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Costanzo DD, Mazza M, Esquinas A. Non-invasive mechanical ventilation in Myasthenic crisis outside Intensive Care Unit setting: a safe step? Neuromuscul Disord 2022. [DOI: 10.1016/j.nmd.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/02/2022] [Indexed: 11/15/2022]
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Maffucci R, Maccari U, Guidelli L, Benedetti L, Fabbroni R, Piccoli B, Bianco A, Scala R. Pulmonologist-Administered Balanced Propofol Analgosedation during Interventional Procedures: An Italian Real-Life Study on Comfort and Safety. Int J Clin Pract 2022; 2022:3368077. [PMID: 35814307 PMCID: PMC9208941 DOI: 10.1155/2022/3368077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 05/17/2022] [Accepted: 05/25/2022] [Indexed: 11/18/2022] Open
Abstract
Propofol-based sedation provides faster recovery than midazolam-based regimens with similar safety and comfort during video flexible bronchoscope (VFB) procedures. Pulmonologist-administered propofol "balanced" analgosedation (PAP-BAS) is still debated in Italy. In this real-life study, PAP-BAS safety and comfort during VFB procedures were investigated. We analysed prospectively the subjects undergoing elective VFB procedures in the Pulmonology and RICU of Arezzo Hospital between February and July 2019. PAP-BAS combined low propofol and meperidine doses titrated to achieve an RASS score between 0 and -3. The primary end-point was the complications' rate. Secondary end-points were as follows: the relation between propofol's dose and a subject's comfort assessed with a VAS, recovery time according to a modified Aldrete score ≥9, RASS, and subjects' will of undergoing the procedure again. We collected postprocedure symptoms' intensity too. Our 158 study patients (67 years; SD ± 14; 64% males) incurred in 25% of complication, fully resolved with medical therapy. Neither recourse to ventilator support nor death was reported. Intraprocedural comfort was good (94% of VAS score ≤2). Among postprocedural symptoms, cough was the most frequently reported, in 36% of the cases. Although half of subjects remembered the procedure, 90% of them would have repeated it, if necessary. 85% of them recovered from procedures within 10 minutes. Complications, VAS, and recovery time were not correlated with propofol dose. To our knowledge, this is the first Italian study showing that PAP-BAS to perform a VFB procedure is safe, well tolerated with a quick recovery. Randomised controlled trials are warranted to confirm these preliminary results.
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Affiliation(s)
- Rosalba Maffucci
- Division of Respiratory Physiopathology and Rehabilitation, A.O.R.N. “Dei Colli”—Monaldi Hospital, Naples, Italy
| | - Uberto Maccari
- Pulmonology and Respiratory Intensive Care Unit, S Donato Hospital Arezzo, Cardio-Neuro-Thoracic and Metabolic Department, Usl Toscana Sudest, Arezzo, Italy
| | - Luca Guidelli
- Pulmonology and Respiratory Intensive Care Unit, S Donato Hospital Arezzo, Cardio-Neuro-Thoracic and Metabolic Department, Usl Toscana Sudest, Arezzo, Italy
| | - Lucia Benedetti
- Pulmonology and Respiratory Intensive Care Unit, S Donato Hospital Arezzo, Cardio-Neuro-Thoracic and Metabolic Department, Usl Toscana Sudest, Arezzo, Italy
| | - Roberto Fabbroni
- Pulmonology and Respiratory Intensive Care Unit, S Donato Hospital Arezzo, Cardio-Neuro-Thoracic and Metabolic Department, Usl Toscana Sudest, Arezzo, Italy
| | - Bruno Piccoli
- Consumer & Sensory Scientist, Adacta International, Naples, Italy
| | - Andrea Bianco
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Raffaele Scala
- Pulmonology and Respiratory Intensive Care Unit, S Donato Hospital Arezzo, Cardio-Neuro-Thoracic and Metabolic Department, Usl Toscana Sudest, Arezzo, Italy
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Abstract
INTRODUCTION Respiratory high dependency units (RHDUs) set up in European countries in the last decade are based on being a transitional step between the intensive care units (ICUs) and the conventional hospital ward in terms of staffing, level of monitoring, and patients' severity. In the pre-COVID-19 era, its main use has been the treatment of hypercapnic acute-on-chronic respiratory failure with noninvasive respiratory support, and more recently, for hypoxemic acute respiratory failure. AREAS COVERED We searched the following databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, limited to the terms: COVID-19 and RHDU, Respiratory Intermediate care Unit, acute respiratory distress syndrome (ARDS), noninvasive ventilation (NIV), high flow nasal cannula (HFNC), prone position, and monitoring. In this review, we summarize RHDU´s dual purpose: on the one hand, to decrease the number of admissions into ICU, and on the other hand, early discharges of patients from ICU with prolonged admissions due to the need of care or laborious weaning from invasive mechanical ventilation. Although this dual purpose of RHDUs has contributed to decrease the overload of the ICUs during the pandemic, the hundreds of patients admitted in hospitals, with approximately 20%-30% needing critical care, has exceeded the forecasts of many hospitals. EXPERT OPINION It seems clear that a reorganization and optimization of the care of patients with severe COVID-19 is necessary, minimizing admissions to the ICU and facilitating an early discharge. During the pandemic, several hospitals have spontaneously created new RHDUs or extended preexisting RHDUs or up-graded respiratory wards in order to receive less sick patients requiring lower levels of monitoring and nurse-to-patient ratios. This article reviews under a European expert perspective this topic and proposes an adaptation and optimization of the RHDUs to meet the emergent needs caused by the pandemic emphasizing the role of the expert application of noninvasive respiratory therapies in preventing intubation and ICU access.
