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Nazeer SA, Chen HY, Chauhan SP, Blackwell SC, Sibai B, Fishel Bartal M. Gestational diabetes mellitus and late preterm birth: outcomes with and without antenatal corticosteroid exposure. Am J Obstet Gynecol MFM 2024; 6:101268. [PMID: 38242498 DOI: 10.1016/j.ajogmf.2023.101268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 09/27/2023] [Revised: 12/14/2023] [Accepted: 12/19/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND Unlike pregestational diabetes mellitus, the American College of Obstetricians and Gynecologists recommends antenatal corticosteroids in those with gestational diabetes mellitus at risk for preterm birth. However, this recommendation is based on limited data, only 10.6% of the Antenatal Late Preterm Steroids study sample had gestational diabetes mellitus. There is a paucity of data on the risk of neonatal respiratory and other morbidity in this population. OBJECTIVE This study aimed to examine respiratory outcomes in parturients with gestational diabetes mellitus who received antenatal corticosteroids and delivered during the late preterm period vs those who did not. STUDY DESIGN This population-based cohort study used the US Vital Statistics dataset between 2016 to 2020. The inclusion criteria were singleton, nonanomalous individuals who delivered between 34.0 to 36.6 weeks with gestational diabetes mellitus and known status of antepartum corticosteroid exposure. The primary outcome, a composite neonatal adverse outcome, included Apgar score <5 at 5 minutes, immediate assisted ventilation, assisted ventilation >6 hours, surfactant use, seizure, or neonatal mortality. The secondary outcome was a composite maternal adverse outcome, including maternal blood transfusion, ruptured uterus, unplanned hysterectomy, and admission to the intensive care unit. Multivariable Poisson regression models were used to estimate adjusted relative risks and 95% confidence intervals. Average annual percent change was calculated to assess changes in rates of corticosteroid exposure over the study period. RESULTS Of 19 million births during the study period, 110,197 (0.6%) met the inclusion criteria, and among them, 23,028 (20.9%) individuals with gestational diabetes mellitus received antenatal corticosteroids. The rate of antenatal steroid exposure remained stable over the 5 years (APC=10.7; 95% confidence interval, -5.4 to 29.4). The composite neonatal adverse outcome was significantly higher among those who received corticosteroids than among those who did not (137.1 vs 216.5 per 1000 live births; adjusted relative risk 1.24; 95% confidence interval, 1.20-1.28). Three components of the composite neonatal adverse outcome-immediate assisted ventilation, intubation >6 hours, and surfactant use-were significantly higher with exposure than without. In addition, the composite maternal adverse outcome was significantly higher among those who received corticosteroids (adjusted relative risk, 1.34; 95% confidence interval, 1.18-1.52). Three components of the composite maternal adverse outcome-admission to intensive care unit, blood transfusion, and unplanned hysterectomy-were significantly higher among the exposed group. Subgroup analysis, among large for gestational age, by gestational age, and race and ethnicity, confirm the trend of increased likelihood of adverse outcomes with exposure to corticosteroid. CONCLUSION Individuals with gestational diabetes mellitus and antenatal corticosteroid exposure, who delivered in the late preterm, were at higher risk of neonatal and maternal adverse outcomes than those unexposed to corticosteroid.
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Affiliation(s)
- Sarah A Nazeer
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX (Drs Nazeer, Chen, Chauhan, Blackwell, Sibai, and Fishel Bartal).
| | - Han-Yang Chen
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX (Drs Nazeer, Chen, Chauhan, Blackwell, Sibai, and Fishel Bartal)
| | - Suneet P Chauhan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX (Drs Nazeer, Chen, Chauhan, Blackwell, Sibai, and Fishel Bartal)
| | - Sean C Blackwell
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX (Drs Nazeer, Chen, Chauhan, Blackwell, Sibai, and Fishel Bartal)
| | - Baha Sibai
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX (Drs Nazeer, Chen, Chauhan, Blackwell, Sibai, and Fishel Bartal)
| | - Michal Fishel Bartal
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX (Drs Nazeer, Chen, Chauhan, Blackwell, Sibai, and Fishel Bartal); Department of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (Dr Fishel Bartal)
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Pérez J, Accoce M, Dorado JH, Gilgado DI, Navarro E, Cardoso GP, Telias I, Rodriguez PO, Brochard L. Failure of First Transition to Pressure Support Ventilation After Spontaneous Awakening Trials in Hypoxemic Respiratory Failure: Influence of COVID-19. Crit Care Explor 2023; 5:e0968. [PMID: 37644972 PMCID: PMC10461949 DOI: 10.1097/cce.0000000000000968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVES To describe the rate of failure of the first transition to pressure support ventilation (PSV) after systematic spontaneous awakening trials (SATs) in patients with acute hypoxemic respiratory failure (AHRF) and to assess whether the failure is higher in COVID-19 compared with AHRF of other etiologies. To determine predictors and potential association of failure with outcomes. DESIGN Retrospective cohort study. SETTING Twenty-eight-bedded medical-surgical ICU in a private hospital (Argentina). PATIENTS Subjects with arterial pressure of oxygen (AHRF to Fio2 [Pao2/Fio2] < 300 mm Hg) of different etiologies under controlled mechanical ventilation (MV). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We collected data during controlled ventilation within 24 hours before SAT followed by the first PSV transition. Failure was defined as the need to return to fully controlled MV within 3 calendar days of PSV start. A total of 274 patients with AHRF (189 COVID-19 and 85 non-COVID-19) were included. The failure occurred in 120 of 274 subjects (43.7%) and was higher in COVID-19 versus non-COVID-19 (49.7% and 30.5%; p = 0.003). COVID-19 diagnosis (odds ratio [OR]: 2.22; 95% CI [1.15-4.43]; p = 0.020), previous neuromuscular blockers (OR: 2.16; 95% CI [1.15-4.11]; p = 0.017) and higher fentanyl dose (OR: 1.29; 95% CI [1.05-1.60]; p = 0.018) increased the failure chances. Higher BMI (OR: 0.95; 95% CI [0.91-0.99]; p = 0.029), Pao2/Fio2 (OR: 0.87; 95% CI [0.78-0.97]; p = 0.017), and pH (OR: 0.61; 95% CI [0.38-0.96]; p = 0.035) were protective. Failure groups had higher 60-day ventilator dependence (p < 0.001), MV duration (p < 0.0001), and ICU stay (p = 0.001). Patients who failed had higher mortality in COVID-19 group (p < 0.001) but not in the non-COVID-19 (p = 0.083). CONCLUSIONS In patients with AHRF of different etiologies, the failure of the first PSV attempt was 43.7%, and at a higher rate in COVID-19. Independent risk factors included COVID-19 diagnosis, fentanyl dose, previous neuromuscular blockers, acidosis and hypoxemia preceding SAT, whereas higher BMI was protective. Failure was associated with worse outcomes.
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Affiliation(s)
- Joaquin Pérez
- Intensive Care Unit, Sanatorio Anchorena, San Martín, Buenos Aires, Argentina
- Intensive Care Unit, Hospital Carlos G. Durand, Ciudad Autónoma de Buenos Aires, Argentina
| | - Matías Accoce
- Intensive Care Unit, Sanatorio Anchorena, San Martín, Buenos Aires, Argentina
- Intensive Care Unit, Hospital de Quemados "Dr. Arturo Humberto Illia," Ciudad Autónoma de Buenos Aires, Argentina
- Faculta de Medicina y Ciencias de la Salud, Universidad Abierta Interamericana, Ciudad Autónoma de Buenos Aires, Argentina
| | - Javier H Dorado
- Intensive Care Unit, Sanatorio Anchorena, San Martín, Buenos Aires, Argentina
| | - Daniela I Gilgado
- Intensive Care Unit, Sanatorio Anchorena, San Martín, Buenos Aires, Argentina
- Intensive Care Unit, Hospital Carlos G. Durand, Ciudad Autónoma de Buenos Aires, Argentina
| | - Emiliano Navarro
- Respiratory and physical therapy department, Centro del Parque, Ciudad Autónoma de Buenos Aires, Argentina
| | - Gimena P Cardoso
- Intensive Care Unit, Sanatorio Anchorena, San Martín, Buenos Aires, Argentina
- Intensive Care Unit, Hospital Donación Francisco Santojanni, Ciudad Autónoma de Buenos Aires, Argentina
| | - Irene Telias
- Department of Critical Care, Keenan Research Center, Li Ka Shing Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - Pablo O Rodriguez
- Intensive Care Unit, Hospital Universitario Sede Pombo (Instituto Universitario CEMIC, Centro de Educación Médica e Investigaciones Clínicas), Ciudad Autónoma de Buenos Aires, Argentina
- Pneumonology section, CEMIC, Ciudad Autónoma de Buenos Aires, Argentina
| | - Laurent Brochard
- Department of Critical Care, Keenan Research Center, Li Ka Shing Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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Ware LB, Soleymanlou N, McAuley DF, Estrada V, Diaz GA, Lacamera P, Kaste R, Choi W, Gupta A, Welte T. TRPC6 inhibitor (BI 764198) to reduce risk and severity of ARDS due to COVID-19: a phase II randomised controlled trial. Thorax 2023; 78:816-824. [PMID: 37024277 PMCID: PMC10359525 DOI: 10.1136/thorax-2022-219668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/31/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Despite the availability of COVID-19 vaccinations, there remains a need to investigate treatments to reduce the risk or severity of potentially fatal complications of COVID-19, such as acute respiratory distress syndrome (ARDS). This study evaluated the efficacy and safety of the transient receptor potential channel C6 (TRPC6) inhibitor, BI 764198, in reducing the risk and/or severity of ARDS in patients hospitalised for COVID-19 and requiring non-invasive, supplemental oxygen support (oxygen by mask or nasal prongs, oxygen by non-invasive ventilation or high-flow nasal oxygen). METHODS Multicentre, double-blind, randomised phase II trial comparing once-daily oral BI 764198 (n=65) with placebo (n=64) for 28 days (+2-month follow-up). PRIMARY ENDPOINT proportion of patients alive and free of mechanical ventilation at day 29. Secondary endpoints: proportion of patients alive and discharged without oxygen (day 29); occurrence of either in-hospital mortality, intensive care unit admission or mechanical ventilation (day 29); time to first response (clinical improvement/recovery); ventilator-free days (day 29); and mortality (days 15, 29, 60 and 90). RESULTS No difference was observed for the primary endpoint: BI 764198 (83.1%) versus placebo (87.5%) (estimated risk difference -5.39%; 95% CI -16.08 to 5.30; p=0.323). For secondary endpoints, a longer time to first response (rate ratio 0.67; 95% CI 0.46 to 0.99; p=0.045) and longer hospitalisation (+3.41 days; 95% CI 0.49 to 6.34; p=0.023) for BI 764198 versus placebo was observed; no other significant differences were observed. On-treatment adverse events were similar between trial arms and more fatal events were reported for BI 764198 (n=7) versus placebo (n=2). Treatment was stopped early based on an interim observation of a lack of efficacy and an imbalance of fatal events (Data Monitoring Committee recommendation). CONCLUSIONS TRPC6 inhibition was not effective in reducing the risk and/or severity of ARDS in patients with COVID-19 requiring non-invasive, supplemental oxygen support. TRIAL REGISTRATION NUMBER NCT04604184.
