIV) failure rate is reported to be 5%-60% of intensive care unit (ICU) patients. Despite all precautions and well-known reasons, the risk factors of NIV failure are unclear for chronic obstructive pulmonary disease (COPD) with acute respiratory failure (ARF). The aim of this study was to examine risk factors for NIV failure in COPD patients with ARF, other than well defined. METHODS The retrospective cohort study was done in ICU of a chest disease hospital. All consecutive COPD patients with hypercapnic ARF were enrolled in study. Demographics, comorbidities, arterial blood gases, reasons of ARF and length of ICU stay were recorded. NIV success was defined as discharge from ICU and NIV failure was defined as need for intubation or died during NIV. Patients were grouped into; NIV failure and success. The groups were compared and NIV failure risk factors were analyzed. RESULTS About 265 NIV success and 142 NIV failure patients were enrolled into the study. Logistic regression test showed the risk factors for NIV failure; higher APACHE-II (≥ 29) (OR:11.71, CI95%4.39-31.18, P < 0.001), culture positivity (OR:7.59, CI95%3.21-17.92, P < 0.001), sepsis (OR:6.53 CI95%3.59-11.85, P < 0.001) and pneumonia (OR:3.71 CI95%0.60-2.02, P < 0.043) significantly. COPD patients using home-based NIV had less risk for NIV failure (OR: 0.49 CI95%0.28-0.87, P < 0.014). CONCLUSIONS APACHE II ≥ 29 score, culture positivity, sepsis and pneumonia are the risk factors for NIV failure in COPD patients with ARF. COPD patients previously on home-based NIV showed half times less risk for NIV failure.
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Affiliation(s)
- Sinem Gungor
- Department of Pulmonary Diseases, Health Sciences University Sureyyapasa Pulmonary Disease and Pulmonary Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ozlem Yazicioglu Mocin
- Department of Pulmonary Diseases, Health Sciences University Sureyyapasa Pulmonary Disease and Pulmonary Surgery Training and Research Hospital, Istanbul, Turkey
| | - Eylem Tuncay
- Department of Pulmonary Diseases, Health Sciences University Sureyyapasa Pulmonary Disease and Pulmonary Surgery Training and Research Hospital, Istanbul, Turkey
| | - Emine Aksoy
- Department of Pulmonary Diseases, Health Sciences University Sureyyapasa Pulmonary Disease and Pulmonary Surgery Training and Research Hospital, Istanbul, Turkey
| | - Nezihe Ciftaslan Goksenoglu
- Department of Pulmonary Diseases, Health Sciences University Sureyyapasa Pulmonary Disease and Pulmonary Surgery Training and Research Hospital, Istanbul, Turkey
| | - Birsen Ocakli
- Department of Pulmonary Diseases, Health Sciences University Sureyyapasa Pulmonary Disease and Pulmonary Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ilim Irmak
- Hacettepe University Medical Faculty, Department of Pulmonary Diseases, Ankara, Turkey
| | - Cuneyt Salturk
- Yeni Yüzyıl University Medical Faculty, Department of Pulmonary Diseases, Istanbul, Turkey
| | - Nalan Adiguzel
- Department of Pulmonary Diseases, Health Sciences University Sureyyapasa Pulmonary Disease and Pulmonary Surgery Training and Research Hospital, Istanbul, Turkey
| | - Zuhal Karakurt
- Department of Pulmonary Diseases, Health Sciences University Sureyyapasa Pulmonary Disease and Pulmonary Surgery Training and Research Hospital, Istanbul, Turkey
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Predictive Factors for Failure of Noninvasive Ventilation in Adult Intensive Care Unit: A Retrospective Clinical Study. Can Respir J 2020; 2020:1324348. [PMID: 32831978 PMCID: PMC7421696 DOI: 10.1155/2020/1324348] [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: 05/30/2020] [Revised: 06/30/2020] [Accepted: 07/16/2020] [Indexed: 11/18/2022] Open
Abstract
Background Noninvasive ventilation (NIV) has been reported to be beneficial for patients with acute respiratory failure in intensive care unit (ICU); however, factors that influence the clinical outcome of NIV were unclarified. We aim to determine the factors that predict the failure of NIV in critically ill patients with acute respiratory failure (ARF). Setting. Adult mixed ICU in a medical university affiliated hospital. Patients and Methods. A retrospective clinical study using data from critical adult patients with initial NIV admitted to ICU in the period August 2016 to November 2017. Failure of NIV was regarded as patients needing invasive ventilation. Logistic regression was employed to determine the risk factor(s) for NIV, and a predictive model for NIV outcome was set up using risk factors. Results Of 101 included patients, 50 were unsuccessful. Although more than 20 variables were associated with NIV failure, multivariate logistic regression demonstrated that only ideal body weight (IBW) (OR 1.110 (95%1.027-1.201), P=0.009), the maximal heart rate during NIV period (HR-MAX) (OR 1.024 (1.004-1.046), P=0.021), the minimal respiratory rate during NIV period (RR-MIN) (OR 1.198(1.051-1.365), P=0.007), and the highest body temperature during NIV period (T-MAX) (OR 1.838(1.038-3.252), P=0.037) were independent risk factors for NIV failure. We set up a predictive model based on these independent risk factors, whose area under the receiver operating characteristic curve (AUROC) was 0.783 (95% CI: 0.676-0.899, P < 0.001), and the sensitivity and specificity of model were 68.75% and 71.43%, respectively, with the optimal cut-off value of 0.4863. Conclusion IBW, HR-MAX, RR-MIN, and T-MAX were associated with NIV failure in patients with ARF. A predictive model based on the risk factors could help to discriminate patients who are vulnerable to NIV failure.
