Usefulness of the HACOR score in predicting success of CPAP in COVID-19-related hypoxemia

Introduction

In COVID-19 associated hypoxemic acute respiratory failure (ARF) without mandatory indication for urgent endotracheal intubation, a trial of CPAP may be considered. We aimed to evaluate HACOR (heart rate, acidosis, consciousness, oxygenation, respiratory rate) score performance in these patients as predictor of CPAP failure.

Methods

Prospective observational multicentric study (three centers in different countries), including adult patients with SARS-CoV-2 pneumonia admitted to a respiratory intermediate care unit, presenting PaO₂/FiO₂ < 300 and PaCO₂ < 45 mmHg, who received CPAP. One hour after starting CPAP, HACOR was calculated.

Results

We enrolled 128 patients, mean age 61,7 years. Mean HACOR at 1 h after starting CPAP was 3,27 ± 3,84 and mean PaO₂/FiO₂ was 203,30 ± 92,21 mmHg; 35 patients (27,3 %) presented CPAP failure: 29 underwent oro-tracheal intubation and 6 died due to COVID-19 (all having a do-not-intubate order). HACOR accuracy for predicting CPAP failure was 82,03 %, while PaO₂/FiO2 accuracy was 81,25 %.

Conclusion

Although HACOR score had a good diagnostic performance in predicting CPAP failure in COVID-19-related ARF, PaO₂/FiO₂ has also shown to be a good predictor of failure.

Secretion management in patients with ineffective airway clearance with non-invasive mechanical ventilation use: Expert guidance for clinical practice

Non-invasive ventilation (NIV) is a mainstay of management of chronic respiratory failure in many disorders which are known to cause abnormal airway secretion clearance. Currently, there is no guidance regarding either the secretion handling during NIV use or the role of NIV in secretion management in these patients. The aim of this document was to provide an overview of the various techniques available in the management of respiratory secretions and their use in conjunction with NIV. Literature search was performed using the keywords, "(secretion OR secretions) AND (noninvasive ventilation OR NIV)" on PubMed and EMBASE. The search yielded 1681 and 509 titles from PubMed and EMBASE, respectively. After screening, 19 articles were included in this review. Suggestions of the expert panel were formulated by mutual consensus after reviewing the relevant literature. The draft of the expert panel's suggestions was circulated among all authors via electronic mail for comments. Any conflicts were resolved by mutual discussion to achieve agreement. The final document was approved by all. This document by the International Network for Airway Secretions Management in NIV describes various airway secretion clearance techniques. It provides the expert panel's suggestions for the use of these techniques in conjunction with NIV for patients with muco-obstructive and neuromuscular disorders.

Global Current Practices of Ventilatory Support Management in COVID-19 Patients: An International Survey

BACKGROUND

As the global outbreak of COVID-19 continues to ravage the world, it is important to understand how frontline clinicians manage ventilatory support and the various limiting factors.

METHODS

An online survey composed of 32 questions was developed and validated by an international expert panel.

RESULTS

Overall, 502 respondents from 40 countries across six continents completed the survey. The mean number (±SD) of ICU beds was 64 ± 84. The most popular initial diagnostic tools used for treatment initiation were arterial blood gas (48%) and clinical presentation (37.5%), while the national COVID-19 guidelines were the most used (61.2%). High flow nasal cannula (HFNC) (53.8%), non-invasive ventilation (NIV) (47%), and invasive mechanical ventilation (IMV) (92%) were mostly used for mild, moderate, and severe COVID-19 cases, respectively. However, only 38.8%, 56.6% and 82.9% of the respondents had standard protocols for HFNC, NIV, and IMV, respectively. The most frequently used modes of IMV and NIV were volume control (VC) (36.1%) and continuous positive airway pressure/pressure support (CPAP/PS) (40.6%). About 54% of the respondents did not adhere to the recommended, regular ventilator check interval. The majority of the respondents (85.7%) used proning with IMV, with 48.4% using it for 12-16 hours, and 46.2% had tried awake proning in combination with HFNC or NIV. Increased staff workload (45.02%), lack of trained staff (44.22%) and shortage of personal protective equipment (PPE) (42.63%) were the main barriers to COVID-19 management.

CONCLUSION

Our results show that general clinical practices involving ventilatory support were highly heterogeneous, with limited use of standard protocols and most frontline clinicians depending on isolated and varied management guidelines. We found increased staff workload, lack of trained staff and shortage of PPE to be the main limiting factors affecting global COVID-19 ventilatory support management.

