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Delacroix E, Millet A, Wroblewski I, Vilotitch A, Pin I, Ego A, Debillon T, Mortamet G. Has the introduction of high-flow nasal cannula modified the clinical characteristics and outcomes of infants with bronchiolitis admitted to pediatric intensive care units? A retrospective study. Arch Pediatr 2021; 28:141-6. [PMID: 33334653 DOI: 10.1016/j.arcped.2020.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 09/14/2020] [Accepted: 11/21/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND This study aimed to assess how the emergence of high-flow nasal cannula (HFNC) has modified the demographic and clinical characteristics as well as outcomes of infants with bronchiolitis admitted to a pediatric intensive care unit (PICU). METHODS This was a single-center retrospective study including infants aged 1 day to 6 months with bronchiolitis requiring HFNC, noninvasive ventilation (NIV), or invasive ventilation on admission. RESULTS A total of 252 infants (mean age 53±36 days) were included in the study. The use of HFNC increased from 18 (21.4%) during 2013-2014 to 53 infants (55.2%) during 2015-2016. The length of stay in the PICU decreased over time from 4.7±2.9 to 3.5±2.7 days (P<0.01) but the hospital length of stay remained similar (P=0.17). On admission, patients supported by HFNC as the first-line therapy were older. The PICU length of stay was similar according to the type of respiratory support (P=0.16), but the hospital length of stay was longer for patients supported by HFNC (P=0.01). CONCLUSION The distribution of respiratory support has significantly changed over time for patients with bronchiolitis and HFNC is increasingly used. The demographic and clinical characteristics of the have not changed over time. However, the PICU length of stay decreased significantly.
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152
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Cortegiani A, Longhini F, Madotto F, Groff P, Scala R, Crimi C, Carlucci A, Bruni A, Garofalo E, Raineri SM, Tonelli R, Comellini V, Lupia E, Vetrugno L, Clini E, Giarratano A, Nava S, Navalesi P, Gregoretti C. High flow nasal therapy versus noninvasive ventilation as initial ventilatory strategy in COPD exacerbation: a multicenter non-inferiority randomized trial. Crit Care 2020; 24:692. [PMID: 33317579 PMCID: PMC7734463 DOI: 10.1186/s13054-020-03409-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/24/2020] [Indexed: 01/03/2023]
Abstract
Background The efficacy and safety of high flow nasal therapy (HFNT) in patients with acute hypercapnic exacerbation of chronic obstructive pulmonary disease (AECOPD) are unclear. Our aim was to evaluate the short-term effect of HFNT versus NIV in patients with mild-to-moderate AECOPD, with the hypothesis that HFNT is non-inferior to NIV on CO2 clearance after 2 h of treatment. Methods We performed a multicenter, non-inferiority randomized trial comparing HFNT and noninvasive ventilation (NIV) in nine centers in Italy. Patients were eligible if presented with mild-to-moderate AECOPD (arterial pH 7.25–7.35, PaCO2 ≥ 55 mmHg before ventilator support). Primary endpoint was the mean difference of PaCO2 from baseline to 2 h (non-inferiority margin 10 mmHg) in the per-protocol analysis. Main secondary endpoints were non-inferiority of HFNT to NIV in reducing PaCO2 at 6 h in the per-protocol and intention-to-treat analysis and rate of treatment changes. Results Seventy-nine patients were analyzed (80 patients randomized). Mean differences for PaCO2 reduction from baseline to 2 h were − 6.8 mmHg (± 8.7) in the HFNT and − 9.5 mmHg (± 8.5) in the NIV group (p = 0.404). By 6 h, 32% of patients (13 out of 40) in the HFNT group switched to NIV and one to invasive ventilation. HFNT was statistically non-inferior to NIV since the 95% confidence interval (CI) upper boundary of absolute difference in mean PaCO2 reduction did not reach the non-inferiority margin of 10 mmHg (absolute difference 2.7 mmHg; 1-sided 95% CI 6.1; p = 0.0003). Both treatments had a significant effect on PaCO2 reductions over time, and trends were similar between groups. Similar results were found in both per-protocol at 6 h and intention-to-treat analysis. Conclusions HFNT was statistically non-inferior to NIV as initial ventilatory support in decreasing PaCO2 after 2 h of treatment in patients with mild-to-moderate AECOPD, considering a non-inferiority margin of 10 mmHg. However, 32% of patients receiving HFNT required NIV by 6 h. Further trials with superiority design should evaluate efficacy toward stronger patient-related outcomes and safety of HFNT in AECOPD. Trial registration: The study was prospectively registered on December 12, 2017, in ClinicalTrials.gov (NCT03370666).
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Affiliation(s)
- Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy. .,Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy.
| | - Federico Longhini
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Fabiana Madotto
- Value-Based Healthcare Unit, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Paolo Groff
- Emergency Department, "S. Maria Della Misericordia" Hospital, Perugia, Italy
| | - Raffaele Scala
- Pulmonology and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy
| | - Claudia Crimi
- Respiratory Medicine Unit, A.O.U. "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Annalisa Carlucci
- Pulmonary Rehabilitation Unit, Department of Medicina E Chirurgia, Istituti Clinici Scientifici Maugeri, Università Insubria Varese, Pavia, Italy
| | - Andrea Bruni
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Eugenio Garofalo
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Santi Maurizio Raineri
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy.,Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Roberto Tonelli
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Vittoria Comellini
- Department of Clinical, Integrated and Experimental Medicine (DIMES), Respiratory and Critical Care Unit, S. Orsola-Malpighi Hospital, Alma Mater University, Bologna, Italy
| | - Enrico Lupia
- Unit of Emergency Medicine, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Luigi Vetrugno
- Department of Medicine, Clinic of Anesthesia and Intensive Care, University of Udine, Udine, Italy
| | - Enrico Clini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences SMECHIMAI, University Hospital of Modena Policlinico, University of Modena Reggio Emilia, Modena, Italy
| | - Antonino Giarratano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy.,Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Stefano Nava
- Department of Clinical, Integrated and Experimental Medicine (DIMES), Respiratory and Critical Care Unit, S. Orsola-Malpighi Hospital, Alma Mater University, Bologna, Italy
| | - Paolo Navalesi
- Section of Anesthesiology and Intensive Care, Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Cesare Gregoretti
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy.,Fondazione 'Giglio', Cefalù, Palermo, Italy
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153
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Abstract
Because of the prevalence of extreme obesity in the United States, there has been an increase in prevalence of obesity hypoventilation syndrome (OHS). There is limited information on the characteristics and pattern of positive airway pressure (PAP) adherence in patients with OHS compared with eucapnic patients with obstructive sleep apnea (OSA). This article discusses in detail the impact of PAP therapy on outcomes in patients with OHS, compares adherence between continuous PAP and noninvasive ventilation in OHS, and compares PAP adherence in patients with OHS to patients with moderate to severe OSA enrolled in clinical trials designed to improve CPAP adherence.
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Affiliation(s)
- Jeremy Wearn
- Sleep Medicine and Internal Medicine, Oregon Health & Science University and Portland VAMC, 3710 SW US Veterans Hospital Rd, PULM3/Sleep, Portland OR 97239, USA
| | - Bimaje Akpa
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, 420 Delaware Street SE, MMC 276, Minneapolis, MN 55455, USA
| | - Babak Mokhlesi
- Sleep Disorders Center, University of Chicago, 5841 South Maryland Avenue, MC6076/Room M630, Chicago, IL 60637, USA.
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154
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Vitacca M, Ceriana P, Prediletto I, Carlucci A, Paneroni M, Ambrosino N, Nava S. Intrinsic Dynamic Positive End-Expiratory Pressure in Stable Patients with Chronic Obstructive Pulmonary Disease. Respiration 2020; 99:1129-1135. [PMID: 33271563 DOI: 10.1159/000511266] [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] [Received: 05/05/2020] [Accepted: 08/31/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Assessment of intrinsic dynamic positive end-expiratory pressure (PEEPi,dyn) may be clinically important in stable patients with chronic obstructive pulmonary disease (COPD), but epidemiological data are scant. OBJECTIVES The aim of our study was (i) to assess the PEEPi,dyn in a large population of stable patients with COPD and (ii) to evaluate the correlations with some noninvasive measurements routinely assessed. METHOD Retrospective analysis of lung mechanics, dynamic volumes, arterial blood gases, dyspnoea by means of the Medical Research Council (MRC) scale, the COPD Assessment Test score, and maximal inspiratory/expiratory pressures in 87 hypercapnic and 62 normocapnic patients. RESULTS The mean PEEPi,dyn was significantly higher in hypercapnic than normocapnic patients (2.8 ± 2.2 vs. 1.9 ± 1.6 cm H2O, respectively, p = 0.0094). PEEPi,dyn did not differ according to Global Initiative for Chronic Obstructive Lung Disease stage, MRC score, or use or not of long-term oxygen therapy. There were significant although weak correlations between PEEPi,dyn and airway obstruction, hyperinflation, respiratory muscle function, arterial CO2 tension, and number of exacerbations/year. The transdiaphragmatic pressure was the strongest variable associated to PEEPi,dyn (R = 0.5713, p = 0.001). CONCLUSION In stable patients with COPD, PEEPi,dyn is higher in hypercapnic patients and weakly correlated to noninvasive measures of lung and respiratory muscle function.
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Affiliation(s)
- Michele Vitacca
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation of the Institute of Lumezzane, Brescia, Italy,
| | - Piero Ceriana
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation of the Institute of Pavia, Pavia, Italy
| | - Irene Prediletto
- Università Alma Mater, Cattedra di Malattie dell'Apparato Respiratorio, Bologna, Italy
| | - Annalisa Carlucci
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation of the Institute of Pavia, Pavia, Italy.,Università dell'Insubria, Dipartimento di Medicina e Chirurgia, Varese-Como, Italy
| | - Mara Paneroni
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation of the Institute of Lumezzane, Brescia, Italy
| | - Nicolino Ambrosino
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation of the Institute of Montescano, Pavia, Italy
| | - Stefano Nava
- Università Alma Mater, Cattedra di Malattie dell'Apparato Respiratorio, Bologna, Italy
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155
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Abstract
An increasing number of patients require prolonged weaning from mechanical ventilation as a result of advanced age, patient comorbidities, technical progress in surgery and intensive care medicine. The data of the WeanNet register show that more than half (64%) of patients transferred from the intensive care unit (ICU) to a specialized weaning center could definitely be weaned from the respirator. Weaning failure was associated with prolonged ventilation prior to transfer to a weaning center, low body mass index, pre-existing neuromuscular diseases and advanced age. The number of patients with out of hospital ventilation who had to be re-hospitalized because of ventilation control or as part of emergency management quadrupled in Germany between 2006 and 2016. Invasive out-of-hospital ventilation and long-term noninvasive ventilation are associated with a significant loss of autonomy and with low quality of life. Therefore, the initiation must be carefully reviewed and regularly re-evaluated in the context of patient comorbidities and, if necessary, decisions should be made with respect to changing treatment targets. Specialized weaning centers have been established for patients in whom weaning on the ICU was unsuccessful. In cases of persisting weaning failure the adequate transition to out-of-hospital ventilation should be managed by a weaning unit. Weaning centers are responsible for outpatient invasive or noninvasive ventilation strategies and control of treatment quality. Depending on the infrastructure and networking of the respective weaning center, it is basically also possible to provide outpatient care for clinically stable patients in a cooperation model together with pulmonologists in private practice experienced in respiratory medicine.