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Affiliation(s)
- Juan Fernando Masa
- San Pedro De Alcantara Hospital, Cáceres, Spain.,Ciber De Enfermedades Respiratorias (Ciberes), Madrid, Spain.,Instituto Universitario De Investigación Biosanitaria De Extremadura (Inube), Spain
| | - Maxime Patout
- 1. Ap-hp, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Service Des Pathologies Du Sommeil (Département R3S), Paris, France.,Sorbonne Université, Inserm, UMRS1158 Neurophysiologie Respiratoire Expérimentale Et Clinique, Paris, France
| | - Raffaele Scala
- Pulmonology and Respiratory Intensive Care Unit. Cardiovascular-thoracic-metabolic Department. Usl Toscana Sudest. San Donato Hospital, Arezzo, Italy
| | - Joao Carlos Winck
- Faculdade De Medicina Da Universidade Do Porto, Centro De Reabilitação Do Norte (Chvng), Vila Nova De Gaia, Portugal
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Renda T, Scala R, Corrado A, Ambrosino N, Vaghi A. Adult Pulmonary Intensive and Intermediate Care Units: The Italian Thoracic Society (ITS-AIPO) Position Paper. Respiration 2021; 100:1027-1037. [PMID: 34102641 DOI: 10.1159/000516332] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 04/01/2021] [Indexed: 11/19/2022] Open
Abstract
The imbalance between the prevalence of patients with acute respiratory failure (ARF) and acute-on-chronic respiratory failure and the number of intensive care unit (ICU) beds requires new solutions. The increasing use of non-invasive respiratory tools to support patients at earlier stages of ARF and the increased expertise of non-ICU clinicians in other types of supportive care have led to the development of adult pulmonary intensive care units (PICUs) and pulmonary intermediate care units (PIMCUs). As in other European countries, Italian PICUs and PIMCUs provide an intermediate level of care as the setting designed for managing ARF patients without severe non-pulmonary dysfunction. The PICUs and PIMCUs may also act as step-down units for weaning patients from prolonged mechanical ventilation and for discharging patients still requiring ventilatory support at home. These units may play an important role in the on-going coronavirus disease 2019 pandemic. This position paper promoted by the Italian Thoracic Society (ITS-AIPO) describes the models, facilities, staff, equipment, and operating methods of PICUs and PIMCUs.
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Affiliation(s)
- Teresa Renda
- Cardio-Thoracic and Vascular Department, Respiratory and Critical Care Unit, Careggi University Hospital, Florence, Italy
| | - Raffaele Scala
- Cardio-Neuro-Thoracic and Metabolic Department, Pulmonology and Respiratory Intensive Care Unit, Arezzo, Italy
| | | | - Nicolino Ambrosino
- Respiratory Rehabilitation Unit of the Institute of Montescano, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Adriano Vaghi
- President of Italian Thoracic Society, Italian Association of Hospital Pulmonologists (ITS-AIPO), Milan, Italy
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5
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Piccioni F, Droghetti A, Bertani A, Coccia C, Corcione A, Corsico AG, Crisci R, Curcio C, Del Naja C, Feltracco P, Fontana D, Gonfiotti A, Lopez C, Massullo D, Nosotti M, Ragazzi R, Rispoli M, Romagnoli S, Scala R, Scudeller L, Taurchini M, Tognella S, Umari M, Valenza F, Petrini F. Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care. Perioper Med (Lond) 2020; 9:31. [PMID: 33106758 PMCID: PMC7582032 DOI: 10.1186/s13741-020-00159-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 09/22/2020] [Indexed: 02/08/2023] Open
Abstract
Introduction Anesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. There remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients. Methods A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. The project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventive Services Task Force criteria. Results Recommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. Recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (ICU) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis. Conclusions These recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.