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Sharma R, Suri JC, Ramakrishnan N, Mani RK, Khilnani GC, Sidhu US. Guidelines for noninvasive ventilation in acute respiratory failure. Indian J Crit Care Med 2020. [DOI: 10.5005/ijccm-17-s1-42] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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37
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Ferrer M, Torres A. Noninvasive Ventilation and High-Flow Nasal Therapy Administration in Chronic Obstructive Pulmonary Disease Exacerbations. Semin Respir Crit Care Med 2020; 41:786-797. [PMID: 32725614 DOI: 10.1055/s-0040-1712101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Noninvasive ventilation (NIV) is considered to be the standard of care for the management of acute hypercapnic respiratory failure in patients with chronic obstructive pulmonary disease exacerbation. It can be delivered safely in any dedicated setting, from emergency rooms to high dependency or intensive care units and wards. NIV helps improving dyspnea and gas exchange, reduces the need for endotracheal intubation, and morbidity and mortality rates. It is therefore recognized as the gold standard in this condition. High-flow nasal therapy helps improving ventilatory efficiency and reducing the work of breathing in patients with severe chronic obstructive pulmonary disease. Early studies indicate that some patients with acute hypercapnic respiratory failure can be managed with high-flow nasal therapy, but more information is needed before specific recommendations for this therapy can be made. Therefore, high-flow nasal therapy use should be individualized in each particular situation and institution, taking into account resources, and local and personal experience with all respiratory support therapies.
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Affiliation(s)
- Miquel Ferrer
- Respiratory Intensive and Intermediate Care Unit, Department of Pneumology, Respiratory Institute, Hospital Clínic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Antoni Torres
- Respiratory Intensive and Intermediate Care Unit, Department of Pneumology, Respiratory Institute, Hospital Clínic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
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Hospach I, Goldstein J, Harenski K, Laffey JG, Pouchoulin D, Raible M, Votteler S, Storr M. In vitro characterization of PrismaLung+: a novel ECCO 2R device. Intensive Care Med Exp 2020; 8:14. [PMID: 32405714 PMCID: PMC7221037 DOI: 10.1186/s40635-020-00301-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 04/01/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Invasive mechanical ventilation is lifesaving in the setting of severe acute respiratory failure but can cause ventilation-induced lung injury. Advances in extracorporeal CO2 removal (ECCO2R) technologies may facilitate more protective lung ventilation in acute respiratory distress syndrome, and enable earlier weaning and/or avoid invasive mechanical ventilation entirely in chronic obstructive pulmonary disease exacerbations. We evaluated the in vitro CO2 removal capacity of the novel PrismaLung+ ECCO2R device compared with two existing gas exchangers. METHODS The in vitro CO2 removal capacity of the PrismaLung+ (surface area 0.8 m2, Baxter) was compared with the PrismaLung (surface area 0.35 m2, Baxter) and A.L.ONE (surface area 1.35 m2, Eurosets) devices, using a closed-loop bovine blood-perfused extracorporeal circuit. The efficacy of each device was measured at varying pCO2 inlet (pinCO2) levels (45, 60, and 80 mmHg) and blood flow rates (QB) of 200-450 mL/min; the PrismaLung+ and A.L.ONE devices were also tested at a QB of 600 mL/min. The amount of CO2 removed by each device was assessed by measurement of the CO2 infused to maintain circuit equilibrium (CO2 infusion method) and compared with measured CO2 concentrations in the inlet and outlet of the CO2 removal device (blood gas analysis method). RESULTS The PrismaLung+ device performed similarly to the A.L.ONE device, with both devices demonstrating CO2 removal rates ~ 50% greater than the PrismaLung device. CO2 removal rates were 73 ± 4.0, 44 ± 2.5, and 72 ± 1.9 mL/min, for PrismaLung+, PrismaLung, and A.L.ONE, respectively, at QB 300 mL/min and pinCO2 45 mmHg. A Bland-Altman plot demonstrated that the CO2 infusion method was comparable to the blood gas analysis method for calculating CO2 removal. The resistance to blood flow across the test device, as measured by pressure drop, varied as a function of blood flow rate, and was greatest for PrismaLung and lowest for the A.L.ONE device. CONCLUSIONS The newly developed PrismaLung+ performed more effectively than PrismaLung, with performance of CO2 removal comparable to A.L.ONE at the flow rates tested, despite the smaller membrane surface area of PrismaLung+ versus A.L.ONE. Clinical testing of PrismaLung+ is warranted to further characterize its performance.