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Affiliation(s)
- K. Fricke
- Lungenklinik Merheim, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Ostmerheimer Str. 200, 51109 Köln, Deutschland
| | - B. Schönhofer
- Pneumologische Praxis und pneumologischer Konsildienst im Klinikum Agnes KarllLaatzen, Klinikum Region Hannover, Hannover, Deutschland
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156
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Moore C, Rebstock D, Katz IM, Noga ML, Caillibotte G, Finlay WH, Martin AR. The influence of flowrate and gas density on positive airway pressure for high flow nasal cannula applied to infant airway replicas. J Biomech 2020; 112:110022. [PMID: 32942204 DOI: 10.1016/j.jbiomech.2020.110022] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 07/31/2020] [Accepted: 08/26/2020] [Indexed: 01/09/2023]
Abstract
High flow nasal cannula (HFNC) therapy has been previously shown to produce positive upper airway pressures in adult and child patients. This work aimed to evaluate and quantify the effects of HFNC flowrate and gas type on airway pressures measured in vitro in infant airway replicas. Ten realistic infant airway replicas, extending from nares to trachea, were connected in turn to a lung simulator and were supplied gas flows through HFNC. Air and heliox were each provided at two weight-indexed flowrates, 1 l/min/kg and 2 l/min/kg. Pressure and lung volume were continuously measured during simulated breathing. For constant simulated patient effort, no statistically significant change in tidal volume was measured between baseline and lower or higher HFNC flowrates, nor was there any significant difference in tidal volume between air and heliox. Tracheal pressure increased with increasing HFNC flow rate, and was highly variable between airway replicas. Higher pressures were measured for air versus heliox. For air supplied at 2 l/min/kg, average airway pressures in excess of 4 cm H2O were generated, with positive end-expiratory pressure (PEEP) ranging from 2.5 to nearly 12 cm H2O across the replicas. A predictive correlation for PEEP was proposed based on supplied gas density and flow velocities exiting the cannula and nares, and was able to account for a portion of variability between airway replicas (R2 = 0.913). Additionally, PEEP was well correlated with, and predictive of, expiratory peak pressure (R2 = 0.939) and average inspiratory pressure (R2 = 0.944).
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Affiliation(s)
- Charles Moore
- Mechanical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Douglas Rebstock
- Mechanical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Ira M Katz
- Medical R&D, Air Liquide Santé International, Paris-Saclay Research Center, Les Loges-en-Josas, France
| | - Michelle L Noga
- Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
| | - Georges Caillibotte
- Medical R&D, Air Liquide Santé International, Paris-Saclay Research Center, Les Loges-en-Josas, France
| | - Warren H Finlay
- Mechanical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew R Martin
- Mechanical Engineering, University of Alberta, Edmonton, Alberta, Canada.
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157
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Abstract
The need for long-term noninvasive positive pressure ventilation (NiPPV) in children with chronic respiratory failure is rapidly growing. This article reviews pediatric-specific considerations of NiPPV therapy. Indications for NiPPV therapy can be categorized by the cause of the respiratory failure: (1) upper airway obstruction, (2) musculoskeletal and/or neuromuscular disease, (3) lower respiratory tract diseases, and (4) control of breathing abnormalities. The role of NiPPV therapy in select rare conditions (spinal muscular atrophy, congenital central hypoventilation syndrome, cerebral palsy, scoliosis, and Chiari malformations) is also reviewed.
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Affiliation(s)
- Jenny Shi
- The Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, 4539 Hill Wing, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; The University of Toronto, Toronto, Ontario, Canada
| | - Nawal Al-Shamli
- The Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, 4539 Hill Wing, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; The University of Toronto, Toronto, Ontario, Canada
| | - Jackie Chiang
- The Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, 4539 Hill Wing, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; The University of Toronto, Toronto, Ontario, Canada
| | - Reshma Amin
- The Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, 4539 Hill Wing, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; The University of Toronto, Toronto, Ontario, Canada.
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158
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Abstract
Obesity hypoventilation syndrome is the most frequent cause of chronic hypoventilation and is increasingly more common with rising obesity rates. It leads to considerable morbidity and mortality, particularly when not recognized and treated adequately. Long-term nocturnal noninvasive ventilation is the mainstay of treatment but evidence suggests that CPAP may be effective in stable patients. Specific perioperative management is required to reduce complications. Some unique syndromes associated with obesity and hypoventilation include rapid-onset obesity with hypoventilation, hypothalamic, autonomic dysregulation (ROHHAD), and Prader-Willi syndrome. Congenital central hypoventilation syndrome (early or late-onset) is a genetic disorder resulting in hypoventilation. Several acquired causes of chronic central hypoventilation also exist. A high level of clinical suspicion is required to appropriately diagnose and manage affected patients.
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159
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Abstract
Weaning to noninvasive ventilation in intensive care unit and bridging the patients to home with respiratory support is evolving as the technology of noninvasive ventilation is improving. In patients with chronic obstructive pulmonary disease exacerbation, timing of initiation of noninvasive ventilation is the key, as persistently hypercapnic patients show benefits. High-intensity pressure support seems to do better in comparison to low-intensity pressure support. In patients with obesity and hypercapnia, obesity hypoventilation cannot be ruled out especially in an inpatient setting, and it is crucial that these patients are discharged with noninvasive ventilation.
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Affiliation(s)
- Ashima S Sahni
- Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois at Chicago, 909 S Wolcott Ave, Room 3135 (MC 719), Chicago, IL 60612, USA.
| | - Lien-Khuong Tran
- Pulmonary, Critical Care and Sleep, Texas Pulmonary & Critical Care Consultants, 1201 Fairmount Avenue, Fort Worth, TX 76104, USA
| | - Lisa F Wolfe
- Department of Pulmonary and Critical Care, Northwestern University, 675 North Saint Clair Street, 14 th floor Pulmonary Medicine, Chicago, Illinois 60611, USA
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160
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Abstract
Individuals with spinal cord injury (SCI) are at increased risk of respiratory complications during wake and sleep. Sleep-disordered breathing (SDB) is commonly associated with SCI and requires an individualized approach to its management. Respiratory control plays a key role in the pathogenesis of SDB in cervical SCI. Noninvasive ventilation plays an important role in the management of respiratory complications in individuals with SCI acutely and in chronic phases. Positive airway pressure treatment may be effective in eliminating SDB and improving sleepiness symptoms, but adherence to treatment is poor and effect on long-term outcomes is questionable.
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Affiliation(s)
- Asil Daoud
- Department of Medicine, John D. Dingell VA Medical Center, Wayne State University, Detroit Medical Center, 3990 John R St, Detroit, MI 48201, USA; Department of Medicine, Wayne State University, Detroit, MI, USA; Detroit Medical Center, Detroit, MI, USA
| | - Samran Haider
- Department of Medicine, John D. Dingell VA Medical Center, Wayne State University, Detroit Medical Center, 3990 John R St, Detroit, MI 48201, USA; Department of Medicine, Wayne State University, Detroit, MI, USA; Detroit Medical Center, Detroit, MI, USA
| | - Abdulghani Sankari
- Department of Medicine, John D. Dingell VA Medical Center, Wayne State University, Detroit Medical Center, 3990 John R St, Detroit, MI 48201, USA; Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University, 3990 John R, 3-Hudson, Detroit, MI 48201, USA; Ascension Providence Hospital, Southfield, MI, USA.
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161
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Abstract
"Home noninvasive ventilation (NIV) is indicated for numerous conditions including neuromuscular disease, thoracic cage disorders, chronic obstructive pulmonary disease, and hypoventilation syndromes. Effective management of patients on home NIV requires clinicians to interpret data downloads from NIV devices. Clinicians must first look at adherence and factors that may impact this including mask comfort and fit. Next, leak assessment is undertaken. Once these are addressed, such information as apnea-hypopnea index, exhaled tidal volume, and percent triggered breaths help clinicians troubleshoot setting changes. Finally, overnight oximetry and transcutaneous CO2 monitoring are useful adjuncts to the data download to optimize NIV settings."
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Affiliation(s)
- Philip Choi
- University of Michigan, 3916 Taubman Center/1500 East Medical Center Drive, SPC 5360, Ann Arbor, MI 48109, USA
| | - Veronique Adam
- Programme National d'assistance Ventilatoire à Domicile, McGill University Health Center, Building V - Division of Clinical Epidemiology, 1025 Pine Ave W, Montreal, Quebec H3A 1A1, Canada
| | - David Zielinski
- Montreal Children's Hospital, Research Institute of McGill University Health Centre, McGill University, 1001 Decarie Boulevard, Montreal, Quebec H4A 3J1, Canada.
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162
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Affiliation(s)
- Erin W MacKintosh
- Department of Pediatrics, University of Washington, Box 359300, Seattle, WA 98195, USA; Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, 4800 Sand Point Way Northeast, M/S OC.7.720, Seattle, WA 98115, USA.
| | - Maida L Chen
- Department of Pediatrics, University of Washington, Box 359300, Seattle, WA 98195, USA; Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, 4800 Sand Point Way Northeast, M/S OC.7.720, Seattle, WA 98115, USA
| | - Joshua O Benditt
- Respiratory Care Services and General Pulmonary Clinic, Department of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, UW Medical Center, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
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163
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Avdeev SN, Yaroshetskiy AI, Tsareva NA, Merzhoeva ZM, Trushenko NV, Nekludova GV, Chikina SY. Noninvasive ventilation for acute hypoxemic respiratory failure in patients with COVID-19. Am J Emerg Med 2020; 39:154-157. [PMID: 33067061 PMCID: PMC7527350 DOI: 10.1016/j.ajem.2020.09.075] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [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: 08/28/2020] [Revised: 09/21/2020] [Accepted: 09/26/2020] [Indexed: 01/08/2023] Open
Abstract
Aim Noninvasive ventilation (NIV) is known to reduce intubation in patients with acute hypoxemic respiratory failure (AHRF). We aimed to assess the outcomes of NIV application in COVID-19 patients with AHRF. Materials & methods In this retrospective cohort study, patients with confirmed diagnosis of COVID-19 and AHRF receiving NIV in general wards were recruited from two university-affiliated hospitals. Demographic, clinical, and laboratory data were recorded at admission. The failure of NIV was defined as intubation or death during the hospital stay. Results Between April 8 and June 10, 2020, 61 patients were enrolled into the final cohort. NIV was successful in 44 out of 61 patients (72.1%), 17 patients who failed NIV therapy were intubated, and among them 15 died. Overall mortality rate was 24.6%. Patients who failed NIV were older, and had higher respiratory rate, PaCO2, D-dimer levels before NIV and higher minute ventilation and ventilatory ratio on the 1-st day of NIV. No healthcare workers were infected with SARS-CoV-2 during the study period. Conclusions NIV is feasible in patients with COVID-19 and AHRF outside the intensive care unit, and it can be considered as a valuable option for the management of AHRF in these patients.