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Affiliation(s)
- Federico Piccioni
- Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Alessandro Bertani
- Division of Thoracic Surgery and Lung Transplantation, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS ISMETT - UPMC, Palermo, Italy
| | - Cecilia Coccia
- Department of Anesthesia and Critical Care Medicine, National Cancer Institute "Regina Elena"-IRCCS, Rome, Italy
| | - Antonio Corcione
- Department of Critical Care Area Monaldi Hospital, Ospedali dei Colli, Naples, Italy
| | - Angelo Guido Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation and Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Roberto Crisci
- Department of Thoracic Surgery, University of L'Aquila, L'Aquila, Italy
| | - Carlo Curcio
- Thoracic Surgery, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Carlo Del Naja
- Department of Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, FG Italy
| | - Paolo Feltracco
- Department of Medicine, Anaesthesia and Intensive Care, University Hospital of Padova, Padova, Italy
| | - Diego Fontana
- Thoracic Surgery Unit - San Giovanni Bosco Hospital, Turin, Italy
| | | | - Camillo Lopez
- Thoracic Surgery Unit, 'V Fazzi' Hospital, Lecce, Italy
| | - Domenico Massullo
- Anesthesiology and Intensive Care Unit, Azienda Ospedaliero Universitaria S. Andrea, Rome, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Riccardo Ragazzi
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria Sant'Anna, Ferrara, Italy
| | - Marco Rispoli
- Anesthesia and Intensive Care, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Stefano Romagnoli
- Department of Health Science, Section of Anesthesia and Critical Care, University of Florence, Florence, Italy.,Department of Anesthesia and Critical Care, Careggi University Hospital, Florence, Italy
| | - Raffaele Scala
- Pneumology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Luigia Scudeller
- Clinical Epidemiology Unit, Scientific Direction, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Marco Taurchini
- Department of Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, FG Italy
| | - Silvia Tognella
- Respiratory Unit, Orlandi General Hospital, Bussolengo, Verona, Italy
| | - Marzia Umari
- Combined Department of Emergency, Urgency and Admission, Cattinara University Hospital, Trieste, Italy
| | - Franco Valenza
- Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.,Department of Oncology and Onco-Hematology, University of Milan, Milan, Italy
| | - Flavia Petrini
- Department of Anaesthesia, Perioperative Medicine, Pain Therapy, RRS and Critical Care Area - DEA ASL2 Abruzzo, Chieti University Hospital, Chieti, Italy
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Guia M, Ciobanu LD, Sreedharan JK, Abdelrahim ME, Gonçalves G, Cabrita B, Alqahtani JS, Duan J, El-Khatib M, Diaz-Abad M, Wittenstein J, Karim HMR, Bhakta P, Ruggeri P, Garuti G, Burns KEA, Soo Hoo GW, Scala R, Esquinas A; International Association of Non Invasive Ventilation. The role of non-invasive ventilation in weaning and decannulating critically ill patients with tracheostomy: A narrative review of the literature. Pulmonology 2021; 27:43-51. [PMID: 32723618 DOI: 10.1016/j.pulmoe.2020.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Invasive mechanical ventilation (IMV) is associated with several complications. Placement of a long-term airway (tracheostomy) is also associated with short and long-term risks for patients. Nevertheless, tracheostomies are placed to help reduce the duration of IMV, facilitate weaning and eventually undergo successful decannulation. METHODS We performed a narrative review by searching PubMed, Embase and Medline databases to identify relevant citations using the search terms (with synonyms and closely related words) "non-invasive ventilation", "tracheostomy" and "weaning". We identified 13 publications comprising retrospective or prospective studies in which non-invasive ventilation (NIV) was one of the strategies used during weaning from IMV and/or tracheostomy decannulation. RESULTS In some studies, patients with tracheostomies represented a subgroup of patients on IMV. Most of the studies involved patients with underlying cardiopulmonary comorbidities and conditions, and primarily involved specialized weaning centres. Not all studies provided data on decannulation, although those which did, report high success rates for weaning and decannulation when using NIV as an adjunct to weaning patient off ventilatory support. However, a significant percentage of patients still needed home NIV after discharge. CONCLUSIONS The review supports a potential role for NIV in weaning patients with a tracheostomy either off the ventilator and/or with its decannulation. Additional research is needed to develop weaning protocols and better characterize the role of NIV during weaning.
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Retucci M, Aliberti S, Ceruti C, Santambrogio M, Tammaro S, Cuccarini F, Carai C, Grasselli G, Oneta AM, Saderi L, Sotgiu G, Privitera E, Blasi F. Prone and Lateral Positioning in Spontaneously Breathing Patients With COVID-19 Pneumonia Undergoing Noninvasive Helmet CPAP Treatment. Chest 2020; 158:2431-2435. [PMID: 32679237 PMCID: PMC7361047 DOI: 10.1016/j.chest.2020.07.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/15/2020] [Accepted: 07/02/2020] [Indexed: 12/19/2022] Open
Affiliation(s)
- Mariangela Retucci
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Sassari, Italy
| | - Stefano Aliberti
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Sassari, Italy.