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Affiliation(s)
- Lorraine B Ware
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Nima Soleymanlou
- TA Cardio-Metabolism & Respiratory, Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut, USA
| | - Danny Francis McAuley
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast Wellcome-Wolfson Institute for Experimental Medicine, Belfast, UK
| | - Vicente Estrada
- Hospital Clínico San Carlos, IdISSC; CIBERINFE, Madrid, Spain
| | - George A Diaz
- Section of Infectious Diseases, Providence Regional Medical Center Everett, Everett, Washington, USA
| | - Peter Lacamera
- Division of Pulmonary and Critical Care Medicine, St Elizabeth's Medical Center, Boston, Massachusetts, USA
| | - Renee Kaste
- TA Cardio-Metabolism & Respiratory, Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut, USA
| | - Wansuk Choi
- TA Cardio-Metabolism & Respiratory, Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut, USA
| | - Abhya Gupta
- TA Inflammation Medicine, Boehringer Ingelheim International GmbH, Biberach an der Riss, Germany
| | - Tobias Welte
- Department of Pneumology, Hannover Medical School, Hannover, Niedersachsen, Germany
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Colombo SM, Scaravilli V, Castagna L, Zanella A, Brioni M, Abbruzzese C, Grasselli G. Neural pressure support ventilation as a novel strategy to improve patient-ventilator synchrony in adult respiratory distress syndrome. Br J Anaesth 2023; 130:e430-e432. [PMID: 36725377 DOI: 10.1016/j.bja.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/01/2023] [Accepted: 01/01/2023] [Indexed: 02/01/2023] Open
Affiliation(s)
- Sebastiano M Colombo
- Department of Anaesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Vittorio Scaravilli
- Department of Anaesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy.
| | - Luigi Castagna
- Department of Anaesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Zanella
- Department of Anaesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Matteo Brioni
- Department of Anaesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Chiara Abbruzzese
- Department of Anaesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- Department of Anaesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Hansen-Flaschen J, Ackrivo J. Practical Guide to Management of Long-term Noninvasive Ventilation for Adults with Chronic Neuromuscular Disease. Respir Care 2023:respcare.10349. [PMID: 36922023 PMCID: PMC10353174 DOI: 10.4187/respcare.10349] [Citation(s) in RCA: 4] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 12/19/2022] [Indexed: 03/17/2023]
Abstract
Recent technological advances in respiratory support and monitoring have dramatically enhanced the utility of long-term noninvasive ventilation. Improvements in quality of life and prolonged survival at home have been demonstrated for several common chronic neuromuscular diseases. Many adults with progressive neuromuscular respiratory disease can now comfortably maintain normal ventilation at home to near total respiratory muscle paralysis without needing a tracheostomy. However, current practice in many communities falls short of that potential. Mastery of the new technology calls for detailed awareness of the respiratory cycle, expert knowledge of mechanical devices, facial interfaces, quantitative monitoring tools for home ventilation, and a willingness to stay current in a rapidly expanding body of clinical research. The depth and breadth of the expertise required to manage home assisted ventilation is giving rise to a new focused medical subspecialty in chronic respiratory failure at the interface between pulmonology, critical care, and sleep medicine. For clinicians seeking pragmatic "how to" guidance, this primer presents a comprehensive, physician-directed management approach to long-term noninvasive ventilation of adults with chronic neuromuscular respiratory disease. Bilevel devices, portable ventilators, ventilation modalities, terminology, and monitoring strategies are reviewed in detail. Building on that knowledge base, we present a step-by-step guide to initiation, refinement, and maintenance of home noninvasive ventilation that is tailored to patient-centered goals of therapy. The "quantitative" approach recommended here fully incorporates routine monitoring of home assisted ventilation using technologies that have only recently become widely available including cloud-based device telemonitoring and noninvasive measurements of blood gases. Strategies for troubleshooting and problem solving are included.
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Affiliation(s)
- John Hansen-Flaschen
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jason Ackrivo
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Soundoulounaki S, Sylligardos E, Akoumianaki E, Sigalas M, Kondili E, Georgopoulos D, Trahanias P, Vaporidi K. Neural Network-Enabled Identification of Weak Inspiratory Efforts during Pressure Support Ventilation Using Ventilator Waveforms. J Pers Med 2023; 13:jpm13020347. [PMID: 36836581 PMCID: PMC9966968 DOI: 10.3390/jpm13020347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/10/2023] [Accepted: 02/15/2023] [Indexed: 02/19/2023] Open
Abstract
During pressure support ventilation (PSV), excessive assist results in weak inspiratory efforts and promotes diaphragm atrophy and delayed weaning. The aim of this study was to develop a classifier using a neural network to identify weak inspiratory efforts during PSV, based on the ventilator waveforms. Recordings of flow, airway, esophageal and gastric pressures from critically ill patients were used to create an annotated dataset, using data from 37 patients at 2-5 different levels of support, computing the inspiratory time and effort for every breath. The complete dataset was randomly split, and data from 22 patients (45,650 breaths) were used to develop the model. Using a One-Dimensional Convolutional Neural Network, a predictive model was developed to characterize the inspiratory effort of each breath as weak or not, using a threshold of 50 cmH2O*s/min. The following results were produced by implementing the model on data from 15 different patients (31,343 breaths). The model predicted weak inspiratory efforts with a sensitivity of 88%, specificity of 72%, positive predictive value of 40%, and negative predictive value of 96%. These results provide a 'proof-of-concept' for the ability of such a neural-network based predictive model to facilitate the implementation of personalized assisted ventilation.
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Affiliation(s)
- Stella Soundoulounaki
- Department of Intensive Care Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Emmanouil Sylligardos
- Institute of Computer Science, Foundation for Research and Technology—Hellas (FORTH), 70013 Heraklion, Greece
- Department of Computer Science, University of Crete, 70013 Heraklion, Greece
| | - Evangelia Akoumianaki
- Department of Intensive Care Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Markos Sigalas
- Institute of Computer Science, Foundation for Research and Technology—Hellas (FORTH), 70013 Heraklion, Greece
| | - Eumorfia Kondili
- Department of Intensive Care Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Dimitrios Georgopoulos
- Department of Intensive Care Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Panos Trahanias
- Institute of Computer Science, Foundation for Research and Technology—Hellas (FORTH), 70013 Heraklion, Greece
- Department of Computer Science, University of Crete, 70013 Heraklion, Greece
| | - Katerina Vaporidi
- Department of Intensive Care Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
- Correspondence:
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Elverson J, Evans H, Dewhurst F. Palliation, end of life care and ventilation withdrawal in neuromuscular disorders. Chron Respir Dis 2023; 20:14799731231175911. [PMID: 37199317 DOI: 10.1177/14799731231175911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND/OBJECTIVES The role of palliative care in the support of patients with neuromuscular disorders (NMDs) is generally recognised in spite of the scarcity of condition-specific evidence in the literature. METHODS We have focussed specifically on palliative and end-of-life care for patients whose neuromuscular disease has an impact on their respiratory function. Reviewing the literature, we have examined where existing palliative care knowledge can be applied to the specific challenges faced by patients with NMDs, identifying where lessons learnt during the management of one condition may need to be judiciously applied to others. RESULTS We highlight lessons for clinical practice centring on six themes: management of complex symptoms; crisis support; relief of caregiver strain; coordination of care; advance care planning; and end of life care. CONCLUSIONS The principles of palliative care are well suited to addressing the complex needs of patients with NMDs and should be considered early in the course of illness rather than limited to care at the end of life. Embedding relationships with specialist palliative care services as part of the wider neuromuscular multidisciplinary team can facilitate staff education and ensure timely referral when more complex palliative care problems arise.
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Affiliation(s)
- Joanna Elverson
- St Oswald's Hospice, Gosforth, UK
- Children's Holistic Integrated Palliative Care Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Hayley Evans
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Felicity Dewhurst
- St Oswald's Hospice, Gosforth, UK
- Population Health Sciences Institute, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, UK
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Fritsch SJ, Dreher M, Simon TP, Marx G, Bickenbach J. Haemoglobin value and red blood cell transfusions in prolonged weaning from mechanical ventilation: a retrospective observational study. BMJ Open Respir Res 2022; 9:9/1/e001228. [PMID: 35701072 PMCID: PMC9198721 DOI: 10.1136/bmjresp-2022-001228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 02/09/2022] [Accepted: 05/30/2022] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION The role of haemoglobin (Hb) value and red blood cell (RBC) transfusions in prolonged weaning from mechanical ventilation (MV) is still controversial. Pathophysiological considerations recommend a not too restrictive transfusion strategy, whereas adverse effects of transfusions are reported. We aimed to investigate the association between Hb value, RBC transfusion and clinical outcome of patients undergoing prolonged weaning from MV. METHODS We performed a retrospective, single-centred, observational study including patients being transferred to a specialised weaning unit. Data on demographic characteristics, comorbidities, current and past medical history and the current course of treatment were collected. Weaning failure and mortality were chosen as primary and secondary endpoint, respectively. Differences between transfused and non-transfused patients were analysed. To evaluate the impact of different risk factors including Hb value and RBC transfusion on clinical outcome, a multivariate logistic regression analysis was used. RESULTS 184 patients from a specialised weaning unit were analysed, of whom 36 (19.6%) failed to be weaned successfully. In-hospital mortality was 18.5%. 90 patients (48.9%) required RBC transfusion during the weaning process, showing a significantly lower Hb value (g/L) (86.3±5.3) than the non-transfusion group (95.8±10.5). In the multivariate regression analysis (OR 3.24; p=0.045), RBC transfusion was associated with weaning failure. However, the transfusion group had characteristics indicating that these patients were still in a more critical state of disease. CONCLUSIONS In our analysis, the need for RBC transfusion was independently associated with weaning failure. However, it is unclear whether the transfusion itself should be considered an independent risk factor or an additional symptom of a persistent critical patient condition.
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Affiliation(s)
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Tim-Philipp Simon
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Gernot Marx
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Johannes Bickenbach
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
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Ball L, Sutherasan Y, Fiorito M, Dall'Orto A, Maiello L, Vargas M, Robba C, Brunetti I, D'Antini D, Raimondo P, Huhle R, Schultz MJ, Rocco PRM, Gama de Abreu M, Pelosi P. Effects of Different Levels of Variability and Pressure Support Ventilation on Lung Function in Patients With Mild-Moderate Acute Respiratory Distress Syndrome. Front Physiol 2021; 12:725738. [PMID: 34744766 PMCID: PMC8569865 DOI: 10.3389/fphys.2021.725738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 06/15/2021] [Accepted: 09/17/2021] [Indexed: 11/14/2022] Open
Abstract
Background: Variable pressure support ventilation (vPSV) is an assisted ventilation mode that varies the level of pressure support on a breath-by-breath basis to restore the physiological variability of breathing activity. We aimed to compare the effects of vPSV at different levels of variability and pressure support (ΔPS) in patients with acute respiratory distress syndrome (ARDS). Methods: This study was a crossover randomized clinical trial. We included patients with mild to moderate ARDS already ventilated in conventional pressure support ventilation (PSV). The study consisted of two blocks of interventions, and variability during vPSV was set as the coefficient of variation of the ΔPS level. In the first block, the effects of three levels of variability were tested at constant ΔPS: 0% (PSV0%, conventional PSV), 15% (vPSV15%), and 30% (vPSV30%). In the second block, two levels of variability (0% and variability set to achieve ±5 cmH2O variability) were tested at two ΔPS levels (baseline ΔPS and ΔPS reduced by 5 cmH2O from baseline). The following four ventilation strategies were tested in the second block: PSV with baseline ΔPS and 0% variability (PSVBL) or ±5 cmH2O variability (vPSVBL), PSV with ΔPS reduced by 5 cmH2O and 0% variability (PSV−5) or ±5 cmH2O variability (vPSV−5). Outcomes included gas exchange, respiratory mechanics, and patient-ventilator asynchronies. Results: The study enrolled 20 patients. In the first block of interventions, oxygenation and respiratory mechanics parameters did not differ between vPSV15% and vPSV30% compared with PSV0%. The variability of tidal volume (VT) was higher with vPSV15% and vPSV30% compared with PSV0%. The incidence of asynchronies and the variability of transpulmonary pressure (PL) were higher with vPSV30% compared with PSV0%. In the second block of interventions, different levels of pressure support with and without variability did not change oxygenation. The variability of VT and PL was higher with vPSV−5 compared with PSV−5, but not with vPSVBL compared with PSVBL. Conclusion: In patients with mild-moderate ARDS, the addition of variability did not improve oxygenation at different pressure support levels. Moreover, high variability levels were associated with worse patient-ventilator synchrony. Clinical Trial Registration:www.clinicaltrials.gov, identifier: NCT01683669.