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Affiliation(s)
- Ingeborg Hospach
- Baxter International, Research and Development, Holger-Crafoord-Str. 26, 72379, Hechingen, Germany
| | - Jacques Goldstein
- Baxter World Trade SPRL, Acute Therapies Global, Braine-l'Alleud, Belgium
| | - Kai Harenski
- Baxter, Baxter Deutschland GmbH, Unterschleissheim, Germany
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, NUI Galway, Galway, Ireland
| | | | - Manuela Raible
- Baxter International, Research and Development, Holger-Crafoord-Str. 26, 72379, Hechingen, Germany
| | - Stefanie Votteler
- Baxter International, Research and Development, Holger-Crafoord-Str. 26, 72379, Hechingen, Germany
| | - Markus Storr
- Baxter International, Research and Development, Holger-Crafoord-Str. 26, 72379, Hechingen, Germany.
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Fubini PE, Suppan L. Prehospital reversal of profound respiratory acidosis and hypercapnic coma by non-invasive ventilation: a report of two cases. Int J Emerg Med 2020; 13:22. [PMID: 32380952 PMCID: PMC7206709 DOI: 10.1186/s12245-020-00284-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/26/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In chronic obstructive pulmonary disease (COPD) patients with acute respiratory failure (ARF), non-invasive ventilation (NIV) is generally recommended and has proven its benefits by reducing endotracheal intubation (ETI) rates, intensive care unit (ICU) admissions, complications, and mortality. Choosing between immediate ETI or NIV trial is often difficult when such patients present with an altered mental status. Some guidelines recommend avoiding NIV when consciousness is impaired given the risk of aspiration, and some authors suggest that a pH < 7.25 is highly predictive of NIV failure. Though clinical response to a well-adjusted NIV treatment can be both swift and spectacular, these contraindications probably encourage physicians to proceed to immediate ETI. Some studies indeed report that NIV was not even considered in as many as 60% of patients who might have benefited from this therapy, though ETI related complications might have been avoided had NIV been successfully applied. CASE PRESENTATION We report two cases of ARF in COPD patients who were successfully treated by NIV in prehospital setting and avoided ETI despite contraindications (altered mental status with a Glasgow Coma Scale < 8) and failure risk factors (severe respiratory acidosis with pH < 7.25). CONCLUSION In COPD patients presenting ARF, NIV trial could be considered even when relative contraindications such as an altered level of consciousness or a severe respiratory acidosis are present.
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Affiliation(s)
- P E Fubini
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and Faculty of Medicine University of Geneva, CH-1211, Geneva, Switzerland.
| | - L Suppan
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and Faculty of Medicine University of Geneva, CH-1211, Geneva, Switzerland
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Kong CW, Wilkinson TM. Predicting and preventing hospital readmission for exacerbations of COPD. ERJ Open Res 2020; 6:00325-2019. [PMID: 32420313 PMCID: PMC7211949 DOI: 10.1183/23120541.00325-2019] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 02/06/2020] [Indexed: 12/17/2022] Open
Abstract
More than a third of patients hospitalised for acute exacerbation of COPD are readmitted to hospital within 90 days. Healthcare professionals and service providers are expected to collaboratively drive efforts to improve hospital readmission rates, which can be challenging due to the lack of clear consensus and guidelines on how best to predict and prevent readmissions. This review identifies these risk factors, highlighting the contribution of multimorbidity, frailty and poor socioeconomic status. Predictive models of readmission that address the multifactorial nature of readmissions and heterogeneity of the disease are reviewed, recognising that in an era of precision medicine, in-depth understanding of the intricate biological mechanisms that heighten the risk of COPD exacerbation and re-exacerbation is needed to derive modifiable biomarkers that can stratify accurately the highest risk groups for targeted treatment. We evaluate conventional and emerging strategies to reduce these potentially preventable readmissions. Here, early recognition of exacerbation symptoms and the delivery of prompt treatment can reduce risk of hospital admissions, while patient education can improve treatment adherence as a key component of self-management strategies. Care bundles are recommended to ensure high-quality care is provided consistently, but evidence for their benefit is limited to date. The search continues for interventions which are effective, sustainable and applicable to a diverse population of patients with COPD exacerbations. Further research into mechanisms that drive exacerbation and affect recovery is crucial to improve our understanding of this complex, highly prevalent disease and to advance the development of more effective treatments.