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Affiliation(s)
- Sergey N Avdeev
- Department of Pulmonology, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
| | - Andrey I Yaroshetskiy
- Department of Pulmonology, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Natalia A Tsareva
- Department of Pulmonology, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Zamira M Merzhoeva
- Department of Pulmonology, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Natalia V Trushenko
- Department of Pulmonology, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Galina V Nekludova
- Department of Pulmonology, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Svetlana Yu Chikina
- Department of Pulmonology, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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164
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Menzella F, Fontana M, Salvarani C, Massari M, Ruggiero P, Scelfo C, Barbieri C, Castagnetti C, Catellani C, Gibellini G, Falco F, Ghidoni G, Livrieri F, Montanari G, Casalini E, Piro R, Mancuso P, Ghidorsi L, Facciolongo N. Efficacy of tocilizumab in patients with COVID-19 ARDS undergoing noninvasive ventilation. Crit Care 2020; 24:589. [PMID: 32993751 PMCID: PMC7523258 DOI: 10.1186/s13054-020-03306-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [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: 07/12/2020] [Accepted: 09/22/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The severity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is extremely variable, ranging from asymptomatic patients to those who develop severe acute respiratory distress syndrome (ARDS). As for now, there are still no really effective therapies for coronavirus disease 2019 (COVID-19). Some evidences suggest that tocilizumab (TCZ) may avoid the progression of severe COVID-19. The aim of this retrospective case-control study was to analyze the efficacy and safety of TCZ in patients with COVID-19 ARDS undergoing noninvasive mechanical ventilation (NIV). METHODS Seventy-nine consecutive patients with severe COVID-19 pneumonia and worsening acute respiratory failure (ARF) were admitted to the Pulmonology Unit of Azienda USL of Reggio Emilia-IRCCS. All patients were inflamed (elevated CRP and IL-6 levels) and received NIV at admission according to the presence of a pO2/FiO2 ratio ≤ 200 mmHg. The possibility of being treated with TCZ depended on the drug availability. The primary outcome was the in-hospital mortality rate. A secondary composite outcome of worsening was represented by the patients who died in the pulmonology unit or were intubated. RESULTS Out of 79 patients, 41 were treated with TCZ. Twenty-eight patients received intravenous (IV) TCZ and 13 patients received subcutaneous (SC) TCZ. In-hospital overall mortality rate was 38% (30/79 patients). The probabilities of dying and being intubated during the follow-up using Kaplan-Meier method were significantly lower in total patients treated with TCZ compared to those of patients not treated with TCZ (log-rank p value = 0.006 and 0.036, respectively). However, using Cox multivariate analyses adjusted for age and Charlson comorbidity index only the association with the reduced risk of being intubated or dying maintained the significance (HR 0.44, 95%CI 0.22-0.89, p = 0.022). Two patients treated with TCZ developed cavitating lung lesions during the follow-up. CONCLUSIONS This study shows that TCZ treatment may be effective in COVID-19 patients with severe respiratory impairment receiving NIV. More data on safety are required. Randomized controlled trials are needed to confirm these results.
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Affiliation(s)
- Francesco Menzella
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy.
| | - Matteo Fontana
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Carlo Salvarani
- Division of Rheumatology, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
- University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Massari
- Infectious Disease Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Patrizia Ruggiero
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Chiara Scelfo
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Chiara Barbieri
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Claudia Castagnetti
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Chiara Catellani
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Giorgia Gibellini
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Francesco Falco
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Giulia Ghidoni
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Francesco Livrieri
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Gloria Montanari
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Eleonora Casalini
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Roberto Piro
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Pamela Mancuso
- Epidemiology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Luca Ghidorsi
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Nicola Facciolongo
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
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165
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Duan J, Chen B, Liu X, Shu W, Zhao W, Li J, Li Y, Hong Y, Pan L, Wang K. Use of high-flow nasal cannula and noninvasive ventilation in patients with COVID-19: A multicenter observational study. Am J Emerg Med 2020; 46:276-281. [PMID: 33046296 PMCID: PMC7388754 DOI: 10.1016/j.ajem.2020.07.071] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [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: 06/03/2020] [Revised: 07/12/2020] [Accepted: 07/24/2020] [Indexed: 02/08/2023] Open
Abstract
Background The use of high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) in patients with COVID-19 is debated. Methods This study was performed in four hospitals of China from January to March 2020. We retrospectively enrolled 23 and 13 COVID-19 patients who used HFNC and NIV as first-line therapy, respectively. Results Among the 23 patients who used HFNC as first-line therapy, 10 experienced HFNC failure and used NIV as rescue therapy. Among the 13 patients who used NIV as first-line therapy, one (8%) used HFNC as rescue therapy due to NIV intolerance. The duration of HFNC + NIV (median 7.1, IQR: 3.5–12.2 vs. 7.3, IQR: 5.3–10.0 days), intubation rate (17% vs. 15%) and mortality (4% vs. 8%) did not differ between patients who used HFNC and NIV as first-line therapy. In total cohorts, 6 (17%) patients received intubation. Time from initiation of HFNC or NIV to intubation was 8.4 days (IQR: 4.4–18.5). And the time from initiation of HFNC or NIV to termination in patients without intubation was 7.1 days (IQR: 3.9–10.3). Among all the patients, C-reactive protein was independently associated with intubation (OR = 1.04, 95% CI: 1.01–1.07). In addition, no medical staff got nosocomial infection who participated in HFNC and NIV management. Conclusions In critically ill patients with COVID-19 who used HFNC and NIV as first-line therapy, the duration of HFNC + NIV, intubation rate and mortality did not differ between two groups. And no medical staff got nosocomial infection during this study.
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Affiliation(s)
- Jun Duan
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Baixu Chen
- Department of Critical Care Medicine, West China hospital of Sichuan University, Chengdu, Sichuan, China
| | - Xiaoyi Liu
- Department of Critical Care Medicine, The Central Hospital of Dazhou, Dazhou, Shichuan, China
| | - Weiwei Shu
- Department of Critical Care Medicine, Yongchuan Hospital of Chongqing Medical University, Yongchuan, Chongqing, China
| | - Wei Zhao
- Department of Oncology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ji Li
- Department of Thoracic Surgery, Chongqing Public Health Medical Center, Chongqing, China
| | - Yishi Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yueling Hong
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Longfang Pan
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ke Wang
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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166
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Abstract
Coronavirus disease-2019 (COVID-19) pandemic has put a severe strain on the healthcare services around the globe. Among the most affected areas of the hospital is critical care. A large number of patients of COVID-19 need critical care especially respiratory care. The acute hypoxemic respiratory failure (AHRF) due to COVID-19 needs careful understanding and strategies for management. Research in AHRF due to COVID-19 has progressed rapidly over the last 6 months. HOW TO CITE THIS ARTICLE Prayag S. Respiratory Care for Severe COVID-19. Indian J Crit Care Med 2020;24(7):493-495.
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Affiliation(s)
- Shirish Prayag
- Critical Care, Prayag Hospital, Pune, Maharashtra, India
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167
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Camillo Ribeiro DDF, Barros FS, Fernandes BL, Nakato AM, Nohama P. Hydrocolloid versus silicone gel for the prevention of nasal injury in newborns submitted to noninvasive ventilation: A randomized clinical trial. Heliyon 2020; 6:e04366. [PMID: 32642588 PMCID: PMC7334427 DOI: 10.1016/j.heliyon.2020.e04366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 02/20/2020] [Accepted: 06/25/2020] [Indexed: 12/03/2022] Open
Abstract
Purpose To compare the effectiveness of the hydrocolloid and the silicone gel on the nasal protection of the newborns (NBs) during the use of noninvasive ventilation (NIV). Materials and methods Thirty-three NBs were selected. They were randomly divided into three groups of 11 NBs, according to the type of nasal protection used: hydrocolloid, thick silicone gel, and thin silicone gel. The stage of the nasal injury and need for exchanging nasal protection were assessed before the connection to the NIV and every 24 h until the physician's authorization for NIV's suspension. Results The mean gestational age was 32.03 ± 3.93 weeks, and the median birth weight was 1760 g (750–3535 g). The incidence of nasal injury using hydrocolloid, thick silicone gel, and a thin silicone gel group was 36.36%, 81.81%, and 72.72%, respectively (p = 0.06). Regarding the injury stage, there was no statistical significance between the three study groups. The hydrocolloid protection type had the best adhesion (p = 0.03) on the NBs' skin. Conclusions Although this study was conducted by local practice patterns, the results showed that the hydrocolloid could be the best choice to prevent the nasal septum base injury in the NB submitted to NIV.