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Affiliation(s)
- Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Anesthesia and Intensive Care, Ospedale Policlinico San Martino Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genova, Italy
| | - Yuda Sutherasan
- Division of Pulmonary and Pulmonary Critical Care Medicine, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Martina Fiorito
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Antonella Dall'Orto
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Lorenzo Maiello
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Maria Vargas
- Department of Neurosciences, Reproductive and Odonthostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Anesthesia and Intensive Care, Ospedale Policlinico San Martino Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genova, Italy
| | - Iole Brunetti
- Anesthesia and Intensive Care, Ospedale Policlinico San Martino Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genova, Italy
| | - Davide D'Antini
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Department of Anaesthesia and Intensive Care, University of Foggia, Foggia, Italy
| | - Pasquale Raimondo
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Department of Anaesthesia and Intensive Care, University of Foggia, Foggia, Italy
| | - Robert Huhle
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Marcus J Schultz
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Department of Intensive Care, Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam University Medical Centers, Location Academic Medical Center (AMC), Amsterdam, Netherlands.,Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Anesthesia and Intensive Care, Ospedale Policlinico San Martino Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genova, Italy
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10
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Proklou A, Papadakis E, Kondili E, Tserlikakis N, Karageorgos V, Konstantinou I, Triantafyllidou E, Bolaki M, Georgopoulos D, Vaporidi K. Ventilatory Ratio Threshold for Unassisted Breathing: A Retrospective Exploratory Analysis. Respir Care 2021; 66:1699-1703. [PMID: 34521761 PMCID: PMC9993549 DOI: 10.4187/respcare.09208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/05/2022]
Abstract
BACKGROUND The ventilatory ratio (VR) is a simple index of ventilatory efficiency and dead space. Because increased dead space and high ventilatory demands impose a limitation to unassisted ventilation, and may predispose patients to injurious strong efforts during assisted ventilation, evaluation of the VR could provide helpful information during weaning. We hypothesize that there is a threshold of VR associated with tolerance of unassisted breathing. METHODS In a retrospective analysis, we included subjects ventilated in a control mode for at least 24 h, who were successfully liberated from mechanical ventilation, without use of noninvasive ventilation, and discharged alive from the ICU. We focused on the successful weaning attempts (the last, if more than one was performed) and evaluated the VR at the beginning and at the end of the assisted ventilation period. RESULTS We examined 2,000 medical records and included in our analysis 572 subjects (age: 68 y, R5-95 = 25-85, 68% male) with main admission diagnosis of respiratory failure (23%), sepsis (11%), brain injury (34%), and postoperative (14%). The VR at the beginning and the end of the assisted ventilation period was 1.5 (R5-95 = 1-2.1) and 1.4 (R5-95 = 1-2), respectively. The median duration of assisted ventilation in subjects with a VR ≥ 2 at the beginning of the assisted ventilation period was 3 d (R5-95 = 0-14 d), significantly longer than in those with a VR < 2, 0.5 d (R5-95 = 0-8 d, P < .001). CONCLUSIONS Successful liberation from assisted ventilation was associated with a VR < 2. A VR > 2 was associated with longer duration of weaning. The VR could be used as an additional tool to facilitate the decision-making process during weaning.
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Affiliation(s)
- Athanasia Proklou
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
| | - Eleftherios Papadakis
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
| | - Eumorfia Kondili
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
| | - Nikos Tserlikakis
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
| | - Vlasios Karageorgos
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
| | - Ioannis Konstantinou
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
| | - Eugenia Triantafyllidou
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
| | - Maria Bolaki
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
| | - Dimitrios Georgopoulos
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
| | - Katerina Vaporidi
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece.
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11
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Naughton PE, Sheers N, Berlowitz DJ, Howard ME, McKim DA, Katz SL. Objective measurement of lung volume recruitment therapy: laboratory and clinical validation. BMJ Open Respir Res 2021; 8:8/1/e000918. [PMID: 34326156 PMCID: PMC8323364 DOI: 10.1136/bmjresp-2021-000918] [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: 03/10/2021] [Accepted: 07/11/2021] [Indexed: 11/29/2022] Open
Abstract
Lung volume recruitment manoeuvres are often prescribed to maintain respiratory health in neuromuscular disease. Unfortunately, no current system accurately records delivered dose. This study determined the performance characteristics of a novel, objective, manual lung volume recruitment bag counter (‘the counter’) with bench and healthy volunteer testing, as well as in individuals with neuromuscular disease. We undertook (1) bench test determination of activation threshold, (2) bench and healthy volunteer fidelity testing during simulated patient interface leak and different pressure compressions and (3) comparisons with self-report in individuals with neuromuscular disease. The data are reported as summary statistics, compression counts, percentage of recorded versus delivered compressions and concordance (Cohen’s kappa (K) and absolute agreement).
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Affiliation(s)
- Phoebe E Naughton
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia.,Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
| | - Nicole Sheers
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia.,Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - David J Berlowitz
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia .,Physiotherapy, Austin Health, Heidelberg, Victoria, Australia.,Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia.,Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Mark E Howard
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia.,Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Douglas A McKim
- Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Respiratory Medicine, Ottawa Hospital Rehabilitation Centre, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sherri L Katz
- Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Respiratory Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
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12
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van Oort PM, Nijsen TM, White IR, Knobel HH, Felton T, Rattray N, Lawal O, Bulut M, Ahmed W, Artigas A, Povoa PR, Martin-Loeches I, Weda H, Goodacre R, Schultz MJ, Dark PM, Fowler SJ, Bos LD. Untargeted Molecular Analysis of Exhaled Breath as a Diagnostic Test for Ventilator-Associated Lower Respiratory Tract Infections (BreathDx). Thorax 2021; 77:79-81. [PMID: 34088787 PMCID: PMC8685633 DOI: 10.1136/thoraxjnl-2021-217362] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 05/11/2021] [Indexed: 11/23/2022]
Abstract
Patients suspected of ventilator-associated lower respiratory tract infections (VA-LRTIs) commonly receive broad-spectrum antimicrobial therapy unnecessarily. We tested whether exhaled breath analysis can discriminate between patients suspected of VA-LRTI with confirmed infection, from patients with negative cultures. Breath from 108 patients suspected of VA-LRTI was analysed by gas chromatography-mass spectrometry. The breath test had a sensitivity of 98% at a specificity of 49%, confirmed with a second analytical method. The breath test had a negative predictive value of 96% and excluded pneumonia in half of the patients with negative cultures. Trial registration number: UKCRN ID number 19086, registered May 2015.
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Affiliation(s)
| | | | - Iain R White
- Laboratory for Environmental and Life Sciences, University of Nova Gorica, Nova Gorica, Slovenia.,Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Hugo H Knobel
- Materials Analysis, Eurofins Materials Science Netherlands BV, Eindhoven, The Netherlands
| | - Timothy Felton
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | | | - Oluwasola Lawal
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | | | - Waqar Ahmed
- Manchester Institute of Biotechnology, University of Manchester, Manchester, UK
| | - Antonio Artigas
- Critical Care Centre, Corporació Sanitària I Universitaria Parc Taulí-Hospital De Sabadell-Ciber Enfermedades Respiratorias, Sabadell, Barcelona, Spain
| | - Pedro R Povoa
- Intensive Care, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | | | | | - Royston Goodacre
- Department of Biochemistry, University of Liverpool, Liverpool, UK
| | - Marcus J Schultz
- Intensive Care, Amsterdam UMC Location AMC, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Paul M Dark
- Intensive care, University of Manchester, Manchester, UK
| | - Stephen J Fowler
- Manchester University NHS Foundation Trust - Wythenshawe Hospital, Manchester, UK.,Division of Infection, Immunity and Respiratory Medicine, NIHR's Manchester Biomedical Research Centre (BRC), the University of Manchester, Manchester, UK
| | - Lieuwe D Bos
- Intensive Care, Amsterdam UMC Location AMC, Amsterdam, The Netherlands .,Respiratory Medicine, Amsterdam UMC Location AMC, Amsterdam, Netherlands
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13
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Griffiths M, Meade S, Summers C, McAuley DF, Proudfoot A, Baladia MM, Dark PM, Diomede K, Finney SJ, Forni LG, Meadows C, Naldrett IA, Patel B, Perkins GD, Samaan MA, Sharifi L, Suntharalingam G, Tarmey NT, Young HF, Wise MP, Irving PM. RAND appropriateness panel to determine the applicability of UK guidelines on the management of acute respiratory distress syndrome (ARDS) and other strategies in the context of the COVID-19 pandemic. Thorax 2021; 77:129-135. [PMID: 34045363 DOI: 10.1136/thoraxjnl-2021-216904] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/25/2021] [Accepted: 04/08/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND COVID-19 has become the most common cause of acute respiratory distress syndrome (ARDS) worldwide. Features of the pathophysiology and clinical presentation partially distinguish it from 'classical' ARDS. A Research and Development (RAND) analysis gauged the opinion of an expert panel about the management of ARDS with and without COVID-19 as the precipitating cause, using recent UK guidelines as a template. METHODS An 11-person panel comprising intensive care practitioners rated the appropriateness of ARDS management options at different times during hospital admission, in the presence or absence of, or varying severity of SARS-CoV-2 infection on a scale of 1-9 (where 1-3 is inappropriate, 4-6 is uncertain and 7-9 is appropriate). A summary of the anonymised results was discussed at an online meeting moderated by an expert in RAND methodology. The modified online survey comprising 76 questions, subdivided into investigations (16), non-invasive respiratory support (18), basic intensive care unit management of ARDS (20), management of refractory hypoxaemia (8), pharmacotherapy (7) and anticoagulation (7), was completed again. RESULTS Disagreement between experts was significant only when addressing the appropriateness of diagnostic bronchoscopy in patients with confirmed or suspected COVID-19. Adherence to existing published guidelines for the management of ARDS for relevant evidence-based interventions was recommended. Responses of the experts to the final survey suggested that the supportive management of ARDS should be the same, regardless of a COVID-19 diagnosis. For patients with ARDS with COVID-19, the panel recommended routine treatment with corticosteroids and a lower threshold for full anticoagulation based on a high index of suspicion for venous thromboembolic disease. CONCLUSION The expert panel found no reason to deviate from the evidence-based supportive strategies for managing ARDS outlined in recent guidelines.