| | - Clara Ceruti
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Dipartimento Professioni Sanitarie, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Martina Santambrogio
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Sassari, Italy
| | - Serena Tammaro
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Sassari, Italy
| | - Filippo Cuccarini
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Sassari, Italy
| | - Claudia Carai
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Sassari, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Sassari, Italy
| | - Anna Maria Oneta
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Dipartimento Professioni Sanitarie, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Saderi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Giovanni Sotgiu
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Emilia Privitera
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Dipartimento Professioni Sanitarie, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Blasi
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Sassari, Italy
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Scala R, Ciarleglio G, Maccari U, Granese V, Salerno L, Madioni C. Ventilator Support and Oxygen Therapy in Palliative and End-of-Life Care in the Elderly. Turk Thorac J 2020; 21:54-60. [PMID: 32163365 DOI: 10.5152/turkthoracj.2020.201401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/25/2019] [Indexed: 11/22/2022]
Abstract
Elderly patients suffering from chronic cardio-pulmonary diseases commonly experience acute respiratory failure. As in younger patients, a well-known therapeutic approach of noninvasive mechanical ventilation is able to prevent orotracheal intubation in a large number of severe scenarios in elderly patients. In addition, this type of ventilation is frequently applied in elderly patients who refuse intubation for invasive mechanical ventilation. The rate of failure of noninvasive ventilation may be reduced by means of the integration of new technological devices (i.e., high-flow nasal cannula, extracorporeal CO2 removal, cough assistance and high-frequency chest wall oscillation, and fiberoptic bronchoscopy). Ethical issues with end-of-life decisions and the choice of the environment are not clearly defined in the treatment of elderly with acute respiratory insufficiency.
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Affiliation(s)
- Raffaele Scala
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Giuseppina Ciarleglio
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Uberto Maccari
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Valentina Granese
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Laura Salerno
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Chiara Madioni
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
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Myers LC, Escobar G, Liu VX. Goldilocks, the Three Bears and Intensive Care Unit Utilization: Delivering Enough Intensive Care But Not Too Much. A Narrative Review. Pulm Ther 2020; 6:23-33. [PMID: 32048242 PMCID: PMC7229100 DOI: 10.1007/s41030-019-00107-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Indexed: 11/05/2022] Open
Abstract
Professional societies have developed recommendations for patient triage protocols, but wide variations in triage patterns for many acute conditions exist among hospitals in the United States. Differences in hospitals’ triage patterns can be attributed to factors such as physician behavior, hospital policy and real-time conditions such as intensive care unit capacity. The patient safety concern is that patients evaluated for admission to the intensive care unit during times of high intensive care unit capacity may have adverse outcomes related to delays in care. Because standardization of a national triage policy is not feasible due to differing resources available at each hospital, local guidelines should prevail that take into account hospitals’ local resources. The goal would be to better match intensive care unit bed supply with demand.
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Affiliation(s)
- Laura C Myers
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Gabriel Escobar
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Vincent X Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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Confalonieri M, Vitacca M, Scala R, Polverino M, Sabato E, Crescimanno G, Ceriana P, Antonaglia C, Siciliano G, Ring N, Zacchigna S, Salton F, Vianello A. Is early detection of late-onset Pompe disease a pneumologist's affair? A lesson from an Italian screening study. Orphanet J Rare Dis 2019; 14:62. [PMID: 30832705 PMCID: PMC6399888 DOI: 10.1186/s13023-019-1037-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 02/21/2019] [Indexed: 01/14/2023] Open
Abstract
Background Late-onset Pompe disease (LOPD) is a recessive disease caused by α-glucosidase (GAA) deficiency, leading to progressive muscle weakness and/or respiratory failure in children and adults. Respiratory derangement can be the first indication of LOPD, but the diagnosis may be difficult for pneumologists. We hypothesize that assessing the GAA activity in suspected patients by a dried blood spot (DBS) may help the diagnosis of LOPD in the pneumological setting. Population and methods We performed a multicenter DBS survey of patients with suspected LOPD according to a predefined clinical algorithm. From February 2015 to December 2017, 140 patients (57 ± 16 yrs., 80 males) were recruited in 19 Italian pneumological units. The DBS test was performed by a drop of blood collected on absorbent paper. Patients with GAA activity < 2.6 μmol/L/h were considered positive. A second DBS test was performed in the patients positive to the first assay. Patients testing positive at the re-test underwent a skeletal muscle biopsy to determine the GAA enzymatic activity. Results 75 recruited subjects had outpatient access, 65 subjects were admitted for an acute respiratory failure episode. Two patients tested positive in both the first and second DBS test (1.4% prevalence), and the LOPD diagnosis was confirmed through histology, with patients demonstrating a deficient GAA muscle activity (3.6 and 9.1 pmol/min/mg). A further five subjects were positive in the first DBS test but were not confirmed at re-test. The two positive cases were both diagnosed after hospitalization for acute respiratory failure and need of noninvasive ventilation. Most of the recruited patients had reduced maximal respiratory pressures (MIP 50 ± 27% and MEP 55 ± 27% predicted), restrictive pattern (FEV1/FVC 81.3 ± 13.6) and hypoxaemia (PaO2 70.9 ± 14.5 mmHg). Respiratory symptoms were present in all the patients, but only 48.6% of them showed muscle weakness in the pelvic girdle and/or in the scapular girdle (35.7%). Conclusions DBS GAA activity test may be a powerful screening tool among pneumologists, particularly in the acute setting. A simple clinical algorithm may aid in the selection of patients on which to administer the DBS test.