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Affiliation(s)
- Débora de Fátima Camillo Ribeiro
- Neonatal Services, Waldemar Monastier Hospital, Rua XV de Novembro 3701, Bom Jesus, Campo Largo, Paraná, Brazil.,Graduate Program on Biomedical Engineering, Universidade Tecnológica Federal do Paraná, Avenida Sete de Setembro 3165, Rebouças, Curitiba, Paraná, Brazil.,Graduate Program on Health Technology, Pontifícia Universidade Católica do Paraná, Rua Imaculada Conceição 1155, Prado Velho, Curitiba, Paraná, Brazil
| | - Frieda Saicla Barros
- Graduate Program on Biomedical Engineering, Universidade Tecnológica Federal do Paraná, Avenida Sete de Setembro 3165, Rebouças, Curitiba, Paraná, Brazil
| | - Beatriz Luci Fernandes
- Graduate Program on Health Technology, Pontifícia Universidade Católica do Paraná, Rua Imaculada Conceição 1155, Prado Velho, Curitiba, Paraná, Brazil
| | - Adriane Muller Nakato
- Graduate Program on Health Technology, Pontifícia Universidade Católica do Paraná, Rua Imaculada Conceição 1155, Prado Velho, Curitiba, Paraná, Brazil
| | - Percy Nohama
- Graduate Program on Biomedical Engineering, Universidade Tecnológica Federal do Paraná, Avenida Sete de Setembro 3165, Rebouças, Curitiba, Paraná, Brazil.,Graduate Program on Health Technology, Pontifícia Universidade Católica do Paraná, Rua Imaculada Conceição 1155, Prado Velho, Curitiba, Paraná, Brazil
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168
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Zhou X, Yao S, Dong P, Chen B, Xu Z, Wang H. Preventive use of respiratory support after scheduled extubation in critically ill medical patients-a network meta-analysis of randomized controlled trials. Crit Care 2020; 24:370. [PMID: 32571369 DOI: 10.1186/s13054-020-03090-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/12/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Respiratory support has been increasingly used after extubation for the prevention of re-intubation and improvement of prognosis in critically ill medical patients. However, the optimal respiratory support method is still under debate. This network meta-analysis (NMA) aims to evaluate the comparative effectiveness of various respiratory support methods used for preventive purposes after scheduled extubation in critically ill medical patients. METHODS A systematic database search was performed from inception to December 19, 2019, for randomized controlled trials (RCTs) that compared a preventive use of different respiratory support methods, including conventional oxygen therapy (COT), noninvasive ventilation (NIV), high-flow oxygen therapy (HFOT), and combinational use of HFOT and NIV (HFOT+NIV), after planned extubation in adult critically ill medical patients. Study selection, data extraction, and quality assessments were performed in duplicate. The primary outcomes included re-intubation rate and short-term mortality. RESULTS Seventeen RCTs comprising 3341 participants with 4 comparisons were included. Compared with COT, NIV significantly reduced the re-intubation rate [risk ratio (RR) 0.55, 95% confidence interval (CI) 0.39 to 0.77; moderate quality of evidence] and short-term mortality (RR 0.66, 95% CI 0.48 to 0.91; moderate quality of evidence). Compared to COT, HFOT had a beneficial effect on the re-intubation rate (RR 0.55, 95% CI 0.35 to 0.86; moderate quality of evidence) but no effect on short-term mortality (RR 0.79, 95% CI 0.56 to 1.12; low quality of evidence). No significant difference in the re-intubation rate or short-term mortality was found among NIV, HFOT, and HFOT+NIV. The treatment rankings based on the surface under the cumulative ranking curve (SUCRA) from best to worst for re-intubation rate were HFOT+NIV (95.1%), NIV (53.4%), HFOT (51.2%), and COT (0.3%), and the rankings for short-term mortality were NIV (91.0%), HFOT (54.3%), HFOT+NIV (43.7%), and COT (11.1%). Sensitivity analyses of trials with a high risk of extubation failure for the primary outcomes indicated that the SUCRA rankings were comparable to those of the primary analysis. CONCLUSIONS After scheduled extubation, the preventive use of NIV is probably the most effective respiratory support method for comprehensively preventing re-intubation and short-term death in critically ill medical patients, especially those with a high risk of extubation failure.
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169
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Abstract
Amyotrophic lateral sclerosis (ALS) is a fatal disease with no cure; however, symptomatic management has an impact on quality of life and survival. Symptom management is best performed in a multidisciplinary care setting, where patients are evaluated by multiple health care professionals. Respiratory failure is a significant cause of morbidity and mortality in patients with ALS. Early initiation of noninvasive ventilation can prolong survival, and adequate use of airway clearance techniques can prevent respiratory infections. Preventing and treating weight loss caused by dysphagia may slow down disease progression, and expert management of spasticity from upper motor neuron dysfunction enhances patient well-being.
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Affiliation(s)
- Jonathan R Brent
- Department of Neurology, Feinberg School of Medicine, Northwestern University, 303 East Chicago Avenue, Chicago, IL 60611, USA
| | - Colin K Franz
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Neurology, Shirley Ryan AbilityLab, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John M Coleman
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Senda Ajroud-Driss
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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170
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Affiliation(s)
- Kangqi Ng
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
| | - Beng Hoong Poon
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
| | - Troy Hai Kiat Puar
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
| | - Jessica Li Shan Quah
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
| | - Wann Jia Loh
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
| | - Yu Jun Wong
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
| | - Thean Yen Tan
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
| | - Jagadesan Raghuram
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
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171
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Abstract
In the United States, preterm birth rates have steadily increased since 2014. Despite the recent advances in neonatal-perinatal care, more than 40% of very low-birth-weight infants develop chronic lung disease (CLD) and almost 25% have feeding difficulties resulting in delayed achievement of full oral feeds and longer hospital stay. Establishment of full oral feeds, a major challenge for preterm infants, becomes magnified among those on respiratory support and/or with CLD. The strategies to minimize aerodigestive disorders include supporting nonnutritive sucking, developing infant-directed feeding protocols, sensory oromotor stimulation, and early introduction of oral feeds.
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172
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Wang J, Jacob-Files E, Becerra R, Mallma G, Tantaleán da Fieno J, Nielsen KR. Sustainability of high flow in a Peruvian PICU: A qualitative analysis. Int Nurs Rev 2020; 67:352-361. [PMID: 32459012 DOI: 10.1111/inr.12589] [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: 09/14/2019] [Revised: 04/15/2020] [Accepted: 04/17/2020] [Indexed: 11/27/2022]
Abstract
AIM To describe nurse and physician perspectives on enabling factors that promote sustainability of high flow use in resource-limited settings. BACKGROUND Over 650 000 children died from respiratory infections in 2016 globally. Many deaths could be prevented with access to advanced paediatric respiratory support, but sustainability of technology in resource-limited settings remains challenging. INTRODUCTION Local providers have expertise related to site-specific barriers to sustainability. Engaging local providers during implementation can identify strategies to promote ongoing technology use beyond initial deployment. METHODS This qualitative descriptive study was conducted five focus groups with nineteen nurses and seven individual interviews with physicians in a Peruvian paediatric intensive care unit. Data were analysed using a realist thematic approach. RESULTS Providers described five important factors for high flow sustainability: (i) Applying high flow to a broader patient population, including use outside the paediatric intensive care unit to increase opportunities for practice; (ii) Establishing a multidisciplinary approach to high flow management at all hours; (iii) Willingness of nurses and physicians to adopt standardization; (iv) Ongoing high flow leadership; (v) Transparency of high flow impact, including frequent reporting of clinical outcomes of high flow patients. DISCUSSION Local providers described strategies to overcome barriers to sustainability of high flow in their clinical setting, many of which are generalizable to implementation projects in other resource-limited settings. CONCLUSION AND POLICY IMPLICATIONS These findings provide nursing, administrative leaders and policymakers with strategies to promote sustainability of new technology in resource-limited settings, including development of guidelines for appropriate clinical use, change management support, leadership development and clinical outcome reporting procedures. Administrative support and oversight are paramount to foster successful implementation in these settings.
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Affiliation(s)
- Jiayu Wang
- Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
| | - Elizabeth Jacob-Files
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, BJF Research, Seattle, WA, USA
| | - Rosario Becerra
- Departamento de Cuidados Intensivos Pediátricos, Instituto Nacional de Salud del Niño, Lima, Peru
| | - Gabriela Mallma
- Departamento de Cuidados Intensivos Pediátricos, Instituto Nacional de Salud del Niño, Lima, Peru
| | - José Tantaleán da Fieno
- Departamento de Cuidados Intensivos Pediátricos, Instituto Nacional de Salud del Niño, Lima, Peru.,Universidad Nacional Federico Villarreal, Lima, Peru
| | - Katie R Nielsen
- Department of Pediatrics, Critical Care Medicine, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
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173
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Park MH, Kim MJ, Kim AJ, Lee MJ, Kim JS. Helmet-based noninvasive ventilation for acute exacerbation of chronic obstructive pulmonary disease: A case report. World J Clin Cases 2020; 8:1939-1943. [PMID: 32518784 PMCID: PMC7262703 DOI: 10.12998/wjcc.v8.i10.1939] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 04/08/2020] [Accepted: 04/30/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Noninvasive ventilation (NIV) reduces intubation rates, mortalities, and lengths of hospital and intensive care unit stays in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Helmet-based NIV is better tolerated than oronasal mask-based ventilation, and thus, allows NIV to be conducted for prolonged periods at higher pressures with minimal air leaks.
CASE SUMMARY A 73-year-old man with a previous diagnosis of COPD stage 4 was admitted to our medical intensive care unit with chief complaints of cough, sputum, and dyspnea of several days’ duration. For 10 mo, he had been on oxygen at home by day and had used an oronasal mask-based NIV at night. At intensive care unit admission, he breathed using respiratory accessory muscles. Hypercapnia and signs of infection were detected, and infiltration was observed in the right lower lung field by chest radiography. Thus, we diagnosed AECOPD by community-acquired pneumonia. After admission, respiratory distress steadily deteriorated and invasive mechanical ventilation became necessary. However, the patient refused this option, and thus, we selected helmet-based NIV as a salvage treatment. After 3 d of helmet-based NIV, his consciousness level and hypercapnia recovered to his pre-hospitalization level.
CONCLUSION Helmet-based NIV could be considered as a salvage treatment when AECOPD patients refuse invasive mechanical ventilation and oronasal mask-based NIV is ineffective.
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Affiliation(s)
- Mi Hwa Park
- Division of Pulmonology, Department of Internal Medicine, Inha University Hospital, Incheon 22332, South Korea
| | - Min Jeong Kim
- Division of Pulmonology, Department of Internal Medicine, Inha University Hospital, Incheon 22332, South Korea
| | - Ah Jin Kim
- Division of Critical Care Medicine, Department of Internal Medicine, Inha University Hospital, Incheon 22332, South Korea
| | - Man-Jong Lee
- Division of Critical Care Medicine, Department of Internal Medicine, Inha University Hospital, Incheon 22332, South Korea
| | - Jung-Soo Kim
- Division of Pulmonology, Department of Internal Medicine, Inha University Hospital, Incheon 22332, South Korea
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174
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Sztajnbok J, Maselli-Schoueri JH, Cunha de Resende Brasil LM, Farias de Sousa L, Cordeiro CM, Sansão Borges LM, Malaque CMSA. Prone positioning to improve oxygenation and relieve respiratory symptoms in awake, spontaneously breathing non-intubated patients with COVID-19 pneumonia. Respir Med Case Rep 2020; 30:101096. [PMID: 32455107 DOI: 10.1016/j.rmcr.2020.101096] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 05/17/2020] [Accepted: 05/17/2020] [Indexed: 12/30/2022] Open
Abstract
Emergency departments are facing an unprecedented challenge in dealing with patients who have coronavirus disease 2019 (COVID-19). The massive number of cases evolving to respiratory failure are leading to a rapid depletion of medical resources such as respiratory support equipment, which is more critical in low- and middle-income countries. In this context, any therapeutic and oxygenation support strategy that conserves medical resources should be welcomed. Prone positioning is a well-known ventilatory support strategy to improve oxygenation levels. Self-proning can be used in the management of selected patients with COVID-19 pneumonia. Here, we describe our experience with two COVID-19-positive patients who were admitted with respiratory failure. The patients were successfully managed with self-proning and noninvasive oxygenation without the need for intubation.