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Affiliation(s)
- Mark Griffiths
- NHLI, Imperial College London, London, UK .,Barts Heart Centre, St Bartholomews Hospital, London, UK.,William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Susanna Meade
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Charlotte Summers
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Daniel Francis McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen's University Belfast, Belfast, UK.,Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
| | | | | | - Paul M Dark
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Kate Diomede
- East Kent Hospitals NHS Foundation Trust, London, UK
| | - Simon J Finney
- Perioperative Medicine, Barts Health NHS Trust, London, UK
| | - Lui G Forni
- Intensive Care, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK.,University of Surrey Faculty of Health and Medical Sciences, Guildford, Surrey, UK
| | - Chris Meadows
- Department of Critical Care, Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Ian A Naldrett
- University of West London, Ealing, UK.,Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Brijesh Patel
- AICU, Royal Brompton & Harefield NHS Foundation Trust, London, UK.,Anaesthetics, Imperial College London, London, UK
| | | | - Mark A Samaan
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | | | - Nicholas T Tarmey
- Academic Department of Critical Care, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | | | - Matt P Wise
- Adult Critical Care, University Hopsital of Wales, Cardiff, UK
| | - Peter M Irving
- Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Immunology and Microbial Sciences, King's College London, London, UK
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14
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Mac Giolla Eain M, O'Sullivan A, Joyce M, MacLoughlin R. In vitro evaluation of disposable transport ventilators with combination aerosol therapy. BMJ Open Respir Res 2021; 8:8/1/e000739. [PMID: 33771812 PMCID: PMC8006849 DOI: 10.1136/bmjresp-2020-000739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 08/10/2020] [Revised: 11/30/2020] [Accepted: 03/13/2021] [Indexed: 11/17/2022] Open
Abstract
Background The COVID-19 pandemic has highlighted the need for alternative short-term, reliable means to aid in the treatment of patients requiring ventilatory support. Concurrent aerosol drug delivery is often prescribed to such patients. As such, this study examines one such short-term option, the disposable gas-powered transport ventilator to effectively deliver aerosol therapy. Factors such as aerosol generator type, patient breathing pattern, humidification and nebuliser position within the respiratory circuit were also examined. Methods Aerosol drug delivery characterisation was undertaken using two different disposable transport ventilators (DTVs). Two different nebuliser types, a closed circuit vibrating mesh nebuliser (VMN) and an open circuit jet nebuliser (JN), at different locations in a respiratory circuit, proximal and distal to an endotracheal tube (ETT), with and without passive humidification, were evaluated in simulated adult and paediatric patients. Results Placement of a nebuliser proximal to the ETT (VMN: 25.19%–34.15% and JN: 3.14%–8.92%), and the addition of a heat and moisture exchange filter (VMN: 32.37%–40.43% and JN: 5.60%–9.91%) resulted in the largest potential lung dose in the adult patient model. Irrespective of nebuliser position and humidification in the respiratory circuit, use of the VMN resulted in the largest potential lung dose (%). A similar trend was recorded in the paediatric model data, where the largest potential lung dose was recorded with both nebuliser types placed proximal to the ETT (VMN: 8.12%–10.89% and JN: 2.15%–3.82%). However, the addition of a heat and moisture exchange filter had no statistically significant effect on the potential lung dose (%) a paediatric patient would receive (p>>0.05). Conclusions This study demonstrates that transport ventilators, such as DTVs, can be used concurrently with aerosol generators to effectively deliver aerosolised medication in both adult and paediatric patients.
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Affiliation(s)
| | | | - Mary Joyce
- R&D Science and Emerging Technologies, Aerogen Ltd, Galway, Ireland
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15
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Jeganathan V, Rautela L, Conti S, Saravanan K, Rigoni A, Graco M, Hannan LM, Howard ME, Berlowitz DJ. Typical within and between person variability in non-invasive ventilator derived variables among clinically stable, long-term users. BMJ Open Respir Res 2021; 8:8/1/e000824. [PMID: 33664121 PMCID: PMC7934749 DOI: 10.1136/bmjresp-2020-000824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 11/04/2020] [Revised: 01/24/2021] [Accepted: 01/26/2021] [Indexed: 12/11/2022] Open
Abstract
Background Despite increasing capacity to remotely monitor non-invasive ventilation (NIV), how remote data varies from day to day and person to person is poorly described. Methods Single-centre, 2-month, prospective study of clinically stable adults on long-term NIV which aimed to document NIV-device variability. Participants were switched to a ventilator with tele-monitoring capabilities. Ventilation settings and masking were not altered. Raw, extensible markup language data files were provided directly from Philips Respironics (EncoreAnywhere). A nested analysis of variance was conducted on each ventilator variable to apportion the relative variation between and within participants. Results Twenty-nine people were recruited (four withdrew, one had insufficient data for analyses; 1364 days of data). Mean age was 54.0 years (SD 18.4), 58.3% male with body mass index of 37.0 kg/m2 (13.7). Mean adherence was 8.53 (2.23) hours/day and all participants had adherence >4 hours/day. Variance in ventilator-derived indices was predominantly driven by differences between participants; usage (61% between vs 39% within), Apnoea–Hypopnoea Index (71% vs 29%), unintentional (64% vs 36%) and total leak (83% vs 17%), tidal volume (93% vs 7%), minute ventilation (92% vs 8%), respiratory rate (92% vs 8%) and percentage of triggered breaths (93% vs 7%). Interpretation In this clinically stable cohort, all device-derived indices were more varied between users than the day-to-day variation within individuals. We speculate that normative ranges and thresholds for clinical intervention need to be individualised, and further research is necessary to determine the clinically important relationships between clinician targets for therapy and patient-reported outcomes.
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Affiliation(s)
- Vishnu Jeganathan
- Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia.,Respiratory and Sleep Medicine, Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
| | - Linda Rautela
- Respiratory and Sleep Medicine, Institute for Breathing and Sleep, Heidelberg, Victoria, Australia.,Department of Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
| | - Simon Conti
- Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia.,Respiratory and Sleep Medicine, Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
| | - Krisha Saravanan
- Respiratory and Sleep Medicine, Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
| | - Alyssa Rigoni
- Respiratory and Sleep Medicine, Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
| | - Marnie Graco
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia.,Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Liam M Hannan
- Respiratory and Sleep Medicine, Institute for Breathing and Sleep, Heidelberg, Victoria, Australia.,Respiratory Medicine, Northern Health, Epping, Victoria, Australia
| | - Mark E Howard
- Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia.,Respiratory and Sleep Medicine, Institute for Breathing and Sleep, Heidelberg, Victoria, Australia.,Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
| | - David J Berlowitz
- Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia .,Respiratory and Sleep Medicine, Institute for Breathing and Sleep, Heidelberg, Victoria, Australia.,Institute for Breathing and Sleep, Heidelberg, Victoria, Australia.,Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
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16
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Tyrrell CSB, Mytton OT, Gentry SV, Thomas-Meyer M, Allen JLY, Narula AA, McGrath B, Lupton M, Broadbent J, Ahmed A, Mavrodaris A, Abdul Pari AA. Managing intensive care admissions when there are not enough beds during the COVID-19 pandemic: a systematic review. Thorax 2021; 76:302-312. [PMID: 33334908 PMCID: PMC7892390 DOI: 10.1136/thoraxjnl-2020-215518] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/28/2020] [Accepted: 10/19/2020] [Indexed: 12/17/2022]
Abstract
The surge in cases of severe COVID-19 has resulted in clinicians triaging intensive care unit (ICU) admissions in places where demand has exceeded capacity. In order to assist difficult triage decisions, clinicians require clear guidelines on how to prioritise patients. Existing guidelines show significant variability in their development, interpretation, implementation and an urgent need for a robust synthesis of published guidance. To understand how to manage which patients are admitted to ICU, and receive mechanical ventilatory support, during periods of high demand during the COVID-19 pandemic, a systematic review was performed. Databases of indexed literature (Medline, Embase, Web of Science, and Global Health) and grey literature (Google.com and MedRxiv), published from 1 January until 2 April 2020, were searched. Search terms included synonyms of COVID-19, ICU, ventilation, and triage. Only formal written guidelines were included. There were no exclusion criteria based on geographical location or publication language. Quality appraisal of the guidelines was performed using the Appraisal of Guidelines for Research and Evaluation Instrument II (AGREE II) and the Appraisal of Guidelines for Research and Evaluation Instrument Recommendation EXcellence (AGREE REX) appraisal tools, and key themes related to triage were extracted using narrative synthesis. Of 1902 unique records identified, nine relevant guidelines were included. Six guidelines were national or transnational level guidance (UK, Switzerland, Belgium, Australia and New Zealand, Italy, and Sri Lanka), with one state level (Kansas, USA), one international (Extracorporeal Life Support Organization) and one specific to military hospitals (Department of Defense, USA). The guidelines covered several broad themes: use of ethical frameworks, criteria for ICU admission and discharge, adaptation of criteria as demand changes, equality across health conditions and healthcare systems, decision-making processes, communication of decisions, and guideline development processes. We have synthesised the current guidelines and identified the different approaches taken globally to manage the triage of intensive care resources during the COVID-19 pandemic. There is limited consensus on how to allocate the finite resource of ICU beds and ventilators, and a lack of high-quality evidence and guidelines on resource allocation during the pandemic. We have developed a set of factors to consider when developing guidelines for managing intensive care admissions, and outlined implications for clinical leads and local implementation.
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Affiliation(s)
| | - Oliver T Mytton
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
- Public Health England, East of England, Cambridge, UK
| | - Sarah V Gentry
- Public Health England, East of England, Cambridge, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - John Lee Y Allen
- Oxford University Hospitals, University of Oxford, Oxford, UK
- Global Tracheostomy Collaborative, Boston, Massachusetts, USA
| | - Antony A Narula
- Global Tracheostomy Collaborative, Boston, Massachusetts, USA
| | - Brendan McGrath
- Global Tracheostomy Collaborative, Boston, Massachusetts, USA
- Manchester Academic Critical Care Research Group (MACC), The University of Manchester, Manchester, UK
| | - Martin Lupton
- Faculty of Medicine, Imperial College London, London, UK
| | - Jo Broadbent
- Public Health England, East of England, Cambridge, UK
| | - Aliko Ahmed
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
- Public Health England, East of England, Cambridge, UK
| | - Angelique Mavrodaris
- Public Health England, East of England, Cambridge, UK
- Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Anees Ahmed Abdul Pari
- Public Health England, East of England, Cambridge, UK
- Cambridge Judge Business School, University of Cambridge, Cambridge, UK
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17
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Slocum C, Shea C, Goldstein R, Zafonte R. Early Trauma Indicators and Rehabilitation Outcomes in Traumatic Spinal Cord Injury. Top Spinal Cord Inj Rehabil 2021; 26:253-260. [PMID: 33536730 DOI: 10.46292/sci20-00017] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Objectives To investigate the relationship between early trauma indicators and neurologic recovery after traumatic SCI using standardized outcome measures from the ISNCSCI examination and standardized functional outcome measures for rehabilitation populations. Methods This is a retrospective review of merged, prospectively collected, multicenter data from the Spinal Cord Injury Model Systems (SCIMS) database and institutional trauma databases from five academic medical centers across the United States. Functional status at inpatient rehabilitation discharge and change in severity and level of injury from initial SCI to inpatient rehabilitation discharge were analyzed to assess neurologic recovery for patients with traumatic SCI. Linear and logistic regression with multiple imputation were used for the analyses. Results A total of 209 patients were identified. Mean age at injury was 47.2 ± 18.9 years, 72.4% were male, 22.4% of patients had complete injuries at presentation to the emergency department (ED), and most patients were admitted with cervical SCI. Mean systolic blood pressure (SBP) was 124.1 ± 29.6 mm Hg, mean ED heart rate was 83.7 ± 19.9 bpm, mean O2 saturation was 96.8% ± 4.0%, and mean Glasgow Coma Scale (GCS) score was 13.3 ± 3.9. The average Injury Severity Score (ISS) in this population was 22.4. Linear regression analyses showed that rehabilitation discharge motor FIM was predicted by motor FIM on admission and ISS. Requiring ventilatory support on ED presentation was negatively associated with improvement of ASIA Impairment Scale (AIS) grade at rehabilitation discharge compared with AIS grade after initial injury. Emergency room physiologic measures (SBP, pulse, oxygen saturation) did not predict discharge motor FIM or improvement in AIS grade or neurological level of injury. Conclusion Our study showed a positive association between discharge FIM and ISS and a negative association between ventilatory support at ED presentation and AIS improvement. The absence of any significant association between other physiologic or clinical variables at ED presentation with rehabilitation outcomes suggests important areas for future clinical research.