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Affiliation(s)
- Chia Wei Kong
- Southampton NIHR Respiratory Biomedical Research Unit, University Hospital Southampton, Southampton, UK
- Clinical and Experimental Sciences, Faculty of Medicine, University Hospital Southampton, Southampton, UK
| | - Tom M.A. Wilkinson
- Southampton NIHR Respiratory Biomedical Research Unit, University Hospital Southampton, Southampton, UK
- Clinical and Experimental Sciences, Faculty of Medicine, University Hospital Southampton, Southampton, UK
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Staudinger T. Update on extracorporeal carbon dioxide removal: a comprehensive review on principles, indications, efficiency, and complications. Perfusion 2020; 35:492-508. [PMID: 32156179 DOI: 10.1177/0267659120906048] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
TECHNOLOGY Extracorporeal carbon dioxide removal means the removal of carbon dioxide from the blood across a gas exchange membrane without substantially improving oxygenation. Carbon dioxide removal is possible with substantially less extracorporeal blood flow than needed for oxygenation. Techniques for extracorporeal carbon dioxide removal include (1) pumpless arterio-venous circuits, (2) low-flow venovenous circuits based on the technology of continuous renal replacement therapy, and (3) venovenous circuits based on extracorporeal membrane oxygenation technology. INDICATIONS Extracorporeal carbon dioxide removal has been shown to enable more protective ventilation in acute respiratory distress syndrome patients, even beyond the so-called "protective" level. Although experimental data suggest a benefit on ventilator induced lung injury, no hard clinical evidence with respect to improved outcome exists. In addition, extracorporeal carbon dioxide removal is a tool to avoid intubation and mechanical ventilation in patients with acute exacerbated chronic obstructive pulmonary disease failing non-invasive ventilation. This concept has been shown to be effective in 56-90% of patients. Extracorporeal carbon dioxide removal has also been used in ventilated patients with hypercapnic respiratory failure to correct acidosis, unload respiratory muscle burden, and facilitate weaning. In patients suffering from terminal fibrosis awaiting lung transplantation, extracorporeal carbon dioxide removal is able to correct acidosis and enable spontaneous breathing during bridging. Keeping these patients awake, ambulatory, and breathing spontaneously is associated with favorable outcome. COMPLICATIONS Complications of extracorporeal carbon dioxide removal are mostly associated with vascular access and deranged hemostasis leading to bleeding. Although the spectrum of complications may differ, no technology offers advantages with respect to rate and severity of complications. So called "high-extraction systems" working with higher blood flows and larger membranes may be more effective with respect to clinical goals.
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Affiliation(s)
- Thomas Staudinger
- Department of Medicine I, Intensive Care Unit, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
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Navarra SM, Congedo MT, Pennisi MA. Indications for Non-Invasive Ventilation in Respiratory Failure. Rev Recent Clin Trials 2020; 15:251-257. [PMID: 32493199 DOI: 10.2174/1574887115666200603151838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/19/2020] [Accepted: 04/28/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Non-invasive ventilation (NIV) is increasingly being used to treat episodes of acute respiratory failure not only in critical care and respiratory wards, but also in emergency departments. AIM Aim of this review is to summarize the current indications for the management of NIV for respiratory failure. METHODS Current literature about the topic was reviewed and critically reported to describe the rationale and physiologic advantages of NIV in various situations of respiratory failure. RESULTS Early NIV use is commonly associated with the significant decrease in endotracheal intubation rate, the incidence of infective complications (especially ventilatory associated pneumonia), Intensive Care Units and the length of hospital stay and, in selected conditions, also in mortality rates. Severe acute exacerbation of chronic obstructive pulmonary disease (pH<7.35 and relative hypercarbia) and acute cardiogenic pulmonary oedema are the most common NIV indications; in these conditions NIV advantages are clearly documented. Not so evident are the NIV benefits in hypoxaemic respiratory failure occurring without prior chronic respiratory disease (De novo respiratory failure). One recent randomized control trial reported in hypoxaemic respiratory failure a survival benefit of high-flow nasal cannulae over standard oxygen therapy and bilevel NIV. Evidence suggests the advantages of NIV also in respiratory failure in immunocompromised patients or chest trauma patients. Use during a pandemic event has been assessed in several observational studies but remains controversial; there also is not sufficient evidence to support the use of NIV treatment in acute asthma exacerbation. CONCLUSION NIV eliminates morbidity related to the endotracheal tube (loss of airway defense mechanism with increased risk of pneumonia) and in selected conditions (COPD exacerbation, acute cardiogenic pulmonary edema, immunosuppressed patients with pulmonary infiltrates and hypoxia) is clearly associated with a better outcome in comparison to conventional invasive ventilation. However, NIV is associated with complications, especially minor complications related to interface. Major complications like aspiration pneumonia, barotrauma and hypotension are infrequent.