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175
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Tusman G, Campos M, Gogniat E. [COVID-19: how to transform a noninvasive ventilation device in a critical care ventilator]. ACTA ACUST UNITED AC 2020; 67:367-373. [PMID: 32419705 PMCID: PMC7225690 DOI: 10.1016/j.redar.2020.05.002] [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: 04/05/2020] [Accepted: 05/10/2020] [Indexed: 01/09/2023]
Abstract
La pandemia del COVID-19 ha hecho estragos, no solo en el número de víctimas fatales sino también en la infraestructura de los hospitales y unidades de cuidados intensivos. El número limitado de respiradores es una preocupación de toda la comunidad dada la demanda masiva y a muy corto plazo de estos equipos. Esta presentación tiene como fin dar soluciones sencillas para ventilar pacientes intubados de modo mandatorio utilizando equipos de ventilación no invasiva. Las soluciones propuestas permiten 2 estrategias claras frente al COVID-19: Reemplazar las máquinas de anestesia para disponer de ellas en pacientes. Usar la opción de equipos de ventilación no invasiva para pacientes con COVID-19 a modo de «puente» y a la espera de la liberación de un respirador específico en la unidad de cuidados críticos.
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Affiliation(s)
- G Tusman
- Departamento de Anestesia, Hospital Privado de Comunidad, Mar del Plata, Argentina.
| | - M Campos
- Departamento de Anestesia, Sanatorio Finochietto, Buenos Aires, Argentina; Centro de Simulación, Asociación de Anestesia, Analgesia y Reanimación de Buenos Aires, Buenos Aires, Argentina
| | - E Gogniat
- Kinesiólogo Respiratorio, Miembro del Capítulo de kinesiología Intensivista y Comité de Neumonología Crítica, Sociedad Argentina de Terapia Intensiva, Buenos Aires, Argentina
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176
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Stefan MS, Pekow PS, Shea CM, Hughes AM, Hill NS, Steingrub JS, Lindenauer PK. Protocol for two-arm pragmatic cluster randomized hybrid implementation-effectiveness trial comparing two education strategies for improving the uptake of noninvasive ventilation in patients with severe COPD exacerbation. Implement Sci Commun 2020; 1:46. [PMID: 32435762 PMCID: PMC7223919 DOI: 10.1186/s43058-020-00028-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 03/23/2020] [Indexed: 11/30/2022] Open
Abstract
Background COPD is the fourth leading cause of death in the US, and COPD exacerbations result in approximately 700,000 hospitalizations annually. Patients with acute respiratory failure due to severe COPD exacerbation are treated with invasive (IMV) or noninvasive mechanical ventilation (NIV). Although IMV reverses hypercapnia/hypoxia, it causes significant morbidity and mortality. There is strong evidence that patients treated with NIV have better outcomes, and NIV is recommended as first line therapy in these patients. Yet, several studies have demonstrated substantial variation in the use of NIV across hospitals, leading to preventable morbidity and mortality. Through a series of mixed-methods studies, we have found that successful implementation of NIV requires physicians, respiratory therapists (RTs), and nurses to communicate and collaborate effectively, suggesting that efforts to increase the use of NIV in COPD need to account for the complex and interdisciplinary nature of NIV delivery and the need for team coordination. Therefore, we propose to compare two educational strategies: online education (OLE) and interprofessional education (IPE) which targets complex team-based care in NIV delivery. Methods and design Twenty hospitals with low baseline rates of NIV use will be randomized to either the OLE or IPE study arm. The primary outcome of the trial is change in the hospital rate of NIV use among patients with COPD requiring ventilatory support. In aim 1, we will compare the uptake change over time of NIV use among patients with COPD in hospitals enrolled in the two arms. In aim 2, we will explore mediators’ role (respiratory therapist autonomy and team functionality) on the relationship between the implementation strategies and implementation effectiveness. Finally, in aim 3, through interviews with providers, we will assess acceptability and feasibility of the educational training. Discussions This study will be among the first to carefully test the impact of IPE in the inpatient setting. This work promises to change practice by offering approaches to facilitate greater uptake of NIV and may generalize to other interventions directed to seriously-ill patients. Trial registration Name of registry: ClinicalTrials.gov Trial registration number: NCT04206735 Date of Registration: December 20, 2019
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Affiliation(s)
- Mihaela S Stefan
- 1Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA USA.,2Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA USA
| | - Penelope S Pekow
- 1Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA USA.,3School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA USA
| | - Christopher M Shea
- 4Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC USA
| | - Ashley M Hughes
- 5College of Applied Health Science, University of Illinois at Chicago, Chicago, IL USA
| | - Nicholas S Hill
- 6Division of Pulmonary and Critical Care Medicine, Tufts University School of Medicine, Boston, MA USA
| | - Jay S Steingrub
- 7Division of Pulmonary and Critical Care, Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA USA
| | - Peter K Lindenauer
- 1Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA USA.,2Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA USA.,8Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA USA
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177
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Ferreyro BL, Angriman F, Munshi L, Del Sorbo L, Ferguson ND, Rochwerg B, Ryu MJ, Saskin R, Wunsch H, da Costa BR, Scales DC. Noninvasive oxygenation strategies in adult patients with acute respiratory failure: a protocol for a systematic review and network meta-analysis. Syst Rev 2020; 9:95. [PMID: 32336293 PMCID: PMC7184712 DOI: 10.1186/s13643-020-01363-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/14/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Acute hypoxemic respiratory failure is one of the leading causes of intensive care unit admission and is associated with high mortality. Noninvasive oxygenation strategies such as high-flow nasal cannula, standard oxygen therapy, and noninvasive ventilation (delivered by either face mask or helmet interface) are widely available interventions applied in these patients. It remains unclear which of these interventions are more effective in decreasing rates of invasive mechanical ventilation and mortality. The primary objective of this network meta-analysis is to summarize the evidence and compare the effect of noninvasive oxygenation strategies on mortality and need for invasive mechanical ventilation in patients with acute hypoxemic respiratory failure. METHODS We will search key databases for randomized controlled trials assessing the effect of noninvasive oxygenation strategies in adult patients with acute hypoxemic respiratory failure. We will exclude studies in which the primary focus is either acute exacerbations of chronic obstructive pulmonary disease or cardiogenic pulmonary edema. The primary outcome will be all-cause mortality (longest available up to 90 days). The secondary outcomes will be receipt of invasive mechanical ventilation (longest available up to 30 days). We will assess the risk of bias for each of the outcomes using the Cochrane Risk of Bias Tool. Bayesian network meta-analyses will be conducted to obtain pooled estimates of head-to-head comparisons. We will report pairwise and network meta-analysis treatment effect estimates as risk ratios and 95% credible intervals. Subgroup analyses will be conducted examining key populations including immunocompromised hosts. Sensitivity analyses will be conducted by excluding those studies with high risk of bias and different etiologies of acute respiratory failure. We will assess certainty in effect estimates using GRADE methodology. DISCUSSION This study will help to guide clinical decision-making when caring for adult patients with acute hypoxemic respiratory failure and improve our understanding of the limitations of the available literature assessing noninvasive oxygenation strategies in acute hypoxemic respiratory failure. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019121755.
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Affiliation(s)
- Bruno L. Ferreyro
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Medicine, Sinai Health System and University Health Network, Toronto, Canada
| | - Federico Angriman
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Laveena Munshi
- Department of Medicine, Sinai Health System and University Health Network, Toronto, Canada
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON Canada
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Canada
| | - Niall D. Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Medicine, Sinai Health System and University Health Network, Toronto, Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada
| | - Michelle J. Ryu
- Sidney Liswood Health Sciences Library, Sinai Health System, Toronto, Canada
| | - Refik Saskin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario Canada
| | - Hannah Wunsch
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Bruno R. da Costa
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Applied Health Research Center (AHRC), Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Damon C. Scales
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario Canada
- Applied Health Research Center (AHRC), Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada
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178
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Hernández Garcés H, Navarro Lacalle A, Lizama López L, Zaragoza Crespo R. Risk factors associated to noninvasive ventilation failure in primary influenza A pneumonia in the critical care setting. Med Intensiva 2021; 45:347-53. [PMID: 34294232 DOI: 10.1016/j.medine.2019.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 11/19/2019] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To evaluate the risk factors associated to noninvasive mechanical ventilation (NIV) failure in patients with primary pneumonia due to influenza A (H1N1)pdm09 virus admitted to the intensive care unit (ICU), and to demonstrate the association of NIV failure to increased mortality and longer stays. DESIGN A cohort study was carried out. SCOPE A mixed ICU (16 beds) in a teaching hospital. PATIENTS Adult patients admitted to the ICU with a diagnosis of pneumonia due to influenza A (H1N1)pdm09 virus requiring mechanical ventilation. MEASUREMENTS Age, sex, severity scores, administration of corticosteroids, oseltamivir within 72h of symptoms onset, days of symptoms prior to admission, affected quadrants, hemodynamic parameters, renal failure, laboratory test data on admission, mortality and stay in ICU and in hospital. RESULTS A total of 54 patients were admitted to the ICU and 49 were ventilated; 29 were females (59.2%), and the mean age±standard deviation was 66.77±14.77 years. Forty-three patients (87.75%) were ventilated with NIV, and 18 (41.9%) of them failed. Patients with NIV failure were younger (63 vs. 74 years; p=0.04), with a higher SOFA score (7 vs. 4; p=0.01) and greater early hemodynamic failure (61.1 vs. 8%; p=0.01). In addition, they presented longer ICU (26.28 vs. 6.88 days; p=0.01) and hospital stay (32.78 vs. 18.8 days; p=0.01). The ICU mortality rate was also higher in the NIV failure group (38.9 vs. 0%; p=0.02). In the multivariate analysis, corticosteroid therapy (OR 7.08; 95% CI 1.23-40.50) and early hemodynamic failure (OR 14.77; 95% CI 2.34-92.97) were identified as independent risk factors for NIV failure. CONCLUSIONS Treatment with corticosteroids and early hemodynamic failure were associated to NIV failure in patients with primary pneumonia due to influenza A (H1N1)pdm09 virus infection admitted to the ICU. The failure of NIV was associated to increased mortality.