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Affiliation(s)
- Chloe Slocum
- Harvard Medical School, Boston, Massachusetts.,Spaulding Rehabilitation Hospital, Boston, Massachusetts
| | - Cristina Shea
- Harvard Medical School, Boston, Massachusetts.,Spaulding Rehabilitation Hospital, Boston, Massachusetts
| | - Richard Goldstein
- Harvard Medical School, Boston, Massachusetts.,Spaulding Rehabilitation Hospital, Boston, Massachusetts
| | - Ross Zafonte
- Harvard Medical School, Boston, Massachusetts.,Spaulding Rehabilitation Hospital, Boston, Massachusetts
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18
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Carpagnano GE, Buonamico E, Migliore G, Resta E, Di Lecce V, de Candia ML, Solfrizzi V, Panza F, Resta O. Bilevel and continuous positive airway pressure and factors linked to all-cause mortality in COVID-19 patients in an intermediate respiratory intensive care unit in Italy. Expert Rev Respir Med 2020; 15:853-857. [PMID: 33334197 PMCID: PMC7784777 DOI: 10.1080/17476348.2021.1866546] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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] [Indexed: 01/08/2023]
Abstract
Objectives: In the present single-centered, retrospective, observational study, we reported findings from 78 consecutive laboratory-confirmed COVID-19 patients with moderate-to-severe acute respiratory distress syndrome (ARDS) hospitalized in an intermediate Respiratory Intensive Care Unit, subdividing the patients into two groups according to their clinical outcome, dead patients and discharged patients.Methods: We further subdivided patients depending on the noninvasive respiratory support used during hospitalization.Results: In those patients who died, we found significant older age and higher multimorbidity and higher values of serum lactate dehydrogenase, C-reactive protein, and D-dimer. Among patients who were submitted to bilevel positive airway pressure (BPAP), those who died had a significant shorter number of days in overall length of stay and lower values of arterial oxygen partial pressure to fractional inspired oxygen ratio (PaO2/FiO2 ratio) compared to those who survived. No difference in all-cause mortality was observed between the two different noninvasive respiratory support groups [48% for continuous positive airway pressure (CPAP) and 52% for BPAP].Conclusion: In COVID-19 patients with moderate-to-severe ARDS using BPAP in an intermediate level of hospital care had more factors associated to all-cause mortality (shorter length of stay and lower baseline PaO2/FiO2 ratio) compared to those who underwent CPAP.
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Affiliation(s)
- Giovanna E Carpagnano
- Institute of Respiratory Disease, Department of Basic Medical Science, Neuroscience, and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
| | - Enrico Buonamico
- Institute of Respiratory Disease, Department of Basic Medical Science, Neuroscience, and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
| | - Giovanni Migliore
- Azienda Universitaria Ospedaliera Consorziale, General Director Office, Policlinico Bari, Italy
| | - Emanuela Resta
- Translational Medicine and Health System Management, University of Foggia, Foggia, Italy
| | - Valentina Di Lecce
- Institute of Respiratory Disease, Department of Basic Medical Science, Neuroscience, and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
| | - Maria Luisa de Candia
- Institute of Respiratory Disease, Department of Basic Medical Science, Neuroscience, and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
| | - Vincenzo Solfrizzi
- "Cesare Frugoni" Internal and Geriatric Medicine and Memory Unit, University of Bari "Aldo Moro", Bari, Italy
| | - Francesco Panza
- Population Health Unit, "Salus in Apulia Study", National Institute of Gastroenterology "Saverio De Bellis", Research Hospital, Bari, Italy
| | - Onofrio Resta
- Institute of Respiratory Disease, Department of Basic Medical Science, Neuroscience, and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
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19
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Hadfield D, Rose L, Reid F, Cornelius V, Hart N, Finney C, Penhaligon B, Harris C, Saha S, Noble H, Smith J, Hopkins PA, Rafferty GF. Factors affecting the use of neurally adjusted ventilatory assist in the adult critical care unit: a clinician survey. BMJ Open Respir Res 2020; 7:7/1/e000783. [PMID: 33293357 PMCID: PMC7725091 DOI: 10.1136/bmjresp-2020-000783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 09/24/2020] [Revised: 11/11/2020] [Accepted: 11/12/2020] [Indexed: 11/25/2022] Open
Abstract
Background Neurally adjusted ventilatory assist (NAVA) involves an intricate interaction between patient, clinician and technology. To improve our understanding of this complex intervention and to inform future trials, this survey aimed to examine clinician attitudes, beliefs and barriers to NAVA use in critically ill adults within an institution with significant NAVA experience. Methods A survey of nurses, doctors and physiotherapists in four Intensive Care Units (ICUs) of one UK university-affiliated hospital (75 NAVA equipped beds). The survey consisted of 39 mixed open and structured questions. The hospital had 8 years of NAVA experience prior to the survey. Results Of 466 distributed questionnaires, 301 (64.6%) were returned from 236 nurses (78.4%), 53 doctors (17.6%) and 12 physiotherapists (4.0%). Overall, 207/294 (70.4%) reported clinical experience. Most agreed that NAVA was safe (136/177, 76.8%) and clinically effective (99/176, 56.3%) and most perceived ‘improved synchrony’, ‘improved comfort’ and ‘monitoring the diaphragm’ to be key advantages of NAVA. ‘Technical issues’ (129/189, 68.3%) and ‘NAVA signal problems’ (94/180, 52.2%) were the most cited clinical disadvantage and cause of mode cross-over to Pressure Support Ventilation (PSV), respectively. Most perceived NAVA to be more difficult to use than PSV (105/174, 60.3%), although results were mixed when compared across different tasks. More participants preferred PSV to NAVA for initiating ventilator weaning (93/171 (54.4%) vs 29/171 (17.0%)). A key barrier to use and a consistent theme throughout was ‘low confidence’ in relation to NAVA use. Conclusions In addition to broad clinician support for NAVA, this survey describes technical concerns, low confidence and a perception of difficulty above that associated with PSV. In this context, high-quality training and usage algorithms are critically important to the design and of future trials, to clinician acceptance and to the clinical implementation and future success of NAVA.
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Affiliation(s)
- Daniel Hadfield
- Critical Care Research, King's College Hospital, London, UK .,King's College London, Centre for Human and Applied Physiological Sciences, London, UK
| | - Louise Rose
- King's College London Florence Nightingale School of Nursing and Midwifery, London, London, UK.,Faculty of Nursing, Midwifery and Palliative Care, King's College, London, UK
| | - Fiona Reid
- King's College London School of Population Health and Environmental Sciences, London, London, UK
| | | | - Nicholas Hart
- Centre for Human and Applied Physiological Sciences, King's College London School of Biomedical Sciences, London, UK.,Lane Fox Respiratory Unit, Guy's and St Thomas' Hospitals NHS Trust, London, London, UK
| | - Clare Finney
- Critical Care Research, King's College Hospital, London, UK
| | | | - Clare Harris
- Critical Care Research, King's College Hospital, London, UK
| | - Sian Saha
- Critical Care Research, King's College Hospital, London, UK
| | - Harriet Noble
- Critical Care Research, King's College Hospital, London, UK
| | - John Smith
- Critical Care Research, King's College Hospital, London, UK
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20
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Kaltsakas G, Hart N. Turbocharging NIV: how to increase oxygen delivery in home mechanical ventilators. Thorax 2020; 76:3. [PMID: 33097603 DOI: 10.1136/thoraxjnl-2020-216117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 09/28/2020] [Accepted: 09/28/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Georgios Kaltsakas
- Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK .,Centre for Human & Applied Physiological Sciences, King's College London, London, UK.,Lane Fox Respiratory Service, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nicholas Hart
- Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human & Applied Physiological Sciences, King's College London, London, UK.,Lane Fox Respiratory Service, Guy's and St Thomas' NHS Foundation Trust, London, UK
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21
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Steinbach R, Prell T, Gaur N, Stubendorff B, Roediger A, Ilse B, Witte OW, Grosskreutz J. Triage of Amyotrophic Lateral Sclerosis Patients during the COVID-19 Pandemic: An Application of the D50 Model. J Clin Med 2020; 9:jcm9092873. [PMID: 32899481 PMCID: PMC7565659 DOI: 10.3390/jcm9092873] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 07/28/2020] [Revised: 08/30/2020] [Accepted: 09/02/2020] [Indexed: 12/11/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive neuromuscular disease, the management of which requires the continuous provision of multidisciplinary therapies. Owing to the novel coronavirus disease (COVID-19) pandemic, regular contact with ALS patients at our center was severely restricted and patient care was at risk by delay of supportive therapies. We established a triage system based on the D50 disease progression model and were thus able to identify a prospective cohort with high disease aggressiveness (D50 < 30). Thirty-seven patients with highly aggressive disease were actively offered follow-up, either via telephone or on-site, depending on their disease-specific needs and abilities. We describe here the procedures, obstacles, and results of these prescient efforts during the restrictions caused by COVID-19 in the period between March and June 2020. In conclusion, four patients with highly aggressive disease were initiated with non-invasive ventilation and two received a gastrostomy. We could show that a comparable amount of advanced care was induced in a retrospective cohort within a similar time period one year prior to the COVID-19 outbreak. Our workflow to identify high-risk patients via D50 model metrics can be easily implemented and integrated within existing centers. It helped to maintain a high quality of advanced care planning for our ALS patients.
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Affiliation(s)
- Robert Steinbach
- Hans Berger Department of Neurology, Jena University Hospital, 07747 Jena, Germany; (T.P.); (N.G.); (B.S.); (A.R.); (B.I.); (O.W.W.); (J.G.)
- Correspondence: ; Tel.: +49-3641-9323-587
| | - Tino Prell
- Hans Berger Department of Neurology, Jena University Hospital, 07747 Jena, Germany; (T.P.); (N.G.); (B.S.); (A.R.); (B.I.); (O.W.W.); (J.G.)
- Center for Healthy Ageing, Jena University Hospital, 07747 Jena, Germany
| | - Nayana Gaur
- Hans Berger Department of Neurology, Jena University Hospital, 07747 Jena, Germany; (T.P.); (N.G.); (B.S.); (A.R.); (B.I.); (O.W.W.); (J.G.)
| | - Beatrice Stubendorff
- Hans Berger Department of Neurology, Jena University Hospital, 07747 Jena, Germany; (T.P.); (N.G.); (B.S.); (A.R.); (B.I.); (O.W.W.); (J.G.)
| | - Annekathrin Roediger
- Hans Berger Department of Neurology, Jena University Hospital, 07747 Jena, Germany; (T.P.); (N.G.); (B.S.); (A.R.); (B.I.); (O.W.W.); (J.G.)
| | - Benjamin Ilse
- Hans Berger Department of Neurology, Jena University Hospital, 07747 Jena, Germany; (T.P.); (N.G.); (B.S.); (A.R.); (B.I.); (O.W.W.); (J.G.)
| | - Otto W. Witte
- Hans Berger Department of Neurology, Jena University Hospital, 07747 Jena, Germany; (T.P.); (N.G.); (B.S.); (A.R.); (B.I.); (O.W.W.); (J.G.)