Validity of a clinical scale in predicting the failure of non-invasive ventilation in hypoxemic patients

INTRODUCTION

The HACOR scale is a clinical score that can predict early failure of NIV in hypoxemic acute respiratory failure (ARF) The aim of this study is to analyze the validity of the HACOR scale.

METHODS

A retrospective study of a cohort of over 2749 episodes on 2711 consecutive patients requiring NIV for hypoxemic ARF in a polyvalent intensive care unit. The scale was measured before starting NIV and at 1, 6, 12, 24 and 48 h after the initiation of NIV.

RESULTS

NIV failure occurred in 963 patients (35%). The value of the HACOR scale before NIV did not differ between success and failure. However, at 1, 6, 12, 24 and 48 h of NIV, the scale values clearly differed between the two groups. The HACOR scale at NIV initiation accurately predicts NIV failure in the first hour, with an optimal cut-off value of 8 points. The AUC for predicting NIV failure with HACOR at 1 h is greater than 0.9 in patients with pneumonia and adult respiratory distress syndrome (ARDS).

CONCLUSIONS

The HACOR scale measured at 1 h after NIV initiation accurately predicts NIV failure, especially in pneumonia and ARDS.

Atelectasis in Bariatric Surgery: Review Analysis and Key Practical Recommendations

Obesity is a condition that affects multiple organ systems, particularly the cardiovascular and respiratory system. In recent years, bariatric surgery has been reported to be the gold standard in the treatment of morbid obesity. Body mass index alone is insufficient to predict risks related to anaesthesia and surgery. Obesity contributes to significant postoperative atelectasis and is considered an independent risk factor for postoperative atelectasis owing to decreased functional residual capacity. The treatment and reversibility of atelectasis developed in obese patients undergoing bariatric surgery are challenging. Therefore, an optimisation of pulmonary functions before surgery, lung-sparing ventilation during the perioperative period, awareness of potential postoperative complications and knowledge about preventive measures and therapeutic approaches have become increasingly important in bariatric surgery. The aim of this review was to aid clinicians in the management of atelectasis in patients undergoing bariatric surgery during the perioperative and postoperative period.

Non-invasive ventilation in palliative care: a systematic review

INTRODUCTION

An ageing population and steady increase in the rates of neoplasms and chronic degenerative diseases poses a challenge for societies and their healthcare systems. Because of the recent and continued advances in therapies, such as the development and widespread use of non-invasive ventilation (NIV), survival rates have increased for these pathologies. For patients with end-stage chronic respiratory diseases, the use of NIV following the onset of acute or severe chronic respiratory failure is a valid option when intubation has been excluded.

EVIDENCE ACQUISITION

The following electronic databases were searched from their inception to January 2000 to December 2017: MEDLINE, EMBASE, CINHAIL, CENTRAL (Cochrane Central register of Controlled Trials), DARE (Database of Abstracts of Reviews of Effectiveness), the Cochrane Database of Systematic Reviews, ACP Journal Club database.

EVIDENCE SYNTHESIS

The available evidence strongly supports the use of NIV in patients presenting with an exacerbation of chronic obstructive pulmonary disease, as well end-stage neuromuscular disease. Few studies support the use of NIV in end-stage interstitial lung disease and in morbid obesity patients. In patients with cancer has been recommend offering NIV as palliative care to improve dyspnea.

CONCLUSIONS

The decision regarding the treatment should be made by the patient, ideally before reaching the terminal stage and after having a frank dialogue with healthcare professionals and family members.

Wyniki badań radiologicznych a odpowiedź na nieinwazyjną wentylację

Mimo że nieinwazyjna wentylacja (NIV) jest prostą oraz użyteczną metodą, obserwuje się znaczne zróżnicowanie w jej stosowaniu pomiędzy krajami, regionami czy nawet szpitalami. Pacjent powinien być oceniony zarówno w stosunku do odpowiedzi subiektywnej (niewydolność oddechowa, świadomość, problemy związane z maską oraz przepływem powietrza), fizjologicznej (częstość oddechów, wysiłek oddechowy, przeciek powietrza), jak i zgodności z respiratorem (wymiana gazowa, pulsoksymetria, gazometria krwi tętniczej). Normalizacja częstości oddechów w ciągu 1 lub 2 godzin po rozpoczęciu leczenia jest jednym z najważniejszych wykładników postępów leczenia. Celem jest utrzymanie częstości oddechów między 20 a 30 oddechami na minutę. Zmniejszenie skurczów międzyżebrowych i nadobojczykowych, oddychania paradoksalnego czy aktywności współczulnej wskazują na powodzenie terapii. Gazometrię krwi tętniczej oznacza się w ciągu pierwszych 2 godzin w celu oceny pH i CO2; a w razie potrzeby także później. Ogólnie rzecz ujmując, NIV ocenia się za pomocą gazometrii krwi tętniczej, parametrów hemodynamicznych i kilku testów laboratoryjnych. Liczba badań dotyczących NIV jest ograniczona. Autorzy niniejszej pracy postawili sobie za cel ocenę radiologicznych implikacji dystrybucji gazu w tkance płucnej w trakcie terapii NIV.