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179
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Ochoa-Hein E, Choi SJ, Gómez-Santillán JA, Oyervides-Alvarado JA, Galindo-Fraga A, Rivero-Sigarroa E, Hernández-Gilsoul T, Domínguez-Cherit JG. Near-zero ventilator-associated pneumonia rates after implementation of a multimodal preventive strategy in a Mexican hospital. Am J Infect Control 2020; 48:446-447. [PMID: 31677926 DOI: 10.1016/j.ajic.2019.09.018] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 09/23/2019] [Accepted: 09/23/2019] [Indexed: 12/16/2022]
Abstract
A multimodal preventive strategy consisting of a ventilator-associated pneumonia (VAP) preventive bundle plus 3 additional sequential interventions (noninvasive ventilation, reeducation of health care workers, and early weaning) was associated with a marked reduction in VAP rates in a Latin American hospital, including 6 consecutive months without VAP cases. A positive association between the percentage of intubated patients and VAP rates was observed.
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Affiliation(s)
- Eric Ochoa-Hein
- Hospital Epidemiology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
| | - Su J Choi
- Intensive Care Unit, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Jonathan A Gómez-Santillán
- Emergency Room, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - José A Oyervides-Alvarado
- Intensive Care Unit, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Arturo Galindo-Fraga
- Hospital Epidemiology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Eduardo Rivero-Sigarroa
- Intensive Care Unit, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Thierry Hernández-Gilsoul
- Emergency Room, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - José G Domínguez-Cherit
- Intensive Care Unit, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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180
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Ozbudak G, Yesilbalkan OU. Effect of transparent film on the duration of pressure ulcer formation for noninvasive ventilation patients: A randomized controlled trial. Niger J Clin Pract 2020; 23:91-97. [PMID: 31929213 DOI: 10.4103/njcp.njcp_673_18] [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: 11/04/2022]
Abstract
Background Due to the prolonged use of face mask in noninvasive ventilation, pressure ulcer is a common complication. Pressure ulcer can occur within a few hours at the site where the mask contacts in 2-70% of cases. Aims The aim of this study is to conduct a randomized controlled trial to investigate the effects of transparent film use on the duration of pressure ulcer formation in the nasal region in patients undergoing noninvasive ventilation. Methods This study was a randomized controlled trial. 46 patients who met the sample selection criteria and agreed to participate in the study were included in the study at a university hospital in İzmir, Turkey. Of them, 25 were assigned to the intervention group and 21 to the control group. Data were collected using the Socio-demographic and Disease-related Characteristics Questionnaire, The Noninvasive Ventilation Parameters Monitoring Form, and The Pressure Ulcer Classification Form at 4-hour intervals. Results The duration of pressure ulcer formation in intervention group was longer than that in control group, and the difference between them was statistically significant (P < 0.05). Conclusion In this study, the use of nasal protective film (transparent film) prolonged the duration of pressure ulcer formation on the nasal bridge in patients who underwent noninvasive mechanical ventilation.
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Affiliation(s)
- G Ozbudak
- Department of Chest Diseases, Ege University Hospital, Izmir, Turkey
| | - O U Yesilbalkan
- Ege University Faculty of Nursing, Internal Medicine Nursing, Izmir, Turkey
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181
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Green E, Bernoth M. The experiences of nurses using noninvasive ventilation: An integrative review of the literature. Aust Crit Care 2020; 33:560-6. [PMID: 32143882 DOI: 10.1016/j.aucc.2020.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 01/03/2020] [Accepted: 01/06/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Noninvasive ventilation (NIV) is a common treatment delivered in critical care and is imperative in the management of many acute respiratory illnesses. Nurses are integral to the initiation and management of NIV, but there is a paucity of evidence on the experiences of nurses in this role. OBJECTIVES The aim of this integrative review was to examine the current available research focused on nurses' experiences of using NIV across a variety of healthcare settings. METHODS Database searches were conducted using EBSCOhost (health) databases, MEDLINE, and Science Direct. Search terms used were combinations of 'nurs∗' or 'experience∗' with 'noninvasive ventilation', 'non invasive ventilation', 'BiPAP', 'CPAP', or 'positive airway pressure'. Inclusion criteria were studies that focused on the experiences of nurses using NIV, were peer reviewed and published in English, and had research designs (collected and analysed quantitative and/or qualitative data). The studies that met the inclusion criteria were individually examined and rated in accordance with the Joanna Briggs Institute Critical Appraisal Checklist for critical and interpretive research. RESULTS The literature search returned a possible 279 matches which were shortlisted based on the title and then again by abstract content before being reviewed in full. After application of inclusion/exclusion criteria, eight articles with a mix of qualitative and quantitative study designs were included in the review. The themes of education, communication, and guideline utilisation were common to many of the findings from both interviews and surveys. CONCLUSION The research examined in this literature review reported some difficulties associated with NIV use including limited education, communication, and variable guideline use. Despite this, nurses were generally able to use NIV to provide positive patient outcomes. CLINICAL TRIAL REGISTRATION NUMBER NA.
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182
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Hakim R, Watanabe-Tejada L, Sukhal S, Tulaimat A. Acute respiratory failure in randomized trials of noninvasive respiratory support: A systematic review of definitions, patient characteristics, and criteria for intubation. J Crit Care 2020; 57:141-7. [PMID: 32145657 DOI: 10.1016/j.jcrc.2020.02.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 02/17/2020] [Accepted: 02/27/2020] [Indexed: 01/18/2023]
Abstract
PURPOSE To examine the definitions of acute respiratory failure, the characteristics of recruited patients, and the criteria for intubation used in randomized trials. METHODS We searched MEDLINE for randomized trials of noninvasive respiratory support modalities in patients with de novo respiratory failure. We included trials from 1995 to 2017 that enrolled 40 or more patients and used intubation as an outcome. RESULTS We examined the reports of 53 trials that enrolled 7225 patients. There was wide variation in the use of variables for defining acute respiratory failure. Dyspnea was rarely measured and the increase in breathing effort was poorly defined. The characteristics of patients enrolled in trials changed over time and differed by the cause of respiratory failure. Intubation was poorly characterized. The criteria for intubation had more variables than the criteria for respiratory failure. CONCLUSIONS We identified deficiencies in the design and reporting of randomized trials, some of which can be remedied by investigators. We also found that patient characteristics differ by the type of respiratory failure. This knowledge can help clinician identify patients at the right moment to benefit from the tested interventions and investigators in developing criteria for enrollment in future trials.
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183
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Abstract
Preterm infants frequently present with respiratory insufficiency requiring respiratory assistance. Invasive mechanical ventilation has been associated with several short and long term complications. Therefore, the practice of early use of non-invasive ventilation has been adopted. Nasal CPAP proved efficacy as an initial therapy for preterm infants. Non-invasive positive pressure ventilation is an alternative used to mitigate CPAP failure in infants with apnea or increased work of breathing. High flow nasal cannula gained popularity primarily due to the ease of its use, despite multiple prominent trials that demonstrated its inferiority. Bi-level positive airway pressure and neurally adjusted non-invasive ventilatory are used in infants with apnea and increased work of breathing. The effectiveness of non invasive ventilation tools can be augmented by having a proper protocol for initiation, weaning, skin care, positioning, and developmental care during their application.
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Affiliation(s)
- Nehad Nasef
- Neonatal Intensive Care Unit, Mansora University Children's Hospital, Mansoura, Egypt.,Department of Pediatrics, Faculty of Medicine, University of Mansoura, Egypt
| | - Hend Me Rashed
- School of Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, OH, USA
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184
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Matlock DN, Bai S, Weisner MD, Comtois N, Beck J, Sinderby C, Courtney SE. Work of Breathing in Premature Neonates: Noninvasive Neurally-Adjusted Ventilatory Assist versus Noninvasive Ventilation. Respir Care 2020; 65:946-953. [PMID: 32071130 DOI: 10.4187/respcare.07257] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND We tested whether work of breathing in premature newborns estimated by phase angle (θ) by using respiratory inductance plethysmography is decreased during neurally-adjusted ventilatory assist (NAVA) noninvasive ventilation (NIV) versus NIV alone. METHODS NAVA NIV and NIV were applied in random order while using respiratory inductance plethysmography to measure the phase angle. RESULTS Patient-ventilator asynchrony was decreased during NAVA NIV; however, the phase angle was not different between the modes. A large number of repeated assists with switches to backup were found when using NAVA NIV. Results of the analysis indicated these were due to the apnea alarm limit set during NAVA NIV. CONCLUSIONS The improvement in patient-ventilator synchrony supports the hypothesis that work of breathing may be decreased with NAVA NIV; however, we were unable to demonstrate this with our study design. Short apnea time settings with NAVA NIV led to a large number of switches to backup and repeated assists during the same neural effort. (ClinicalTrials.gov registration NCT02788110.).
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Affiliation(s)
- David N Matlock
- Department of Pediatrics, Neonatology Division, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
| | - Shasha Bai
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio
| | | | - Norman Comtois
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Jennifer Beck
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Institute for Biomedical Engineering and Science Technology, Ryerson University and St. Michael's Hospital, Toronto, Ontario, Canada
| | - Christer Sinderby
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute for Biomedical Engineering and Science Technology, Ryerson University and St. Michael's Hospital, Toronto, Ontario, Canada
| | - Sherry E Courtney
- Department of Pediatrics, Neonatology Division, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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185
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Cheng PC, Panitch HB, Hansen-Flaschen J. Transition of patients with neuromuscular disease and chronic ventilator-dependent respiratory failure from pediatric to adult pulmonary care. Paediatr Respir Rev 2020; 33:3-8. [PMID: 31053356 DOI: 10.1016/j.prrv.2019.03.005] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 03/28/2019] [Indexed: 11/25/2022]
Abstract
Improvements in medical care have allowed many children with neuromuscular disease and chronic respiratory failure to survive into adulthood. There are currently no published guidelines to facilitate transition from pediatric to adult respiratory care in this population. The transition process in neuromuscular disease and chronic respiratory failure is uniquely challenging in that the patients are often declining in health and losing independence as they approach adulthood. Barriers to transition include lack of access to adult providers, incompatible health insurance, loss of resources within patients' medical structures, absence of transition preparation, and patient and family insecurity with a new healthcare system. The six core elements and optimal time frame of transition should be applied, with special consideration of the psychosocial aspects associated with neuromuscular disease. Successful transition revolves around information, open communication between young adults and their medical care team, and individualized planning to ensure optimal health and quality of life.