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Affiliation(s)
- Marco Confalonieri
- Pneumology Unit, Dept. of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy. .,Pulmonology Unit, University Hospital of Cattinara, Strada di Fiume 447, 34149, Trieste, Italy.
| | - Michele Vitacca
- ICS S. Maugeri, Care and Research Institute, Respiratory Rehabilitation Unit, Lumezzane, Bs, Italy
| | - Raffaele Scala
- Pneumology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Mario Polverino
- Lung Diseases High Specialty Institute, Medical Sciences Department, Scafati, Salerno, Italy
| | - Eugenio Sabato
- Pneumology Unit, "A. Perrino" General Hospital, Brindisi, Italy
| | - Grazia Crescimanno
- Institute of Biomedicine and Molecular Immunology, Italian National Research Council, Palermo, Italy
| | - Piero Ceriana
- ICS S. Maugeri, Care and Research Institute, Pulmonary Rehabilitation Unit, Pavia, Italy
| | - Caterina Antonaglia
- Pneumology Unit, Dept. of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Gabriele Siciliano
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Pisa, Italy
| | - Nadja Ring
- International Centre for Genetic Engineering and Biotechnology, Trieste, Italy
| | - Serena Zacchigna
- International Centre for Genetic Engineering and Biotechnology, Trieste, Italy
| | - Francesco Salton
- Pneumology Unit, Dept. of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Andrea Vianello
- Respiratory Pathophysiology and Intensive Care Unit, Department of Cardio-Thoracic, University-City Hospital of Padova, Padova, Italy
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Scala R, Schultz M, Bos LDJ, Artigas A. New Surviving Sepsis Campaign guidelines: back to the art of medicine. Eur Respir J 2018; 52:52/1/1701818. [PMID: 29997181 DOI: 10.1183/13993003.01818-2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 05/26/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Raffaele Scala
- Pulmonology and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy
| | - Marcus Schultz
- Dept of Intensive Care, Academic Medical Center, Amsterdam, the Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Lieuwe D J Bos
- Dept of Intensive Care, Academic Medical Center, Amsterdam, the Netherlands.,Dept of Respiratory Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Antonio Artigas
- Corporación Sanitaria Universitaria Parc Tauli, CIBER Enfermedades Respiratorias, Autonomous University of Barcelona, Sabadell, Spain
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12
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Scala R, Pisani L. Noninvasive ventilation in acute respiratory failure: which recipe for success? Eur Respir Rev 2018; 27:27/149/180029. [DOI: 10.1183/16000617.0029-2018] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 04/16/2018] [Indexed: 12/12/2022] Open
Abstract
Noninvasive positive-pressure ventilation (NPPV) to treat acute respiratory failure has expanded tremendously over the world in terms of the spectrum of diseases that can be successfully managed, the locations of its application and achievable goals.The turning point for the successful expansion of NPPV is its ability to achieve the same physiological effects as invasive mechanical ventilation with the avoidance of the life-threatening risks correlated with the use of an artificial airway.Cardiorespiratory arrest, extreme psychomotor agitation, severe haemodynamic instability, nonhypercapnic coma and multiple organ failure are absolute contraindications for NPPV. Moreover, pitfalls of NPPV reduce its rate of success; consistently, a clear plan of what to do in case of NPPV failure should be considered, especially for patients managed in unprotected setting. NPPV failure is likely to be reduced by the application of integrated therapeutic tools in selected patients handled by expert teams.In conclusion, NPPV has to be considered as a rational art and not just as an application of science, which requires the ability of clinicians to both choose case-by-case the best “ingredients” for a “successful recipe” (i.e.patient selection, interface, ventilator, interface,etc.) and to avoid a delayed intubation if the ventilation attempt fails.
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13
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Ergan B, Nasiłowski J, Winck JC. How should we monitor patients with acute respiratory failure treated with noninvasive ventilation? Eur Respir Rev 2018; 27:27/148/170101. [PMID: 29653949 DOI: 10.1183/16000617.0101-2017] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 12/21/2017] [Indexed: 12/12/2022] Open
Abstract
Noninvasive ventilation (NIV) is currently one of the most commonly used support methods in hypoxaemic and hypercapnic acute respiratory failure (ARF). With advancing technology and increasing experience, not only are indications for NIV getting broader, but more severe patients are treated with NIV. Depending on disease type and clinical status, NIV can be applied both in the general ward and in high-dependency/intensive care unit settings with different environmental opportunities. However, it is important to remember that patients with ARF are always very fragile with possible high mortality risk. The delay in recognition of unresponsiveness to NIV, progression of respiratory failure or new-onset complications may result in devastating and fatal outcomes. Therefore, it is crucial to understand that timely action taken according to monitoring variables is one of the key elements for NIV success. The purpose of this review is to outline basic and advanced monitoring techniques for NIV during an ARF episode.