- Center for Healthy Ageing, Jena University Hospital, 07747 Jena, Germany
| | - Julian Grosskreutz
- Hans Berger Department of Neurology, Jena University Hospital, 07747 Jena, Germany; (T.P.); (N.G.); (B.S.); (A.R.); (B.I.); (O.W.W.); (J.G.)
- Center for Healthy Ageing, Jena University Hospital, 07747 Jena, Germany
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22
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Tse BC, Block B, Figueroa H, Yao R. Adverse neonatal outcomes associated with pregestational diabetes mellitus in infants born preterm. Am J Obstet Gynecol MFM 2020; 2:100213. [PMID: 33345923 DOI: 10.1016/j.ajogmf.2020.100213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/06/2020] [Accepted: 08/12/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Pregestational diabetes mellitus is associated with a higher risk of adverse pregnancy outcomes. Based on the available data, it is unclear whether infants born preterm to mothers with pregestational diabetes mellitus are at a higher risk of adverse outcomes than other preterm infants. OBJECTIVE This study aimed to quantify the neonatal complications associated with pregestational diabetes mellitus in infants born preterm. STUDY DESIGN This was a retrospective cohort study of all nonanomalous singleton neonates born in Texas from 2006 to 2014. Analysis was limited to births between 24 and 36 weeks' gestation and excluded multiple births, stillbirths, fetal congenital anomalies, neonates born to mothers with gestational diabetes mellitus, and neonates born to mothers with chronic hypertension. Results were stratified by pregestational diabetes mellitus status. Neonatal outcomes of interest included infant death, neonatal intensive care unit admission, low 5-minute Apgar scores, assisted ventilation of >6 hours, surfactant administration, and seizures. Multivariate logistic regression analysis was performed to estimate the association between pregestational diabetes mellitus and neonatal outcomes controlling for potential confounding variables. RESULTS After predefined exclusions, 277,210 births were analyzed, 4164 of which were to mothers with pregestational diabetes mellitus. The comparison group consisted of mothers without pregestational diabetes mellitus. The preterm infant mortality rates between the pregestational diabetic and nondiabetic groups were similar. However, after adjusting for confounding variables, there was an increased risk of infant mortality for preterm neonates born to mothers with pregestational diabetes mellitus. In infants born preterm, pregestational diabetes mellitus was associated with an increased risk of infant death, low 5-minute Apgar score, prolonged assisted ventilation, surfactant requirement, and neonatal intensive care unit admission. Neonates born before 34 weeks' gestation had an increased risk of assisted ventilation of >6 hours, neonatal intensive care unit admission, and seizure. Neonates born to mothers with pregestational diabetes mellitus in the late preterm period between 34 and 36 weeks' gestation had an increased risk of low Apgar score at 5 minutes, assisted ventilation of >6 hours, surfactant use, and neonatal intensive care unit admission. CONCLUSION Pregestational diabetes mellitus is associated with a higher risk of adverse neonatal outcomes in infants born preterm.
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Affiliation(s)
- Beverly C Tse
- Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA
| | - Barry Block
- Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA
| | - Heather Figueroa
- Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA
| | - Ruofan Yao
- Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA.
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23
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Burns GP, Lane ND, Tedd HM, Deutsch E, Douglas F, West SD, Macfarlane JG, Wiscombe S, Funston W. Improved survival following ward-based non-invasive pressure support for severe hypoxia in a cohort of frail patients with COVID-19: retrospective analysis from a UK teaching hospital. BMJ Open Respir Res 2020; 7:7/1/e000621. [PMID: 32624494 PMCID: PMC7337887 DOI: 10.1136/bmjresp-2020-000621] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [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: 04/24/2020] [Revised: 06/11/2020] [Accepted: 06/23/2020] [Indexed: 11/06/2022] Open
Abstract
Since the outbreak of COVID-19 in China in December 2019, a pandemic has rapidly developed on a scale that has overwhelmed health services in a number of countries. COVID-19 has the potential to lead to severe hypoxia; this is usually the cause of death if it occurs. In a substantial number of patients, adequate arterial oxygenation cannot be achieved with supplementary oxygen therapy alone. To date, there has been no clear guideline endorsement of ward-based non-invasive pressure support (NIPS) for severely hypoxic patients who are deemed unlikely to benefit from invasive ventilation. We established a ward-based NIPS service for COVID-19 PCR-positive patients, with severe hypoxia, and in whom escalation to critical care for invasive ventilation was not deemed appropriate. A retrospective analysis of survival in these patients was undertaken. Twenty-eight patients were included. Ward-based NIPS for severe hypoxia was associated with a 50% survival in this cohort. This compares favourably with Intensive Care National Audit and Research Centre survival data following invasive ventilation in a less frail, less comorbid and younger population. These results suggest that ward-based NIPS should be considered as a treatment option in an integrated escalation strategy in all units managing respiratory failure secondary to COVID-19.
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Affiliation(s)
- Graham P Burns
- Department of Respiratory Medicine, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK .,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Nicholas D Lane
- Department of Respiratory Medicine, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Hilary M Tedd
- Department of Respiratory Medicine, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | - Elizabeth Deutsch
- Department of Respiratory Medicine, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | - Florence Douglas
- Department of Respiratory Medicine, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | - Sophie D West
- Department of Respiratory Medicine, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Jim G Macfarlane
- Department of Respiratory Medicine, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | - Sarah Wiscombe
- Department of Respiratory Medicine, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | - Wendy Funston
- Department of Respiratory Medicine, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
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24
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Anand R, McAuley DF, Blackwood B, Yap C, ONeill B, Connolly B, Borthwick M, Shyamsundar M, Warburton J, Meenen DV, Paulus F, Schultz MJ, Dark P, Bradley JM. Mucoactive agents for acute respiratory failure in the critically ill: a systematic review and meta-analysis. Thorax 2020; 75:623-631. [PMID: 32513777 PMCID: PMC7402561 DOI: 10.1136/thoraxjnl-2019-214355] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 11/19/2019] [Revised: 04/08/2020] [Accepted: 04/21/2020] [Indexed: 12/29/2022]
Abstract
PURPOSE Acute respiratory failure (ARF) is a common cause of admission to intensive care units (ICUs). Mucoactive agents are medications that promote mucus clearance and are frequently administered in patients with ARF, despite a lack of evidence to underpin clinical decision making. The aim of this systematic review was to determine if the use of mucoactive agents in patients with ARF improves clinical outcomes. METHODS We searched electronic and grey literature (January 2020). Two reviewers independently screened, selected, extracted data and quality assessed studies. We included trials of adults receiving ventilatory support for ARF and involving at least one mucoactive agent compared with placebo or standard care. Outcomes included duration of mechanical ventilation. Meta-analysis was undertaken using random-effects modelling and certainty of the evidence was assessed using Grades of Recommendation, Assessment, Development and Evaluation. RESULTS Thirteen randomised controlled trials were included (1712 patients), investigating four different mucoactive agents. Mucoactive agents showed no effect on duration of mechanical ventilation (seven trials, mean difference (MD) -1.34, 95% CI -2.97 to 0.29, I2=82%, very low certainty) or mortality, hospital stay and ventilator-free days. There was an effect on reducing ICU length of stay in the mucoactive agent groups (10 trials, MD -3.22, 95% CI -5.49 to -0.96, I2=89%, very low certainty). CONCLUSION Our findings do not support the use of mucoactive agents in critically ill patients with ARF. The existing evidence is of low quality. High-quality randomised controlled trials are needed to determine the role of specific mucoactive agents in critically ill patients with ARF. PROSPERO REGISTRATION NUMBER CRD42018095408.
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Affiliation(s)
- Rohan Anand
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Daniel F McAuley
- 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
| | - Chee Yap
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Brenda ONeill
- Centre for Health and Rehabilitation Technologies, Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK
| | - Bronwen Connolly
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK.,Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia.,Lane Fox Respiratory Unit, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - Mark Borthwick
- Oxford Critical Care, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Murali Shyamsundar
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - John Warburton
- Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - David van Meenen
- University of Amsterdam, Academic Medical Center Department of Intensive Care Medicine, Amsterdam, Noord-Holland, Netherlands
| | - Frederique Paulus
- University of Amsterdam, Academic Medical Center Department of Intensive Care Medicine, Amsterdam, Noord-Holland, Netherlands
| | - Marcus J Schultz
- University of Amsterdam, Academic Medical Center Department of Intensive Care Medicine, Amsterdam, Noord-Holland, Netherlands.,Mahidol University, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand.,Nuffield Department of Medicine, Oxford University, Oxford, Oxfordshire, UK
| | - Paul Dark
- Division of Infection, Immunity and Respiratory Medicine, NIHR Manchester Biomedical Research Centre, The University of Manchester, Manchester, UK
| | - Judy M Bradley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
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25
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Irvin Babcock C, Paladino L. Advances in the methodology of co-ventilation during a disaster. Thorax 2020; 75:448. [PMID: 32327567 DOI: 10.1136/thoraxjnl-2020-214967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Charlene Irvin Babcock
- Department of Emergency Medicine, Ascension St John Hospital and Medical Center, Detroit, Michigan, USA
| | - Lorenzo Paladino
- Department of Emergency Medicine, State University of New York Downstate Medical Center, Brooklyn, New York, USA.,Department of Emergency Medicine, Kings County Hospital Center, Brooklyn, New York, USA
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26
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Abdo M, Ward I, O'Dell K, Ford B, Pierce JR, Fischer EV, Crooks JL. Impact of Wildfire Smoke on Adverse Pregnancy Outcomes in Colorado, 2007-2015. Int J Environ Res Public Health 2019; 16:E3720. [PMID: 31581673 PMCID: PMC6801422 DOI: 10.3390/ijerph16193720] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/26/2019] [Accepted: 09/28/2019] [Indexed: 11/30/2022]
Abstract
Colorado is regularly impacted by long-range transport of wildfire smoke from upwind regions. This smoke is a major source of ambient PM2.5. Maternal exposure to total PM2.5 during pregnancy has been linked to decreased birth weight and other adverse outcomes, although the impact of wildfire smoke contribution has only recently been investigated. The objective of this study was to estimate associations between adverse pregnancy outcomes and ambient wildfire smoke PM2.5. Wildfire smoke PM2.5 exposures were estimated using a previously published method incorporating ground-based monitors and remote sensing data. Logistic regression models stratified by ZIP code and mixed models with random intercept by ZIP code were used to test for associations. The primary outcomes of interest were preterm birth and birth weight. Secondary outcomes included gestational hypertension, gestational diabetes, neonatal intensive care unit admission, assisted ventilation, small for gestational age, and low birth weight. Exposure to wildfire smoke PM2.5 over the full gestation and during the second trimester were positively associated with pre-term birth (OR = 1.076 (μg/m3)-1 [95% CI = 1.016, 1.139; p = 0.013] and 1.132 (μg/m3)-1 [95% CI = 1.088, 1.178]; p < 0.0001, respectively), while exposure during the first trimester was associated with decreased birth weight (-5.7 g/(μg/m3) [95% CI: -11.1, -0.4; p = 0.036]). Secondary outcomes were mixed.