Continuous noninvasive ventilation for respiratory failure in patients with amyotrophic lateral sclerosis: current perspectives

Respiratory failure is a recognized late complication of amyotrophic lateral sclerosis. It is related to the neurological progression of the diseases with the impairment of the respiratory musculature. Survival and quality of life of amyotrophic lateral sclerosis patients is improved by using noninvasive mechanical ventilation. The rate of long-term mechanical ventilation is different within and between countries. Cultural factors, socioeconomic conditions, and physician attitude often influence the decision to start noninvasive ventilation. Technical elements, like the choice of the correct interface, solid caregivers support, and the communication between the patient and the physician are essential for achieving therapeutic goals, especially in the case of continuous treatment.

Humidification therapy; long-term effects in COPD and OSAS patients

Humidification therapy is widely used in patients during invasive ventilation and the importance of heating and humidifying the inhaled air is well defined in both the acute and long term setting. On the other hand the continuous usage of humidification in noninvasive ventilation is controversial and the long term effects are still not well defined. The usage of noninvasive ventilation is especially important in hypercapnic Chronic obstructive pulmonary disease (COPD) and also the obstructive sleep apnea syndrome (OSAS) patients and compliance to this treatment is essential in long term. Limited number of studies have shown that heated humidification is preferred by COPD patients and might help in mucus clearance, reduce mucus viscosity and help in expectoration, but there was shown no priority as far as concerns the lung function or blood gas parameters. Humidification might also be important in long term oxygen treatment since the inhalation of dry air can lead to ciliary dysfunction, alterations in mucus properties and mucociliary clearance impairment. Studies concerning OSAS patients showed that humidification helps to reduce the nasal symptoms but plays no role in increasing the compliance of patients in long term. Multi-center studies with large number of patients are needed to identify patients' groups who are likely to benefit from the addition of humidification to noninvasive therapy.

Management of acute respiratory failure in interstitial lung diseases: overview and clinical insights

Background

Interstitial lung diseases (ILDs) are a heterogeneous group of diseases characterized by widespread fibrotic and inflammatory abnormalities of the lung. Respiratory failure is a common complication in advanced stages or following acute worsening of the underlying disease. Aim of this review is to evaluate the current evidence in determining the best management of acute respiratory failure (ARF) in ILDs.

Methods

A literature search was performed in the Medline/PubMed and EMBASE databases to identify studies that investigated the management of ARF in ILDs (the last search was conducted on November 2017).

Results

In managing ARF, it is important to establish an adequate diagnostic and therapeutic management depending on whether the patient has an underlying known chronic ILD or ARF is presenting in an unknown or de novo ILD. In the first case both primary causes, such as acute exacerbations of the disease, and secondary causes, including concomitant pulmonary infections, fluid overload and pulmonary embolism need to be investigated. In the second case, a diagnostic work-up that includes investigations in regards to ILD etiology, such as autoimmune screening and bronchoalveolar lavage, should be performed, and possible concomitant causes of ARF have to be ruled out.

Oxygen supplementation and ventilatory support need to be titrated according to the severity of ARF and patients’ therapeutic options. High-Flow Nasal oxygen might potentially be an alternative to conventional oxygen therapy in patients requiring both high flows and high oxygen concentrations to correct hypoxemia and control dyspnea, however the evidence is still scarce. Neither Non-Invasive Ventilation (NIV) nor Invasive Mechanical Ventilation (IMV) seem to change the poor outcomes associated to advanced stages of ILDs. However, in selected patients, such as those with less severe ARF, a NIV trial might help in the early recognition of NIV-responder patients, who may present a better short-term prognosis. More invasive techniques, including IMV and Extracorporeal Membrane Oxygenation, should be limited to patients listed for lung transplant or with reversible causes of ARF.

Conclusions

Despite the overall poor prognosis of ARF in ILDs, a personalized approach may positively influence patients’ management, possibly leading to improved outcomes. However, further studies are warranted.