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Affiliation(s)
- Simone Maria Navarra
- Department of Emergency Medicine, Fondazione Policlinico Universitario "A Gemelli" IRCCS - Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Teresa Congedo
- Department of Thoracic Surgery, Fondazione Policlinico Universitario "A Gemelli" IRCCS - Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Mariano Alberto Pennisi
- Department of Anesthesiology and Intensive Care, Fondazione Policlinico Universitario "A Gemelli" IRCCS - Universita Cattolica del Sacro Cuore, Rome, Italy
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Lief L, McSparron J. Acute Exacerbation of COPD. EVIDENCE-BASED CRITICAL CARE 2020. [PMCID: PMC7121203 DOI: 10.1007/978-3-030-26710-0_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Ratan A. The use of non-invasive ventilation in an exacerbation of chronic obstructive pulmonary disease: a case study. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2019; 28:1461-1467. [PMID: 31835932 DOI: 10.12968/bjon.2019.28.22.1461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
This article aims to assist nurses and other health professionals to care for patients who have type 2 respiratory failure as a result of chronic obstructive pulmonary disease, and who require non-invasive ventilation. It outlines findings of a case study that are commonplace in the acute medical setting and aims to highlight important factors that impact on patient care and patient outcome, and to help nursing staff to implement recommended and best practices.
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Affiliation(s)
- Andrew Ratan
- Staff Nurse, Newcastle upon Tyne Hospitals NHS Foundation Trust
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45
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Barrett NA, Hart N, Camporota L. Assessment of Work of Breathing in Patients with Acute Exacerbations of Chronic Obstructive Pulmonary Disease. COPD 2019; 16:418-428. [PMID: 31694406 DOI: 10.1080/15412555.2019.1681390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The assessment of the work of breathing (WOB) of patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) is difficult, particularly when the patient first presents with acute hypercapnia and respiratory acidosis. Acute exacerbations of COPD patients are in significant respiratory distress and noninvasive measurements of WOB are easier for the patient to tolerate. Given the interest in using alternative therapies to noninvasive ventilation, such as high flow nasal oxygen therapy or extracorporeal carbon dioxide removal, understanding the physiological changes are key and this includes assessment of WOB. This narrative review considers the role of three different methods of assessing WOB in patients with acute exacerbations of COPD. Esophageal pressure is a very well validated measure of WOB, however the ability of patients with acute exacerbations of COPD to tolerate esophageal tubes is poor. Noninvasive alternative measurements include parasternal electromyography (EMG) and electrical impedance tomography (EIT). EMG is easily applied and is a well validated measure of neural drive but is more likely to be degraded by the electrical environment in intensive care or high dependency. EIT is less well validated as a tool for WOB in COPD but extremely well tolerated by patients. Each of the different methods assess WOB in a different way and have different advantages and disadvantages. For research into therapies treating acute exacerbations of COPD, combinations of EIT, EMG and esophageal pressure are likely to be better than only one of these.