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Affiliation(s)
- Mona Abdo
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO 80045, USA.
| | | | - Katelyn O'Dell
- Department of Atmospheric Science, Colorado State University, Fort Collins, CO 80523, USA.
| | - Bonne Ford
- Department of Atmospheric Science, Colorado State University, Fort Collins, CO 80523, USA.
| | - Jeffrey R Pierce
- Department of Atmospheric Science, Colorado State University, Fort Collins, CO 80523, USA.
| | - Emily V Fischer
- Department of Atmospheric Science, Colorado State University, Fort Collins, CO 80523, USA.
| | - James L Crooks
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO 80045, USA.
- Division of Biostatistics and Bioinformatics and Department of Biomedical Research, National Jewish Health, Denver, CO 80206, USA.
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27
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Affiliation(s)
- Mark Griffiths
- Barts Heart Centre, St Bartholomews Hospital, London, UK .,NHLI, Imperial College London, London, UK
| | - Eddy Fan
- Toronto General Hospital, Toronto, Ontario, Canada
| | - Simon V Baudouin
- Department of Medicine, Newcastle University, Newcastle upon Tyne, UK
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28
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Lane ND, Brewin K, Hartley TM, Gray WK, Burgess M, Steer J, Bourke SC. Specialist emergency care and COPD outcomes. BMJ Open Respir Res 2018; 5:e000334. [PMID: 30397485 PMCID: PMC6203006 DOI: 10.1136/bmjresp-2018-000334] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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: 06/28/2018] [Revised: 08/10/2018] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION In exacerbation of chronic obstructive pulmonary disease (ECOPD) requiring hospitalisation greater access to respiratory specialists improves outcome, but is not consistently delivered. The UK National Confidential Enquiry into Patient Outcome and Death 2015 enquiry showed over 25% of patients receiving acute non-invasive ventilation (NIV) for ECOPD died in hospital. On 16 June 2015 the Northumbria Specialist Emergency Care Hospital (NSECH) opened, introducing 24/7 specialty consultant on-call, direct admission from the emergency department to specialty wards and 7-day consultant review. A Respiratory Support Unit opened for patients requiring NIV. Before NSECH the NIV service included mandated training and competency assessment, 24/7 single point of access, initiation of ventilation in the emergency department, a door-to-mask time target, early titration of ventilation pressures and structured weaning. Pneumonia or hypercapnic coma complicating ECOPD have never been considered contraindications to NIV. After NSECH staff-patient ratios increased, the NIV pathway was streamlined and structured daily multidisciplinary review introduced. We compared our outcomes with historical and national data. METHODS Patients hospitalised with ECOPD between 1 January 2013 and 31 December 2016 were identified from coding, with ventilation status and radiological consolidation confirmed from records. Age, gender, admission from nursing home, consolidation, revised Charlson Index, key comorbidities, length of stay, and inpatient and 30-day mortality were captured. Outcomes pre-NSECH and post-NSECH opening were compared and independent predictors of survival identified via logistic regression. RESULTS There were 6291 cases. 24/7 specialist emergency care was a strong independent predictor of lower mortality. Length of stay reduced by 1 day, but 90-day readmission rose in both ventilated and non-ventilated patients. CONCLUSION Provision of 24/7 respiratory specialist emergency care improved ECOPD survival and shortened length of stay for both non-ventilated and ventilated patients. The potential implications in respect to service design and provision nationally are substantial and challenging.
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Affiliation(s)
- Nicholas David Lane
- Respiratory Research Division, Research and Development, Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, North Shields, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Karen Brewin
- Respiratory Research Division, Research and Development, Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, North Shields, UK
| | - Tom Murray Hartley
- Respiratory Research Division, Research and Development, Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, North Shields, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - William Keith Gray
- Respiratory Research Division, Research and Development, Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, North Shields, UK
| | - Mark Burgess
- Respiratory Research Division, Research and Development, Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, North Shields, UK
| | - John Steer
- Respiratory Research Division, Research and Development, Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, North Shields, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen C Bourke
- Respiratory Research Division, Research and Development, Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, North Shields, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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29
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Koyama Y, Uchiyama A, Yoshida J, Yoshida T, Yamashita T, Fujino Y. A Comparison of the Adjustable Ranges of Inspiratory Pressurization During Pressure Controlled Continuous Mandatory Ventilation of 5 ICU Ventilators. Respir Care 2018; 63:849-858. [PMID: 29765004 DOI: 10.4187/respcare.05286] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Faster inspiratory pressurization can improve patient-ventilator synchrony and reduce the patient's work of breathing during pressure controlled continuous mandatory (PC-CMV) ventilation. The characteristics of the pressurization ramp settings are not standardized across ventilators from different manufacturers. We performed a bench test of 5 models of ICU ventilators to examine the effects of pressurization ramp settings on the actual pressurization. METHODS A twin-bellows lung model was used, in which one bellow simulates inspiratory muscle activity and the other simulates an adult normal lung model. We made the inspiratory effort by changing the tidal volume of the inspiratory muscle bellow. The effect of pressurization ramp settings on the performance of each ventilator was examined at 3 inspiratory effort levels (ie, none, ordinary, and strong). The pressurization ramp was set at 4 or 5 evenly divided steps from the minimum to maximum for each ventilator. The following parameters were measured: tidal volume, mean airway pressure, maximal inspiratory flow, time to maximal flow, and pressure-time products at 0.3 s (PTP0.3) and 0.5 s (PTP0.5) from the beginning of inspiration. PTP0.3 and PTP0.5 indicated levels of inspiratory pressurization. RESULTS A proportional increase in PTP0.3 and PTP0.5 was observed with an increase in the pressurization ramp settings of the recent models of ventilators. PTP0.3 and PTP0.5 at ordinary and strong effort levels were similar in the recent models of ventilators. The actual adjustable ranges of PTP0.3 and PTP0.5 associated with change in the pressurization ramp settings differed between the 5 ventilators. CONCLUSIONS The adjustable ranges of the pressurization were largely different among the different types of ventilators. The actual absolute inspiratory pressurization during PC-CMV varied between the different ventilators even at similar pressurization ramp settings. Users should be mindful of the differences in the pressurization ramp settings.
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Affiliation(s)
- Yukiko Koyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine
| | - Akinori Uchiyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine.
| | - Junko Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine
| | - Takeshi Yoshida
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada, and with the Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tomonori Yamashita
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine
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30
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Boussaïd G, Prigent H, Laforet P, Raphaël JC, Annane D, Orlikowski D, Lofaso F. Effect and impact of mechanical ventilation in myotonic dystrophy type 1: a prospective cohort study. Thorax 2018; 73:1075-1078. [PMID: 29572271 DOI: 10.1136/thoraxjnl-2017-210610] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 01/25/2018] [Accepted: 01/29/2018] [Indexed: 01/01/2023]
Abstract
Few studies have assessed the impact of home ventilation in patients with myotonic dystrophy type 1 (DM1) and no specific recommendations are available. We assessed the survival associated with category of home ventilation adherence of patients with DM1 followed up at a home ventilation unit using a Cox proportional hazards model. 218 patients were included; those who refused or delayed their acceptance of non-invasive ventilation were at higher risk for severe events (invasive ventilation or death) (P=0.03). Risk of death was associated with orthopnoea (HR 2.37; 95% CI 1.17 to 4.80; P<0.02) and adherence category (100 to 90% vs >75%: HR 3.26; 95% CI 1.32 to 8.04; P<0.03). Failure to use home ventilation as prescribed may be associated with increased mortality in patients with DM1.
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Affiliation(s)
- Ghilas Boussaïd
- CIC 1429, INSERM, AP-HP, Hôpital Raymond Poincaré, Garches, France.,Association Française contre les Myopathies-Téléthon, Évry, France.,Université de Versailles Saint-Quentin-en-Yvelines, INSERM U1179, Versailles, France
| | - Hélène Prigent
- Université de Versailles Saint-Quentin-en-Yvelines, INSERM U1179, Versailles, France.,Service d'Explorations Fonctionnelles Respiratoires, AP-HP, Hôpital Raymond Poincaré, Garches, France
| | - Pascal Laforet
- Institut de Myologie, Centre de Référence de Pathologie Neuromusculaire Paris-Est, GH Pitié-Salpêtrière, Paris, France
| | - Jean-Claude Raphaël
- Pôle de ventilation à domicile, AP-HP, Hôpital Raymond Poincaré, Garches, France
| | - Djillali Annane
- CIC 1429, INSERM, AP-HP, Hôpital Raymond Poincaré, Garches, France.,Université de Versailles Saint-Quentin-en-Yvelines, INSERM U1179, Versailles, France.,Pôle de ventilation à domicile, AP-HP, Hôpital Raymond Poincaré, Garches, France
| | - David Orlikowski
- CIC 1429, INSERM, AP-HP, Hôpital Raymond Poincaré, Garches, France.,Université de Versailles Saint-Quentin-en-Yvelines, INSERM U1179, Versailles, France.,Pôle de ventilation à domicile, AP-HP, Hôpital Raymond Poincaré, Garches, France
| | - Frédéric Lofaso
- Association Française contre les Myopathies-Téléthon, Évry, France.,Université de Versailles Saint-Quentin-en-Yvelines, INSERM U1179, Versailles, France.,Service d'Explorations Fonctionnelles Respiratoires, AP-HP, Hôpital Raymond Poincaré, Garches, France
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31
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Junhasavasdikul D, Telias I, Grieco DL, Chen L, Gutierrez CM, Piraino T, Brochard L. Expiratory Flow Limitation During Mechanical Ventilation. Chest 2018; 154:948-962. [PMID: 29432712 DOI: 10.1016/j.chest.2018.01.046] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 01/27/2018] [Accepted: 01/30/2018] [Indexed: 12/13/2022] Open
Abstract
Expiratory flow limitation (EFL) is present when the flow cannot rise despite an increase in the expiratory driving pressure. The mechanisms of EFL are debated but are believed to be related to the collapsibility of small airways. In patients who are mechanically ventilated, EFL can exist during tidal ventilation, representing an extreme situation in which lung volume cannot decrease, regardless of the expiratory driving forces. It is a key factor for the generation of auto- or intrinsic positive end-expiratory pressure (PEEP) and requires specific management such as positioning and adjustment of external PEEP. EFL can be responsible for causing dyspnea and patient-ventilator dyssynchrony, and it is influenced by the fluid status of the patient. EFL frequently affects patients with COPD, obesity, and heart failure, as well as patients with ARDS, especially at low PEEP. EFL is, however, most often unrecognized in the clinical setting despite being associated with complications of mechanical ventilation and poor outcomes such as postoperative pulmonary complications, extubation failure, and possibly airway injury in ARDS. Therefore, prompt recognition might help the management of patients being mechanically ventilated who have EFL and could potentially influence outcome. EFL can be suspected by using different means, and this review summarizes the methods to specifically detect EFL during mechanical ventilation.