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Affiliation(s)
- Begum Ergan
- Division of Intensive Care, Dept of Pulmonary and Critical Care, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey .,Both authors contributed equally
| | - Jacek Nasiłowski
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Warsaw, Poland.,Both authors contributed equally
| | - João Carlos Winck
- Northern Rehabilitation Centre Cardio-Pulmonary Group, Vila Nova de Gaia, Respiratory Medicine Units of Trofa-Saúde Alfena Hospital and Braga-Centro Hospital and Faculty of Medicine University of Porto, Porto, Portugal
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14
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Brill AK, Pickersgill R, Moghal M, Morrell MJ, Simonds AK. Mask pressure effects on the nasal bridge during short-term noninvasive ventilation. ERJ Open Res 2018; 4:00168-2017. [PMID: 29637077 PMCID: PMC5890023 DOI: 10.1183/23120541.00168-2017] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 02/23/2018] [Indexed: 11/05/2022] Open
Abstract
The aim of this study was to assess the influence of different masks, ventilator settings and body positions on the pressure exerted on the nasal bridge by the mask and subjective comfort during noninvasive ventilation (NIV). We measured the pressure over the nasal bridge in 20 healthy participants receiving NIV via four different NIV masks (three oronasal masks, one nasal mask) at three different ventilator settings and in the seated or supine position. Objective pressure measurements were obtained with an I-Scan pressure-mapping system. Subjective comfort of the mask fit was assessed with a visual analogue scale. The masks exerted mean pressures between 47.6±29 mmHg and 91.9±42.4 mmHg on the nasal bridge. In the supine position, the pressure was lower in all masks (57.1±31.9 mmHg supine, 63.9±37.3 mmHg seated; p<0.001). With oronasal masks, a change of inspiratory positive airway pressure (IPAP) did not influence the objective pressure over the nasal bridge. Subjective discomfort was associated with higher IPAP and positively correlated with the pressure on the skin. Objective measurement of pressure on the skin during mask fitting might be helpful for mask selection. Mask fitting in the supine position should be considered in the clinical routine.
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Affiliation(s)
- Anne-Kathrin Brill
- Academic Unit of Sleep and Breathing, National Heart and Lung Institute, Imperial College, London, UK.,Dept of Pulmonary Medicine, University and University Hospital Bern, Bern, Switzerland
| | - Rachel Pickersgill
- Academic Unit of Sleep and Breathing, National Heart and Lung Institute, Imperial College, London, UK
| | - Mohammad Moghal
- Academic Unit of Sleep and Breathing, National Heart and Lung Institute, Imperial College, London, UK.,National Institute for Health Research (NIHR) Respiratory Biomedical Research Unit, Royal Brompton and Harefield Foundation Trust and Imperial College, London, UK
| | - Mary J Morrell
- Academic Unit of Sleep and Breathing, National Heart and Lung Institute, Imperial College, London, UK.,National Institute for Health Research (NIHR) Respiratory Biomedical Research Unit, Royal Brompton and Harefield Foundation Trust and Imperial College, London, UK
| | - Anita K Simonds
- Academic Unit of Sleep and Breathing, National Heart and Lung Institute, Imperial College, London, UK.,National Institute for Health Research (NIHR) Respiratory Biomedical Research Unit, Royal Brompton and Harefield Foundation Trust and Imperial College, London, UK
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15
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Abstract
PURPOSE Intermediate care units (IMCUs) represent an alternative care setting with nurse staffing levels between those of the general ward and the intensive care unit (ICU). Despite rising prevalence, little is known about IMCU practices across US hospitals. The purpose of this study is to characterize utilization patterns and assess for variation. MATERIALS AND METHODS A 14-item survey was distributed to a random nationwide sample of pulmonary and critical care physicians between January and April 2017. RESULTS A total of 51 physicians from 24 different states completed the survey. Each response represented a unique institution, the majority of which were public (59%), academic (73%), and contained at least 1 IMCU (65%). Of the IMCUs surveyed, 58% operated as 1 mixed unit that admitted medical, cardiac, and surgical patients as opposed to having separate subspecialty units. Ninety-one percent of units admitted step-down patients from the ICU, but 39% of units accepted a mix of step-up patients, step-down patients, postoperative patients, and patients from the emergency department. Intensivists managed care in 21% of units whereas 36% had no intensivist involvement. CONCLUSION Organization practices vary considerably between IMCUs across institutions. The impact of different organization practices on patient outcomes should be assessed.