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Affiliation(s)
- N A Barrett
- Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom.,Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - N Hart
- Lane Fox Respiratory Unit, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - L Camporota
- Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom.,Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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Tams C, Stephan PJ, Euliano NR, Martin AD, Patel R, Ataya A, Gabrielli A. Breathing variability predicts the suggested need for corrective intervention due to the perceived severity of patient-ventilator asynchrony during NIV. J Clin Monit Comput 2019; 34:1035-1042. [PMID: 31664660 DOI: 10.1007/s10877-019-00408-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 10/21/2019] [Indexed: 10/25/2022]
Abstract
Patient-ventilator asynchrony is associated with intolerance to noninvasive ventilation (NIV) and worsened outcomes. Our goal was to develop a tool to determine a patient needs for intervention by a practitioner due to the presence of patient-ventilator asynchrony. We postulated that a clinician can determine when a patient needs corrective intervention due to the perceived severity of patient-ventilator asynchrony. We hypothesized a new measure, patient breathing variability, would indicate when corrective intervention is suggested by a bedside practitioner due to the perceived severity of patient-ventilator asynchrony. With IRB approval data was collected on 78 NIV patients. A panel of experts reviewed retrospective data from a development set of 10 NIV patients to categorize them into one of the three categories. The three categories were; "No to mild asynchrony-no intervention needed", "moderate asynchrony-non-emergent corrective intervention required", and "severe asynchrony-immediate intervention required". A stepwise regression with a F-test forward selection criterion was used to develop a positive linear logic model predicting the expert panel's categorizations of the need for corrective intervention. The model was incorporated into a software tool for clinical implementation. The tool was implemented prospectively on 68 NIV patients simultaneous to a bedside practitioner scoring the need for corrective intervention due to the perceived severity of patient-ventilator asynchrony. The categories from the tool and the practitioner were compared with the rate of agreement, sensitivity, specificity, and receiver operator characteristic analyses. The rate of agreement in categorizing the suggested need for clinical intervention due to the perceived presence of patient-ventilator asynchrony between the tool and experienced bedside practitioners was 95% with a Kappa score of 0.85 (p < 0.001). Further analysis found a specificity of 84% and sensitivity of 99%. The tool appears to accurately match the suggested need for corrective intervention by a bedside practitioner. Application of the tool allows for continuous, real time, and non-invasive monitoring of patients receiving NIV, and may enable early corrective interventions to ameliorate potential patient-ventilator asynchrony.
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Affiliation(s)
- Carl Tams
- Convergent Engineering, 107 SW 140th Terrace, STE 1, Newberry, FL, 32669, USA
| | - Paul J Stephan
- Convergent Engineering, 107 SW 140th Terrace, STE 1, Newberry, FL, 32669, USA
| | - Neil R Euliano
- Convergent Engineering, 107 SW 140th Terrace, STE 1, Newberry, FL, 32669, USA.
| | - A Daniel Martin
- Department of Physical Therapy, College of Public Health & Health Professions, University of Florida, Gainesville, FL, 32610, USA
| | - Rohit Patel
- Department of Anesthesiology and Department of Emergency Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, PO Box 100254, Gainesville, FL, 32610, USA
| | - Ali Ataya
- Department of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Gainesville, FL, 32610, USA
| | - Andrea Gabrielli
- Department of Anesthesiology Perioperative Medicine and Pain Management, University of Miami Health System, 1611 NW 12th Ave (C-301), Miami, FL, 33136, USA
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Use High-Flow Nasal Cannula for Acute Respiratory Failure Patients in the Emergency Department: A Meta-Analysis Study. Emerg Med Int 2019; 2019:2130935. [PMID: 31737365 PMCID: PMC6815584 DOI: 10.1155/2019/2130935] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 09/16/2019] [Indexed: 12/29/2022] Open
Abstract
Objective To evaluate the efficacy of high-flow nasal cannula (HFNC) therapy compared with conventional oxygen therapy (COT) or noninvasive ventilation (NIV) for the treatment of acute respiratory failure (ARF) in emergency departments (EDs). Method We comprehensively searched 3 databases (PubMed, EMBASE, and the Cochrane Library) for articles published from database inception to 12 July 2019. This study included only randomized controlled trials (RCTs) that were conducted in EDs and compared HFNC therapy with COT or NIV. The primary outcome was the intubation rate. The secondary outcomes were the mortality rate, intensive care unit (ICU) admission rate, ED discharge rate, need for escalation, length of ED stay, length of hospital stay, and patient dyspnea and comfort scores. Result Five RCTs (n = 775) were included. There was a decreasing trend regarding the application of HFNC therapy and the intubation rate, but the difference was not statistically significant (RR, 0.53; 95% CI, 0.26–1.09; p=0.08; I2 = 0%). We found that compared with patients who underwent COT, those who underwent HFNC therapy had a reduced need for escalation (RR, 0.41; 95% CI, 0.22–0.78; p=0.006; I2 = 0%), reduced dyspnea scores (MD −0.82, 95% CI −1.45 to −0.18), and improved comfort (SMD −0.76 SD, 95% CI −1.01 to −0.51). Compared with the COT group, the HFNC therapy group had a similar mortality rate (RR, 1.25; 95% CI, 0.79–1.99; p=0.34; I2 = 0%), ICU admission rate (RR, 1.11; 95% CI, 0.58–2.12; p=0.76; I2 = 0%), ED discharge rate (RR, 1.04; 95% CI, 0.63–1.72; p=0.87; I2 = 0%), length of ED stay (MD 1.66, 95% CI −0.95 to 4.27), and hospital stay (MD 0.9, 95% CI −2.06 to 3.87). Conclusion Administering HFNC therapy in ARF patients in EDs might decrease the intubation rate compared with COT. In addition, it can decrease the need for escalation, decrease the patient's dyspnea level, and increase the patient's comfort level compared with COT.
