High-flow nasal cannula oxygen therapy and noninvasive ventilation for preventing extubation failure during weaning from mechanical ventilation assessed by lung ultrasound score: A single-center randomized study

[Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]

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.

Optimization of lung ultrasound in ultrafast-track anesthesia for non-cyanotic congenital heart disease surgery

Objective

We aimed to explore the feasibility of lung ultrasound for perioperative assessment and the optimal effect of lung ultrasound in reducing lung complications during non-cyanotic congenital heart disease (CHD) surgery using ultrafast-track anesthesia.

Methods

Sixty patients were treated at Shenzhen Children's Hospital between 2019 and 2020. Of these, 30 patients in group N had an indication for extubation and ultrafast-track anesthesia after congenital heart surgery; the tracheal catheter was removed, and the patients were sent to the cardiac intensive care unit (CICU) for further monitoring and treatment. Another 30 patients were in group L and also had an indication for extubation and ultrafast-track anesthesia; in addition we compared lung ultrasound score (LUS) before and after surgery, when we found the cases that LUS ≥ 15, for whom targeted optimization treatment would be carried out. The tracheal catheter was removed after LUS <15 days before the patients were sent to the CICU. In all cases, the LUS and PaO2/FiO2 ratios (P/F) of both groups were recorded at the time of anesthesia induction (T0), before extubation (T1), and 5 min (T2), 1 h (T3), and 24 h (T4) after extubation. The incidence of pulmonary complications, LUS, and P/F were compared between the two groups.

Results

There was great consistency between LUS and radiographic findings. Comparing the data of the two groups at T2, T3 and T4, the P/F was higher and the LUS was lower in group L than in group N. The incidence of lung complications in group L (18 cases, 60 %) was lower than that in group N (26 cases, 86.7 %, χ2 = 5.46, P = 0.02); comparing LUS between T0 and T3, LUS decreased in a greater number of cases in group L (15, 50 %) than in group N (7 cases, 23.3 %, χ2 = 4.59, P = 0.032).

Conclusion

Lung ultrasonography can effectively help assess lung conditions. Optimization guided by lung ultrasound in ultrafast track anesthesia can significantly reduce postoperative lung complications.

Accuracy of lung and diaphragm ultrasound in predicting infant weaning outcomes: a systematic review and meta-analysis

Background

Although lung and diaphragm ultrasound are valuable tools for predicting weaning results in adults with MV, their relevance in children is debatable. The goal of this meta-analysis was to determine the predictive value of lung and diaphragm ultrasound in newborn weaning outcomes.

Methods

For eligible studies, the databases MEDLINE, Web of Science, Cochrane Library, PubMed, and Embase were thoroughly searched. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) method was used to evaluate the study's quality. Results were gathered for sensitivity, specificity, diagnostic odds ratio (DOR), and the area under the curve of summary receiver operating characteristic curves (AUSROC). To investigate the causes of heterogeneity, subgroup analyses and meta-regression were conducted.

Results

A total of 11 studies were suitable for inclusion in the meta-analysis, which included 828 patients. The pooled sensitivity and specificity of lung ultrasound (LUS) were 0.88 (95%CI, 0.85-0.90) and 0.81 (95%CI, 0.75-0.87), respectively. The DOR for diaphragmatic excursion (DE) is 13.17 (95%CI, 5.65-30.71). The AUSROC for diaphragm thickening fraction (DTF) is 0.86 (95%CI, 0.82-0.89). The most sensitive and specific method is LUS. The DE and DTF were the key areas where study heterogeneity was evident.

Conclusions

Lung ultrasonography is an extremely accurate method for predicting weaning results in MV infants. DTF outperforms DE in terms of diaphragm ultrasound predictive power.

Efficacy of preventive use of oxygen therapy after planned extubation in high-risk patients with extubation failure: A network meta-analysis of randomized controlled trials

Background

Extubation failure is common in critically ill patients, especially those with high-risk factors, and is associated with poor prognosis. Prophylactic use of oxygen therapy after extubation has been gradually introduced. However, the best respiratory support method is still unclear.

Purpose

This study aimed to evaluate the efficacy of four post-extubation respiratory support approaches in reducing reintubation and respiratory failure in patients at high-risk of extubation failure.

Methods

A comprehensive search was performed in Cochrane Central Register of Controlled Trials, PubMed, EMBASE, and Web of Science from inception to June 2022. Randomized controlled trials (RCTs) comparing post-extubation preventive use of respiratory management strategies, including conventional oxygen therapy (COT), non-invasive ventilation (NIV), and high-flow nasal catheter (HFNC) in high-risk patients with extubation failure were reviewed. Primary outcomes were reintubation rate and respiratory failure. Secondary outcomes included intensive care unit (ICU) mortality, ICU stay and length of hospital stay (LOS).

Results

Seventeen RCTs comprising 2813 participants were enrolled. Compared with COT, the three respiratory support methods (NIV, HFNC, NIV + HFNC) were all effective in preventing reintubation [odds ratio (OR) 0.46, 95% confidence interval (CI) 0.32–0.67; OR 0.26, 95% CI 0.14–0.48; OR 0.62, 95% CI 0.39–0.97, respectively] and respiratory failure (OR 0.23, 95% CI 0.10–0.52; OR 0.15, 95% CI 0.04–0.60; OR 0.26, 95% CI 0.10–0.72, respectively). NIV and NIV + HFNC also reduced ICU mortality (OR 0.40, 95% CI 0.22–0.74; OR 0.32, 95% CI 0.12–0.85). NIV + HFNC ranked best in terms of reintubation rate, respiratory failure and ICU mortality based on the surface under the cumulative ranking curve (SUCRA) (99.3, 87.1, 88.2, respectively). Although there was no significant difference in shortening ICU stay and LOS among the four methods, HFNC ranked first based on the SUCRA.

Conclusion

Preventive use of NIV + HFNC after scheduled extubation is probably the most effective respiratory support method for preventing reintubation, respiratory failure and ICU death in high-risk patients with extubation failure. HFNC alone seems to be the best method to shorten ICU stay and LOS.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42022340623].

ERS International Congress, Virtual 2021: Highlights from the Respiratory Intensive Care Assembly Early Career Members

Early Career Members of Assembly 2 (Respiratory Intensive Care) attended the European Respiratory Society International Congress through a virtual platform in 2021. Sessions of interest to our assembly members included symposia on the implications of acute respiratory distress syndrome phenotyping on diagnosis and treatment, safe applications of noninvasive ventilation in hypoxaemic respiratory failure, and new developments in mechanical ventilation and weaning, and a guidelines session on applying high-flow therapy in acute respiratory failure. These sessions are summarised in this article.

Early Career Members of @ERSAssembly2 attended the #ERSCongress 2021, and reported on symposia on ARDS phenotyping, noninvasive ventilation in hypoxic respiratory failure, ventilator weaning and high-flow therapy in acute respiratory failurehttps://bit.ly/3D68r50