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Affiliation(s)
- Blair Wendlandt
- Division of Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Thomas Bice
- Division of Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Shannon Carson
- Division of Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Lydia Chang
- Division of Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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16
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Hukins C, Wong M, Murphy M, Upham J. Management of hypoxaemic respiratory failure in a Respiratory High-dependency Unit. Intern Med J 2017; 47:784-792. [DOI: 10.1111/imj.13403] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 02/10/2017] [Accepted: 02/13/2017] [Indexed: 01/25/2023]
Affiliation(s)
- Craig Hukins
- Department of Respiratory and Sleep Medicine; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Mimi Wong
- School of Medicine; The University of Queensland; Brisbane Queensland Australia
| | - Michelle Murphy
- Department of Respiratory and Sleep Medicine; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - John Upham
- Department of Respiratory and Sleep Medicine; Princess Alexandra Hospital; Brisbane Queensland Australia
- School of Medicine; The University of Queensland; Brisbane Queensland Australia
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17
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Nicolini A, Scala R, Cavalleri MA. Real-time visual-feedback mask-fitting during non-invasive ventilation: A 'technological' gain over 'human' sensing? Respirology 2017; 22:1245-1246. [PMID: 28612978 DOI: 10.1111/resp.13101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 05/24/2017] [Indexed: 11/28/2022]
Affiliation(s)
| | - Raffaele Scala
- Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
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18
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Abstract
Acute respiratory failure is a frequent complication in elderly patients especially if suffering from chronic cardio-pulmonary diseases. Non-invasive mechanical ventilation constitutes a successful therapeutic tool in the elderly as, like in younger patients, it is able to prevent endotracheal intubation in a wide range of acute conditions; moreover, this ventilator technique is largely applied in the elderly in whom invasive mechanical ventilation is considered not appropriated. Furthermore, the integration of new technological devices, ethical issues and environment of treatment are still largely debated in the treatment of acute respiratory failure in the elderly. This review aims at reporting and critically analyzing the peculiarities in the management of acute respiratory failure in elderly people, the role of noninvasive mechanical ventilation, the potential advantages of applying alternative or integrated therapeutic tools (i.e. high-flow nasal cannula oxygen therapy, non-invasive and invasive cough assist devices and low-flow carbon-dioxide extracorporeal systems), drawbacks in physician’s communication and “end of life” decisions. As several areas of this topic are not supported by evidence-based data, this report takes in account also “real-life” data as well as author’s experience. The choice of the setting and of the timing of non-invasive mechanical ventilation in elderly people with advanced cardiopulmonary disease should be carefully evaluated together with the chance of using integrated or alternative supportive devices. Last but not least, economic and ethical issues may often challenges the behavior of the physicians towards elderly people who are hospitalized for acute respiratory failure at the end stage of their cardiopulmonary and neoplastic diseases.
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Ozsancak Ugurlu A, Sidhom SS, Khodabandeh A, Ieong M, Mohr C, Lin DY, Buchwald I, Bahhady I, Wengryn J, Maheshwari V, Hill NS. Where is Noninvasive Ventilation Actually Delivered for Acute Respiratory Failure? Lung 2015. [PMID: 26210474 DOI: 10.1007/s00408-015-9766-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Few studies have examined locations of noninvasive ventilation (NIV) application for acute respiratory failure (ARF). We aimed to track actual locations of NIV delivery and related outcomes. METHODS Observational cohort study based at 8 acute care hospitals in Massachusetts on adult patients admitted for ARF requiring ventilatory support during pre-determined time intervals. RESULTS Of 1225 ventilator starts, 499 were NIV; 209 (42%) in intensive care units (ICU), 185 (37%) in emergency departments (ED), 91 (18%) on general wards, and 14 (3%) in other units. Utilization (% of all ventilator starts) (1), success (2) and in-hospital mortality (3) rates for patients initiated on NIV in ICU, ED, and general and other wards were (1) 38, 36, 73, and 52%, (2) 60, 77, 68, and 93% and (3) 25, 12, 17, and 0%, respectively (p < 0.05 for all). Patients with acute-on-chronic lung disease (ACLD) and acute pulmonary edema (APE) were begun on NIV most often in EDs and patients with 'de novo' ARF and neurologic disorders most often in ICU's. Approximately 2/3 of patients begun on NIV outside of ICUs were transferred within 72 h to ICUs, wards or other units. CONCLUSIONS Most NIV starts occurred in ICUs and EDs but utilization rate was highest (>50%) on general wards where a fifth of NIV starts took place. Actual location depended on etiology of ARF as patients with ACLD and APE were started more often in EDs and "de novo" ARF in ICU. NIV failure and mortality rates were higher in ICUs related to the greater proportion of patients with "de novo" ARF.