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Bellou V, Belbasis L, Konstantinidis AK, Tzoulaki I, Evangelou E. Prognostic models for outcome prediction in patients with chronic obstructive pulmonary disease: systematic review and critical appraisal. BMJ 2019; 367:l5358. [PMID: 31585960 PMCID: PMC6776831 DOI: 10.1136/bmj.l5358] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To map and assess prognostic models for outcome prediction in patients with chronic obstructive pulmonary disease (COPD). DESIGN Systematic review. DATA SOURCES PubMed until November 2018 and hand searched references from eligible articles. ELIGIBILITY CRITERIA FOR STUDY SELECTION Studies developing, validating, or updating a prediction model in COPD patients and focusing on any potential clinical outcome. RESULTS The systematic search yielded 228 eligible articles, describing the development of 408 prognostic models, the external validation of 38 models, and the validation of 20 prognostic models derived for diseases other than COPD. The 408 prognostic models were developed in three clinical settings: outpatients (n=239; 59%), patients admitted to hospital (n=155; 38%), and patients attending the emergency department (n=14; 3%). Among the 408 prognostic models, the most prevalent endpoints were mortality (n=209; 51%), risk for acute exacerbation of COPD (n=42; 10%), and risk for readmission after the index hospital admission (n=36; 9%). Overall, the most commonly used predictors were age (n=166; 41%), forced expiratory volume in one second (n=85; 21%), sex (n=74; 18%), body mass index (n=66; 16%), and smoking (n=65; 16%). Of the 408 prognostic models, 100 (25%) were internally validated and 91 (23%) examined the calibration of the developed model. For 286 (70%) models a model presentation was not available, and only 56 (14%) models were presented through the full equation. Model discrimination using the C statistic was available for 311 (76%) models. 38 models were externally validated, but in only 12 of these was the validation performed by a fully independent team. Only seven prognostic models with an overall low risk of bias according to PROBAST were identified. These models were ADO, B-AE-D, B-AE-D-C, extended ADO, updated ADO, updated BODE, and a model developed by Bertens et al. A meta-analysis of C statistics was performed for 12 prognostic models, and the summary estimates ranged from 0.611 to 0.769. CONCLUSIONS This study constitutes a detailed mapping and assessment of the prognostic models for outcome prediction in COPD patients. The findings indicate several methodological pitfalls in their development and a low rate of external validation. Future research should focus on the improvement of existing models through update and external validation, as well as the assessment of the safety, clinical effectiveness, and cost effectiveness of the application of these prognostic models in clinical practice through impact studies. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017069247.
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Affiliation(s)
- Vanesa Bellou
- Department of Hygiene and Epidemiology, University of Ioannina Medical School, Ioannina, Greece
- Department of Respiratory Medicine, University Hospital of Ioannina, University of Ioannina Medical School, Ioannina, Greece
| | - Lazaros Belbasis
- Department of Hygiene and Epidemiology, University of Ioannina Medical School, Ioannina, Greece
| | - Athanasios K Konstantinidis
- Department of Respiratory Medicine, University Hospital of Ioannina, University of Ioannina Medical School, Ioannina, Greece
| | - Ioanna Tzoulaki
- Department of Hygiene and Epidemiology, University of Ioannina Medical School, Ioannina, Greece
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
- MRC-PHE Center for Environment, School of Public Health, Imperial College London, London, UK
| | - Evangelos Evangelou
- Department of Hygiene and Epidemiology, University of Ioannina Medical School, Ioannina, Greece
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
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Duan J, Wang S, Liu P, Han X, Tian Y, Gao F, Zhou J, Mou J, Qin Q, Yu J, Bai L, Zhou L, Zhang R. Early prediction of noninvasive ventilation failure in COPD patients: derivation, internal validation, and external validation of a simple risk score. Ann Intensive Care 2019; 9:108. [PMID: 31565779 PMCID: PMC6766459 DOI: 10.1186/s13613-019-0585-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 09/21/2019] [Indexed: 01/04/2023] Open
Abstract
Background Early identification of noninvasive ventilation (NIV) failure is a promising strategy for reducing mortality in chronic obstructive pulmonary disease (COPD) patients. However, a risk-scoring system is lacking. Methods To develop a scale to predict NIV failure, 500 COPD patients were enrolled in a derivation cohort. Heart rate, acidosis (assessed by pH), consciousness (assessed by Glasgow coma score), oxygenation, and respiratory rate (HACOR) were entered into the scoring system. Another two groups of 323 and 395 patients were enrolled to internally and externally validate the scale, respectively. NIV failure was defined as intubation or death during NIV. Results Using HACOR score collected at 1–2 h of NIV to predict NIV failure, the area under the receiver operating characteristic curves (AUC) was 0.90, 0.89, and 0.71 for the derivation, internal-validation, and external-validation cohorts, respectively. For the prediction of early NIV failure in these three cohorts, the AUC was 0.91, 0.96, and 0.83, respectively. In all patients with HACOR score > 5, the NIV failure rate was 50.2%. In these patients, early intubation (< 48 h) was associated with decreased hospital mortality (unadjusted odds ratio = 0.15, 95% confidence interval 0.05–0.39, p < 0.01). Conclusions HACOR scores exhibited good predictive power for NIV failure in COPD patients, particularly for the prediction of early NIV failure (< 48 h). In high-risk patients, early intubation was associated with decreased hospital mortality.