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Affiliation(s)
- Detajin Junhasavasdikul
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Irene Telias
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Domenico Luca Grieco
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli," Rome, Italy
| | - Lu Chen
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Cinta Millan Gutierrez
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Thomas Piraino
- Department of Respiratory Therapy, St. Michael's Hospital, Toronto, ON, Canada; Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
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32
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Nonoyama ML, McKim DA, Road J, Guerriere D, Coyte PC, Wasilewski M, Avendano M, Katz SL, Amin R, Goldstein R, Zagorski B, Rose L. Healthcare utilisation and costs of home mechanical ventilation. Thorax 2018; 73:thoraxjnl-2017-211138. [PMID: 29374088 DOI: 10.1136/thoraxjnl-2017-211138] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 11/23/2017] [Accepted: 12/11/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND Individuals using home mechanical ventilation (HMV) frequently choose to live at home for quality of life, despite financial burden. Previous studies of healthcare utilisation and costs do not consider public and private expenditures, including caregiver time. OBJECTIVES To determine public and private healthcare utilisation and costs for HMV users living at home in two Canadian provinces, and examine factors associated with higher costs. METHODS Longitudinal, prospective observational cost analysis study (April 2012 to August 2015) collecting data on public and private (out-of-pocket, third-party insurance, caregiving) costs every 2 weeks for 6 months using the Ambulatory and Home Care Record. Functional Independence Measure (FIM) was used at baseline and study completion. Regression models examined variables associated with total monthly costs selected a priori using Andersen and Newman's framework for healthcare utilisation, relevant literature, and clinical expertise. Data are reported in 2015 Canadian dollars ($C1=US$0.78=₤0.51=€0.71). RESULTS We enrolled 134 HMV users; 95 with family caregivers. Overall median (IQR) monthly healthcare cost was $5275 ($2291-$10 181) with $2410 (58%) publicly funded; $1609 (39%) family caregiving; and $141 (3%) out-of-pocket (<1% third-party insurance). Median healthcare costs were $8733 ($5868-$15 274) for those invasively ventilated and $3925 ($1212-$7390) for non-invasive ventilation. Variables associated with highest monthly costs were amyotrophic lateral sclerosis (1.88, 95% CI 1.09 to 3.26, P<0.03) and lower FIM quintiles (higher dependency) (up to 6.98, 95% CI 3.88 to 12.55, P<0.0001) adjusting for age, sex, tracheostomy and ventilation duration. CONCLUSIONS For HMV users, most healthcare costs were publicly supported or associated with family caregiving. Highest costs were incurred by the most dependent users. Understanding healthcare costs for HMV users will inform policy decisions to optimise resource allocation, helping individuals live at home while minimising caregiver burden.
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Affiliation(s)
- Mika L Nonoyama
- Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada
- Department of Respiratory Therapy, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Douglas A McKim
- Division of Respiratory Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Denise Guerriere
- Division of Respirology, Department of Medicine, Institute for Heart and Lung Health, University of British Columbia, Vancouver, British Columbia, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Canadian Centre for Health Economics, Toronto, Ontario, Canada
| | - Peter C Coyte
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Marina Wasilewski
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Monica Avendano
- Respiratory Medicine, West Park Healthcare Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sherri L Katz
- Division of Respirology, Department of Pediatrics, CHEO, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Research Unit, CHEO Research Institute, Ottawa, Ontario, Canada
| | - Reshma Amin
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Roger Goldstein
- Respiratory Medicine, West Park Healthcare Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Brandon Zagorski
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Louise Rose
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Okuda M, Tanaka N, Naito K, Kumada T, Fukuda K, Kato Y, Kido Y, Okuda Y, Nohara R. Evaluation by various methods of the physiological mechanism of a high-flow nasal cannula (HFNC) in healthy volunteers. BMJ Open Respir Res 2017; 4:e000200. [PMID: 29071075 PMCID: PMC5647476 DOI: 10.1136/bmjresp-2017-000200] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [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: 03/28/2017] [Revised: 06/20/2017] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Several reports have described the usefulness of a high-flow nasal cannula (HFNC). However, the physiological mechanisms of this system are unclear. In the current study, various methods were used to investigate the physiological mechanisms of an HFNC in healthy volunteers. METHODS The physiological mechanisms of the constant-flow and constant-pressure models of HFNC were studied in 10 healthy volunteers by the oesophageal balloon method, the electrical impedance method and the forced oscillation technique (FOT). RESULTS The tidal volume (TV) increased markedly during HFNC (off, 30 L/min, 50 L/min: 685.6±236.5 mL, 929.8±434.7 mL, 968.8±451.1 mL). The end-inspiratory oesophageal pressure (EIOP) was not significantly different, but there was a tendency for it to decrease. HFNC 30 L/min and 50 L/min, the increment in TV and the difference in EIOP showed strong negative correlations (p=0.0025, 0.003). The end-expiratory oesophageal pressure (EEOP) increased. The respiratory system reactance at 5 Hz (X5) by FOT decreased significantly. There was a flow rate-dependent EEOP increase, and the positive end-expiratory pressure (PEEP) effect of HFNC was confirmed. There was a correlation between the difference in X5 and the difference in EEOP during HFNC 30 L/min and 50 L/min, with correlation coefficients of 0.534 and 0.404 (p=0.112, 0.281). The amount of change in EEOP and the fluctuation in X5 were positively correlated. CONCLUSIONS The PEEP effect of HFNC was confirmed by the electrical impedance method and FOT. The increment in TV and the difference in EIOP of HFNC showed strong negative correlations.
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Affiliation(s)
- Miyuki Okuda
- Federation of National Public Service Personnel Mutual Aid Association Hirakata Kohsai Hospital, Hirakata, Osaka, Japan
| | - Nobuya Tanaka
- Federation of National Public Service Personnel Mutual Aid Association Hirakata Kohsai Hospital, Hirakata, Osaka, Japan
| | | | | | - Koji Fukuda
- Federation of National Public Service Personnel Mutual Aid Association Hirakata Kohsai Hospital, Hirakata, Osaka, Japan
| | - Yuto Kato
- Federation of National Public Service Personnel Mutual Aid Association Hirakata Kohsai Hospital, Hirakata, Osaka, Japan
| | - Yuto Kido
- Federation of National Public Service Personnel Mutual Aid Association Hirakata Kohsai Hospital, Hirakata, Osaka, Japan
| | | | - Ryuji Nohara
- Federation of National Public Service Personnel Mutual Aid Association Hirakata Kohsai Hospital, Hirakata, Osaka, Japan
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Zbrzeski A, Bornat Y, Hillen B, Siu R, Abbas J, Jung R, Renaud S. Bio-Inspired Controller on an FPGA Applied to Closed-Loop Diaphragmatic Stimulation. Front Neurosci 2016; 10:275. [PMID: 27378844 PMCID: PMC4909776 DOI: 10.3389/fnins.2016.00275] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [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: 02/03/2016] [Accepted: 06/01/2016] [Indexed: 12/02/2022] Open
Abstract
Cervical spinal cord injury can disrupt connections between the brain respiratory network and the respiratory muscles which can lead to partial or complete loss of ventilatory control and require ventilatory assistance. Unlike current open-loop technology, a closed-loop diaphragmatic pacing system could overcome the drawbacks of manual titration as well as respond to changing ventilation requirements. We present an original bio-inspired assistive technology for real-time ventilation assistance, implemented in a digital configurable Field Programmable Gate Array (FPGA). The bio-inspired controller, which is a spiking neural network (SNN) inspired by the medullary respiratory network, is as robust as a classic controller while having a flexible, low-power and low-cost hardware design. The system was simulated in MATLAB with FPGA-specific constraints and tested with a computational model of rat breathing; the model reproduced experimentally collected respiratory data in eupneic animals. The open-loop version of the bio-inspired controller was implemented on the FPGA. Electrical test bench characterizations confirmed the system functionality. Open and closed-loop paradigm simulations were simulated to test the FPGA system real-time behavior using the rat computational model. The closed-loop system monitors breathing and changes in respiratory demands to drive diaphragmatic stimulation. The simulated results inform future acute animal experiments and constitute the first step toward the development of a neuromorphic, adaptive, compact, low-power, implantable device. The bio-inspired hardware design optimizes the FPGA resource and time costs while harnessing the computational power of spike-based neuromorphic hardware. Its real-time feature makes it suitable for in vivo applications.
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Affiliation(s)
- Adeline Zbrzeski
- Bordeaux INP, IMS, UMR 5218Talence, France; Univ. Bordeaux, IMS, UMR 5218Talence, France
| | - Yannick Bornat
- Bordeaux INP, IMS, UMR 5218Talence, France; Univ. Bordeaux, IMS, UMR 5218Talence, France
| | - Brian Hillen
- Department of Biomedical Engineering, Florida International University Miami, FL, USA
| | - Ricardo Siu
- Department of Biomedical Engineering, Florida International University Miami, FL, USA
| | - James Abbas
- School of Biological and Health Systems Engineering, Arizona State University Tempe, AZ, USA
| | - Ranu Jung
- Department of Biomedical Engineering, Florida International University Miami, FL, USA
| | - Sylvie Renaud
- Bordeaux INP, IMS, UMR 5218Talence, France; Univ. Bordeaux, IMS, UMR 5218Talence, France
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Abstract
Parental requests for gastrostomies, tracheostomies, or assisted ventilation in children with profound disabilities raise ethical concerns about children's interests, parental decision-making, and health care costs. The underlying concern for many relates to the perceived value of these children. Clinicians should make efforts to appreciate the family's perspective regarding children with profound disabilities who require respiratory and nutritional medical support. Finding opportunities to learn about the family members' lives outside of the health care setting may facilitate a deeper understanding of what it means to live with a child who has profound disabilities. In conversations with families, referring to interventions as futile and conditions as lethal will obscure the value-based nature of these decisions. Respiratory and nutritional interventions are not clearly against the interests of most children. Even for children with a limited life span, life-sustaining interventions may be important for the child and family. Health care costs are a serious societal issue; however, the costs associated with profound disabilities are not the most significant contributor. Societal decisions not to provide life-sustaining health care to children with profound disabilities would require a public process. Clinicians may have personal views regarding decisions for their own family or for their vision for society. However, clinicians have professional obligations to families who have different values. It is important to present balanced information and support parental decision-making so parents may decide to forgo or use life-sustaining interventions according to their values and goals.
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Affiliation(s)
- Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, and Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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Escobar GJ, McCormick MC, Zupancic JAF, Coleman-Phox K, Armstrong MA, Greene JD, Eichenwald EC, Richardson DK. Unstudied infants: outcomes of moderately premature infants in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed 2006; 91:F238-44. [PMID: 16611647 PMCID: PMC2672722 DOI: 10.1136/adc.2005.087031] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2006] [Indexed: 11/04/2022]
Abstract
BACKGROUND Newborns of 30-34 weeks gestation comprise 3.9% of all live births in the United States and 32% of all premature infants. They have been studied much less than very low birthweight infants. OBJECTIVE To measure in-hospital outcomes and readmission within three months of discharge of moderately premature infants. DESIGN Prospective cohort study including retrospective chart review and telephone interviews after discharge. SETTING Ten birth hospitals in California and Massachusetts. PATIENTS Surviving moderately premature infants born between October 2001 and February 2003. MAIN OUTCOME MEASURES (a) Occurrence of assisted ventilation during the hospital stay after birth; (b) adverse in-hospital outcomes-for example, necrotising enterocolitis; (c) readmission within three months of discharge. RESULTS With the use of prospective cluster sampling, 850 eligible infants and their families were identified, randomly selected, and enrolled. A total of 677 families completed a telephone interview three months after hospital discharge. During the birth stay, these babies experienced substantial morbidity: 45.7% experienced assisted ventilation, and 3.2% still required supplemental oxygen at 36 weeks. Readmission within three months occurred in 11.2% of the cohort and was higher among male infants and those with chronic lung disease. CONCLUSIONS Moderately premature infants experience significant morbidity, as evidenced by high rates of assisted ventilation, use of oxygen at 36 weeks, and readmission. Such morbidity deserves more research.
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Affiliation(s)
- G J Escobar
- Kaiser Permanente Medical Care Program, Division of Research, Perinatal Research Unit, Oakland, CA 94612, USA.
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