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Affiliation(s)
- Aylin Ozsancak Ugurlu
- Department of Pulmonary Disease, Baskent University, Oymaci sok. No: 2, 34662, Altunizade/Istanbul, Turkey.
| | - Samy S Sidhom
- Pulmonary Department, Newton-Wellesley Hospital, Newton, MA, USA
| | | | | | | | | | | | | | | | | | - Nicholas S Hill
- Department of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
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20
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Confalonieri M, Trevisan R, Demsar M, Lattuada L, Longo C, Cifaldi R, Jevnikar M, Santagiuliana M, Pelusi L, Pistelli R. Opening of a respiratory intermediate care unit in a general hospital: impact on mortality and other outcomes. Respiration 2015; 90:235-42. [PMID: 26160422 DOI: 10.1159/000433557] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 05/16/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Respiratory intermediate care units (RICUs) are specialized areas aimed at optimizing the cost-benefit ratio of care. No data exist about the impact of opening a RICU on hospital outcomes. OBJECTIVES We wondered if opening a RICU may improve the outcomes of patients with acute respiratory failure (ARF), acute exacerbation of chronic obstructive pulmonary disease (AECOPD), or community-acquired pneumonia (CAP). METHODS We analyzed the discharge abstracts of 2,372 admissions to the RICU and internal medicine units (IMUs) for ARF, AECOPD, and CAP. The IMUs at the Hospital of Trieste comprise emergency and internal wards. In order to investigate the determinants of outcomes, a matched case-control study was performed using clinical records. RESULTS The in-hospital mortality rate was lower in the RICU vs. IMUs (5.4 vs. 19.1%, p = 0.0001). Statistical differences did not change when comparing the RICU with the emergency and internal wards. After adjusting for potential confounders, the risk of death for patients with CAP, AECOPD, or ARF was significantly higher in the IMUs than in the RICU (OR 6.90, 3.19, and 6.7, respectively, p < 0.04). Both the frequency of transfer to the ICU (6 vs. 12%, p = 0.0001, OR 0.38) and the hospital stay (9.3 vs. 12.1 days, p = 0.0001) were reduced in patients admitted to the RICU compared to those admitted to non-RICUs. Significant differences were found in care management concerning chest physiotherapy, mechanical ventilation, antibiotics, and corticosteroids. CONCLUSIONS The opening of a RICU may be advantageous to reduce in-hospital mortality, the need for ICU admission, and the hospital stay of patients with AECOPD, CAP, and ARF. Better use of care resources contributed to better patient management in the RICU.
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Affiliation(s)
- Marco Confalonieri
- Department of Pneumology and Respiratory Intermediate Care Unit, University Hospital of Cattinara, Trieste, Italy
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22
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Abstract
Stepdown beds provide an intermediate level of care for patients with requirements somewhere between that of the general ward and the intensive care unit. Models of care include incorporation of stepdown beds into intensive care units, stand-alone units, or incorporation of beds into standard wards. Stepdown beds may be used to provide a higher level of care for patients deteriorating on a ward ("step-up"), a lower level of care for patients transitioning out of intensive care ("stepdown") or a lateral transfer of care from a recovery room for postoperative patients. These units are one possible strategy to improve critical care cost-effectiveness and patient flow without compromising quality, but these potential benefits remain primarily theoretical as few patient-level studies provide concrete evidence. This narrative review provides a general overview of the theory of stepdown beds in the care of hospitalized patients and a summary of what is known about their impact on patient flow and outcomes and highlights areas for future research.
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Affiliation(s)
- Meghan Prin
- 1 Department of Anesthesiology, Columbia University, New York, New York
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23
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Scala R, Esquinas A. Noninvasive mechanical ventilation for very old patients with limitations of care: is the ICU the most appropriate setting? Crit Care 2012; 16:429. [PMID: 22694869 PMCID: PMC3580635 DOI: 10.1186/cc11352] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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24
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Affiliation(s)
- N Ambrosino
- Weaning and Rehabilitation Unit, Auxilium Vitae Rehabilitation Centre, Volterra, Italy.
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25
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Abstract
The burden of acute respiratory failure (ARF) has become one of the greatest epidemiological challenges for the modern health systems. Consistently, the imbalance between the increasing prevalence of acutely de-compensated respiratory diseases and the shortage of high-daily cost ICU beds has stimulated new health cost-effective solutions. Respiratory High-Dependency Care Units (RHDCU) provide a specialised environment for patients who require an "intermediate" level of care between the ICU and the ward, where non-invasive monitoring and assisted ventilation techniques are preferentially applied. Since they are dedicated to the management of "mono-organ" decompensations, treatment of ARF patients in RHDCU avoids the dangerous "under-assistance" in the ward and unnecessary "over-assistance" in ICU. RHDCUs provide a specialised quality of care for ARF with health resources optimisation and their spread throughout health systems has been driven by their high-level of expertise in non-invasive ventilation (NIV), weaning from invasive ventilation, tracheostomy care, and discharging planning for ventilator-dependent patients.
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Affiliation(s)
- Raffaele Scala
- UO Pneumologia, UTIR e Interventistica, Campo di Marte Hospital, Lucca, Italy.
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