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Affiliation(s)
- Jun Duan
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, People's Republic of China.
| | - Shengyu Wang
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Xi'an Medical University, Xi'an, 710077, People's Republic of China
| | - Ping Liu
- Department of Respiratory and Critical Care Medicine, The People's Hospital of Changshou, Chongqing, 401220, People's Republic of China
| | - Xiaoli Han
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Yao Tian
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Xi'an Medical University, Xi'an, 710077, People's Republic of China
| | - Fan Gao
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Xi'an Medical University, Xi'an, 710077, People's Republic of China
| | - Jing Zhou
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Xi'an Medical University, Xi'an, 710077, People's Republic of China
| | - Junhuan Mou
- Department of Respiratory and Critical Care Medicine, The People's Hospital of Changshou, Chongqing, 401220, People's Republic of China
| | - Qian Qin
- Department of Respiratory and Critical Care Medicine, The People's Hospital of Changshou, Chongqing, 401220, People's Republic of China
| | - Jingrong Yu
- Department of Respiratory and Critical Care Medicine, The People's Hospital of Changshou, Chongqing, 401220, People's Republic of 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, People's Republic of China
| | - Lintong Zhou
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Rui Zhang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, People's Republic of China
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Barrett NA, Kostakou E, Hart N, Douiri A, Camporota L. Extracorporeal carbon dioxide removal for acute hypercapnic exacerbations of chronic obstructive pulmonary disease: study protocol for a randomised controlled trial. Trials 2019; 20:465. [PMID: 31362776 PMCID: PMC6664508 DOI: 10.1186/s13063-019-3548-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 06/29/2019] [Indexed: 01/14/2023] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is a common cause of chronic respiratory failure and its course is punctuated by a series of acute exacerbations which commonly lead to hospital admission. Exacerbations are managed through the application of non-invasive ventilation and, when this fails, tracheal intubation and mechanical ventilation. The need for mechanical ventilation significantly increases the risk of death. An alternative therapy, extracorporeal carbon dioxide removal (ECCO2R), has been shown to be efficacious in removing carbon dioxide from the blood; however, its impact on respiratory physiology and patient outcomes has not been explored. Methods/design A randomised controlled open label trial of patients (12 in each arm) with acute exacerbations of COPD at risk of failing conventional therapy (NIV) randomised to either remaining on NIV or having ECCO2R added to NIV with a primary endpoint of time to cessation of NIV. The change in respiratory physiology following the application of ECCO2R and/or NIV will be measured using electrical impedance tomography, oesophageal pressure and parasternal electromyography. Additional outcomes, including patient tolerance, outcomes, need for readmission, changes in blood gases and biochemistry and procedural complications, will be measured. Physiological changes will be compared within one patient over time and between the two groups. Healthcare costs in the UK system will also be compared between the two groups. Discussion COPD is a common disease and exacerbations are a leading cause of hospital admission in the UK and worldwide, with a sizeable mortality. The management of patients with COPD consumes significant hospital and financial resources. This study seeks to understand the feasibility of a novel approach to the management of patients with acute exacerbations of COPD as well as to understand the underlying physiological changes to explain why the approach does or does not assist this patient cohort. Detailed respiratory physiology has not been previously undertaken using this technique and there are no other randomised controlled trials currently in the literature. Trial registration ClinicalTrials.gov, NCT02086084. Electronic supplementary material The online version of this article (10.1186/s13063-019-3548-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicholas A Barrett
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Rd, London, SE1 7EH, UK. .,Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK.
| | - Eirini Kostakou
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Rd, London, SE1 7EH, UK
| | - Nicholas Hart
- Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK.,Lane Fox Respiratory Unit, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Rd, London, SE1 7EH, UK
| | - Abdel Douiri
- School of Population Health & Environmental Sciences, King's College London, London, WC2R 2LS, UK.,National Institute for Health Research Biomedical Research Centre, Guy's and St Thomas' NHS Trust and King's College London, London, UK
| | - Luigi Camporota
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Rd, London, SE1 7EH, UK.,Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
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