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Affiliation(s)
- Pi Chun Cheng
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Howard B Panitch
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - John Hansen-Flaschen
- Division of Pulmonary, Allergy, & Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
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186
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Diaz-Abad M, Porter N, Zilliox L, Todd N. Use of Noninvasive Ventilation with Volume-Assured Pressure Support in Neuralgic Amyotrophy with Bilateral Diaphragmatic Paralysis. Open Respir Med J 2020; 13:45-47. [PMID: 31908687 PMCID: PMC6918536 DOI: 10.2174/1874306401913010045] [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: 03/03/2019] [Revised: 05/24/2019] [Accepted: 06/18/2019] [Indexed: 11/30/2022] Open
Abstract
Neuralgic Amyotrophy (NA) is a rare, acute onset inflammatory brachial plexopathy that frequently presents with acute pain followed by shoulder girdle muscle weakness. Phrenic nerve involvement affecting the diaphragms occurs in 7-10% of cases. We present the case of a 52-year-old man with neuralgic amyotrophy with phrenic nerve involvement and bilateral diaphragmatic paralysis with marked respiratory symptoms and sleep hypoventilation, who was treated with non-invasive ventilation with volume assured pressure support mode. By 21 months post disease onset, the patient had experienced marked improvement in orthopnea, sleep quality and functional status. This is the first reported case of the use of this mode of noninvasive ventilation in neuralgic amyotrophy.
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Affiliation(s)
- Montserrat Diaz-Abad
- Department of Medicine, University of Maryland School of Medicine, 100 South Paca Street 2nd Fl, Baltimore, Maryland, 21201, USA
| | - Neil Porter
- Department of Neurology, University of Maryland School of Medicine, 100 South Paca Street 3rd Fl, Baltimore, Maryland, 21201, USA
| | - Lindsay Zilliox
- Department of Neurology, University of Maryland School of Medicine, 100 South Paca Street 3rd Fl, Baltimore, Maryland, 21201, USA
| | - Nevins Todd
- Department of Medicine, University of Maryland School of Medicine, 100 South Paca Street 2nd Fl, Baltimore, Maryland, 21201, USA
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187
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Hernández Garcés H, Navarro Lacalle A, Lizama López L, Zaragoza Crespo R. Risk factors associated to noninvasive ventilation failure in primary influenza A pneumonia in the critical care setting. Med Intensiva 2020. [PMID: 31924443 DOI: 10.1016/j.medin.2019.11.007] [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: 10/25/2022]
Abstract
OBJECTIVE To evaluate the risk factors associated to noninvasive mechanical ventilation (NIV) failure in patients with primary pneumonia due to influenza A (H1N1)pdm09 virus admitted to the intensive care unit (ICU), and to demonstrate the association of NIV failure to increased mortality and longer stays. DESIGN A cohort study was carried out. SCOPE A mixed ICU (16 beds) in a teaching hospital. PATIENTS Adult patients admitted to the ICU with a diagnosis of pneumonia due to influenza A (H1N1)pdm09 virus requiring mechanical ventilation. MEASUREMENTS Age, sex, severity scores, administration of corticosteroids, oseltamivir within 72h of symptoms onset, days of symptoms prior to admission, affected quadrants, hemodynamic parameters, renal failure, laboratory test data on admission, mortality and stay in ICU and in hospital. RESULTS A total of 54 patients were admitted to the ICU and 49 were ventilated; 29 were females (59.2%), and the mean age±standard deviation was 66.77±14.77 years. Forty-three patients (87.75%) were ventilated with NIV, and 18 (41.9%) of them failed. Patients with NIV failure were younger (63 vs. 74 years; P=.04), with a higher SOFA score (7 vs. 4; P=.01) and greater early hemodynamic failure (61.1 vs. 8%; P=.01). In addition, they presented longer ICU (26.28 vs. 6.88 days; P=.01) and hospital stay (32.78 vs. 18.8 days; P=.01). The ICU mortality rate was also higher in the NIV failure group (38.9 vs. 0%; P=.02). In the multivariate analysis, corticosteroid therapy (OR 7.08; 95% CI 1.23-40.50) and early hemodynamic failure (OR 14.77; 95% CI 2.34-92.97) were identified as independent risk factors for NIV failure. CONCLUSIONS Treatment with corticosteroids and early hemodynamic failure were associated to NIV failure in patients with primary pneumonia due to influenza A (H1N1)pdm09 virus infection admitted to the ICU. The failure of NIV was associated to increased mortality.
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Affiliation(s)
- H Hernández Garcés
- Servicio de Medicina Intensiva, Hospital Universitario Doctor Peset, Valencia, España.
| | - A Navarro Lacalle
- Servicio de Medicina Intensiva, Hospital Universitario Doctor Peset, Valencia, España
| | - L Lizama López
- Servicio de Medicina Intensiva, Hospital Universitario Doctor Peset, Valencia, España
| | - R Zaragoza Crespo
- Servicio de Medicina Intensiva, Hospital Universitario Doctor Peset, Valencia, España
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188
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S Rolim D, Galas FRB, Faria LS, Amorim EF, Regenga MM, Troster EJ. Use of Noninvasive Ventilation in Respiratory Failure After Extubation During Postoperative Care in Pediatrics. Pediatr Cardiol 2020; 41:729-35. [PMID: 32025758 DOI: 10.1007/s00246-020-02290-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 01/17/2020] [Indexed: 11/23/2022]
Abstract
The purpose of this study was to determine the rate of failure of noninvasive ventilation (NIV) after cardiac surgery in pediatric patients with respiratory failure after extubation and to identify predictive success factors. This was a prospective cohort study of pediatric patients diagnosed with congenital heart disease who underwent heart surgery and used NIV. Data were collected from 170 patients with a median age of 2 months. No patient presented cardiorespiratory arrest nor any other complication during the use of NIV. The success rate for the use of NIV was 61.8%. Subjects were divided for analysis into successful and failed NIV groups. Statistical analysis used Chi-square, Mann-Whitney, and Student's t tests, which were performed after univariate and multivariate logistic regression for p < 0.05. In the multivariate analysis, only the minimal pressure gradient (OR 1.45 with p = 0.007), maximum oxygen saturation (OR 0.88 with p = 0.011), and maximum fraction of inspired oxygen (FiO2) (OR 1.16 with p < 0.001) influenced NIV failure. The following variables did not present a statistical difference: extracorporeal circulation time (p = 0.669), pulmonary hypertension (p = 0.254), genetic syndrome (p = 0.342), RACHS-1 score (p = 0.097), age (p = 0.098), invasive mechanical ventilation duration (p = 0.186), and NIV duration (p = 0.804). In conclusion, NIV can be successfully used in children who, after cardiac surgery, develop respiratory failure in the 48 h following extubation. Although the use of higher pressure gradients and higher FiO2 are associated with a greater failure rate for NIV use, it was found to be generally safe.
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189
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Holbird S, Holt T, Shaw A, Hansen G. Noninvasive ventilation for pediatric interfacility transports: a retrospective study. World J Pediatr 2020; 16:422-425. [PMID: 32405709 PMCID: PMC7222886 DOI: 10.1007/s12519-020-00363-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/31/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND To characterize pediatric patients supported with continuous positive airway pressure and bilevel positive airway pressure (CPAP/BiPAP) or high-flow nasal cannula (HFNC) during interfacility transport (IFT). METHODS A retrospective study with a provincial pediatric transport team from a tertiary hospital pediatric intensive care unit. Pediatric patients aged 28 days to < 17 years, who required IFT between January 2017 and December 2018, were identified through a transport registry and were included in the study. RESULTS A total of 118 (26.7%) patients received CPAP/BIPAP or HFNC support for IFT. The most common respiratory diagnosis was bronchiolitis (46%). These patients were placed on respiratory support, 31.4 minutes after the transport team's arrival. None required intubation during their IFT, despite mean transport times of 163 minutes. CONCLUSIONS This study may provide important information for programs with large catchment areas, in which large distances and transport times should not be barriers to NIV implementation.
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Affiliation(s)
- Samantha Holbird
- grid.25152.310000 0001 2154 235XCollege of Medicine, University of Saskatchewan, Saskatoon, SK Canada
| | - Tanya Holt
- Division of Pediatric Critical Care, Jim Pattison Children’s Hospital, 103 Hospital Drive, Saskatoon, SK S7N 0W8 Canada
| | - Adam Shaw
- Division of Pediatric Critical Care, Jim Pattison Children’s Hospital, 103 Hospital Drive, Saskatoon, SK S7N 0W8 Canada
| | - Gregory Hansen
- Division of Pediatric Critical Care, Jim Pattison Children's Hospital, 103 Hospital Drive, Saskatoon, SK, S7N 0W8, Canada.
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190
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Davis JW, Pillow JJ, Cooper MN, Dahl MJ. Electrostatic Filters to Reduce COVID-19 Spread in Bubble CPAP: An in vitro Study of Safety and Efficacy. Neonatology 2020; 117:736-741. [PMID: 33249414 PMCID: PMC7801988 DOI: 10.1159/000512146] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/08/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Bubble CPAP may be used in infants with suspected or confirmed COVID-19. Electrostatic filters may reduce cross infection. This study aims to determine if including a filter in the bubble CPAP circuit impacts stability of pressure delivery. METHODS A new electrostatic filter was placed before (pre) or after (post) the bubble CPAP generator, or with no filter (control) in an in vitro study. Pressure was recorded at the nasal interface for 18 h (6 L/min; 7 cm H2O) on 3 occasions for each configuration. Filter failure was defined as pressure >9 cm H2O for 60 continuous minutes. The filter was weighed before and after each experiment. RESULTS Mean (SD) time to reach the fail point was 257 (116) min and 525 (566) min for filter placement pre- and post-CPAP generator, respectively. Mean pressure was higher throughout in the pre-generator position compared to control. The filter weight was heavier at end study in the pre- compared to the post-generator position. CONCLUSIONS Placement of the filter at the pre-generator position in a bubble CPAP circuit should be avoided due to unstable mean pressure. Filters are likely to become saturated with water over time. The post-generator position may accommodate a filter, but regular pressure monitoring and early replacement are required.
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Affiliation(s)
- Jonathan W Davis
- Neonatology, Child and Adolescent Health Service, Hospital Avenue, Nedlands, Washington, Australia, .,Medical School, The University of Western Australia, Perth, Washington, Australia,
| | - J Jane Pillow
- School of Human Sciences, The University of Western Australia, Perth, Washington, Australia
| | - Matthew N Cooper
- Biometrics, Telethon Kids Institute, University of Western Australia, Nedlands, Washington, Australia
| | - Mar Janna Dahl
- School of Human Sciences, The University of Western Australia, Perth, Washington, Australia
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191
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Cunha-Goncalves D, Nord A, Bianco F, Salomone F, Ricci F, Schlun M, Linner R, Perez-de-Sa V. Impact of Body Position on Lung Deposition of Nebulized Surfactant in Newborn Piglets on Nasal Continuous Positive Airway Pressure. Neonatology 2020; 117:467-473. [PMID: 32604091 DOI: 10.1159/000508349] [Citation(s) in RCA: 5] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 04/26/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The ideal body position during surfactant nebulization is not known. OBJECTIVE The aim of this study was to determine whether body positioning during surfactant nebulization influences surfactant distribution and deposition in the lungs. METHODS Twenty-four 12- to 36-h-old full-termpiglets (1.3-2.2 kg) on nasal continuous positive airway pressure (nCPAP) were randomized into four groups: lateral decubitus with right or left side up, prone or supine positions (n = 6 each). All animals received 200 mg kg-1 of poractant alfa mixed with 200 MBq of 99mtechnetium-nanocolloid via a customized eFlow-Neos investigational vibrating-membrane nebulizer. Surfactant deposition (percentage of the administered dose) was measured by gamma scintigraphy. RESULTS Comparing all groups, the mean total lung surfactant deposition was significantly higher in the prone position (32.4 ± 7.7%, p = 0.03). The deposition in this group was higher in the right lung (21.0 ± 8.6 vs. 11.3 ± 5.7%, p = 0.04). When nebulization was performed in the lateral decubitus, most of the surfactant was found in the dependent lung, regardless of which side the piglet lay on (right side up 15.3 ± 1.0 vs. 3.4 ± 1.0%, p = 0.06, and left side up 11.2 ± 9.8 vs. 1.8 ± 0.7%, p = 0.04). CONCLUSIONS In spontaneously breathing animals on nCPAP, the prone position yielded the highest lung dose. Higher deposition rates in the dependent lung while on lateral decubitus indicates that deposition was also influenced by gravity.
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Affiliation(s)
- Doris Cunha-Goncalves
- Department of Cardiothoracic Anesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden, .,Department of Clinical Sciences, Lund University, Lund, Sweden,
| | - Anders Nord
- Department of Pediatric Anesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Federico Bianco
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici SpA, Parma, Italy
| | - Fabrizio Salomone
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici SpA, Parma, Italy
| | - Francesca Ricci
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici SpA, Parma, Italy
| | | | - Rikard Linner
- Department of Cardiothoracic Anesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Valeria Perez-de-Sa
- Department of Pediatric Anesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
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192
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Estay AS, Mariani GL, Alvarez CA, Milet B, Agost D, Avila CP, Roldan L, Abdala DA, Keller R, Galletti MF, González A. Randomized Controlled Trial of Nonsynchronized Nasal Intermittent Positive Pressure Ventilation versus Nasal CPAP after Extubation of VLBW Infants. Neonatology 2020; 117:193-199. [PMID: 32388511 DOI: 10.1159/000506164] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 01/27/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Nasal continuous positive airway pressure (NCPAP) is a useful method of respiratory support after extubation. However, some infants fail despite CPAP use and require reintubation. Some evidence suggests that synchronized nasal intermittent positive pressure ventilation (NIPPV) may decrease extubation failure in preterm infants. Nonsynchronized NIPPV (NS-NIPPV) is being widely used in preterm infants without conclusive evidence of its benefits and side effects. Our aim was to evaluate whether NS-NIPPV decreases extubation failure compared with NCPAP in ventilated very low birth weight infants (VLBWI) with respiratory distress syndrome (RDS). METHODS Randomized controlled trial of ventilated VLBWI being extubated for the first time. Before extubation, infants were randomized to receive NCPAP or NS-NIPPV. Primary outcome was the need for reintubation within 72 h. RESULTS 220 infants were included. The mean ± SD birth weight was 1,027 ± 256 g and gestational age 27.8 ± 1.9 weeks. Demographic and clinical characteristics were similar in both groups. Extubation failure was 32.4% for NCPAP versus 32.1% for NS-NIPPV, p = 0.98. The frequency of deaths, bronchopulmonary dysplasia, intraventricular hemorrhage, air leaks, necrotizing enterocolitis and duration of respiratory support did not differ between groups. CONCLUSIONS In this population of VLBWI, NS-NIPPV did not decrease extubation failure after RDS compared with NCPAP.
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Affiliation(s)
- Alberto S Estay
- Departamento de Neonatología, Pontificia Universidad Católica de Chile, Santiago, Chile,
| | - Gonzalo L Mariani
- Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Daniel Agost
- Hospital Luis Carlos Lagomaggiore, Mendoza, Argentina
| | | | | | | | | | - María F Galletti
- Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Alvaro González
- Departamento de Neonatología, Pontificia Universidad Católica de Chile, Santiago, Chile
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193
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Abstract
High-flow nasal cannula (HFNC) is a relatively safe and effective noninvasive ventilation method that was recently accepted as a treatment option for acute respiratory support before endotracheal intubation or invasive ventilation. The action mechanism of HFNC includes a decrease in nasopharyngeal resistance, washout of dead space, reduction in inflow of ambient air, and an increase in airway pressure. In preterm infants, HFNC can be used to prevent reintubation and initial noninvasive respiratory support after birth. In children, flow level adjustments are crucial considering their maximal efficacy and complications. Randomized controlled studies suggest that HFNC can be used in cases of moderate to severe bronchiolitis upon initial low-flow oxygen failure. HFNC can also reduce intubation and mechanical ventilation in children with respiratory failure. Several observational studies have shown that HFNC can be beneficial in acute asthma and other respiratory distress. Multicenter randomized studies are warranted to determine the feasibility and adherence of HFNC and continuous positive airway pressure in pediatric intensive care units. The development of clinical guidelines for HFNC, including flow settings, indications, and contraindications, device management, efficacy identification, and safety issues are needed, particularly in children.
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Affiliation(s)
- Ji-Won Kwon
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
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194
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Racca F, Vianello A, Mongini T, Ruggeri P, Versaci A, Vita GL, Vita G. Practical approach to respiratory emergencies in neurological diseases. Neurol Sci 2019; 41:497-508. [PMID: 31792719 PMCID: PMC7224095 DOI: 10.1007/s10072-019-04163-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 11/15/2019] [Indexed: 02/06/2023]
Abstract
Many neurological diseases may cause acute respiratory failure (ARF) due to involvement of bulbar respiratory center, spinal cord, motoneurons, peripheral nerves, neuromuscular junction, or skeletal muscles. In this context, respiratory emergencies are often a challenge at home, in a neurology ward, or even in an intensive care unit, influencing morbidity and mortality. More commonly, patients develop primarily ventilatory impairment causing hypercapnia. Moreover, inadequate bulbar and expiratory muscle function may cause retained secretions, frequently complicated by pneumonia, atelectasis, and, ultimately, hypoxemic ARF. On the basis of the clinical onset, two main categories of ARF can be identified: (i) acute exacerbation of chronic respiratory failure, which is common in slowly progressive neurological diseases, such as movement disorders and most neuromuscular diseases, and (ii) sudden-onset respiratory failure which may develop in rapidly progressive neurological disorders including stroke, convulsive status epilepticus, traumatic brain injury, spinal cord injury, phrenic neuropathy, myasthenia gravis, and Guillain-Barré syndrome. A tailored assistance may include manual and mechanical cough assistance, noninvasive ventilation, endotracheal intubation, invasive mechanical ventilation, or tracheotomy. This review provides practical recommendations for prevention, recognition, management, and treatment of respiratory emergencies in neurological diseases, mostly in teenagers and adults, according to type and severity of baseline disease.
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Affiliation(s)
- Fabrizio Racca
- Department of Anaesthesia and Intensive Care, Sant'Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Andrea Vianello
- Respiratory Pathophysiology Division, University of Padua, Padua, Italy
| | - Tiziana Mongini
- Neuromuscular Center, Department of Neurosciences, University of Turin, Turin, Italy
| | - Paolo Ruggeri
- Unit of Pneumology, Department BIOMORF, University of Messina, Messina, Italy
| | - Antonio Versaci
- Intensive Care Unit, AOU Policlinico "G. Martino", Messina, Italy
| | - Gian Luca Vita
- Nemo Sud Clinical Centre for Neuromuscular Disorders, Messina, Italy
| | - Giuseppe Vita
- Nemo Sud Clinical Centre for Neuromuscular Disorders, Messina, Italy. .,Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
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195
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Xu Z, Wu Y, Li B, Zheng L, Liu J, Shen K. Noninvasive ventilation in a young infant with congenital central hypoventilation and 7-year follow-up. Pediatr Investig 2019; 3:261-264. [PMID: 32851333 PMCID: PMC7331288 DOI: 10.1002/ped4.12167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 10/20/2019] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Congenital central hypoventilation syndrome (CCHS) is a rare disorder characterized by alveolar hypoventilation and autonomic system dysregulation secondary to mutations of the PHOX2B gene. Treatment consists of assisted ventilation using positive-pressure ventilators via tracheostomy, bi-level positive airway pressure (BPAP) via a noninvasive interface, negative-pressure ventilators, or diaphragm pacing. The long-term use of BPAP in younger children at home has been less frequently reported. CASE PRESENTATION We present a case of a 2-month-old infant with CCHS who was successfully managed by BPAP without the need for tracheostomy and followed up for 7 years. CONCLUSION CCHS is a rare disease that manifests as nocturnal desaturation and carbon dioxide retention in early life. Noninvasive ventilation can be successfully used in young infants via an appropriate mask.
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Affiliation(s)
- Zhifei Xu
- Department of Respiratory MedicineBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Yunxiao Wu
- Beijing Key Laboratory of Pediatric Otolaryngology, Head and Neck SurgeryBeijing Pediatric Research InstituteBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Bei Li
- Department of Otolaryngology, Head and Neck SurgeryBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Li Zheng
- Department of Otolaryngology, Head and Neck SurgeryBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Jingyuan Liu
- Department of Pediatric Critical Care MedicineBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Kunling Shen
- Department of Respiratory MedicineBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
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196
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Bhakta P, Karim HMR, O'Brien B, Esquinas A. Letter to the editor: Aeration changes induced by high flow nasal cannula are more homogeneous than those generated by non-invasive ventilation in healthy subjects. J Crit Care 2019; 57:275-276. [PMID: 31757577 DOI: 10.1016/j.jcrc.2019.10.007] [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: 08/22/2019] [Accepted: 10/17/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Pradipta Bhakta
- Department of Anaesthesia and Intensive Care, Temple Street Children's University Hospital, Dublin, Ireland.
| | - Habib Md Reazaul Karim
- Department of Anaesthesia and Critical Care, All India Institute of Medical Sciences, Raipur, India
| | - Brian O'Brien
- Department of Anaesthesia and Intensive Care, Cork University Hospital, Cork, Ireland
| | - Antonio Esquinas
- Department of Cardiac Anesthesia and Intensive Care, Intensive Care Unit; Hospital Morales Meseguer, Murcia, Spain
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197
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Nong L, Liang W, Yu Y, Xi Y, Liu D, Zhang J, Zhou J, Yang C, He W, Liu X, Li Y, Chen R. Noninvasive ventilation support during fiberoptic bronchoscopy-guided nasotracheal intubation effectively prevents severe hypoxemia. J Crit Care 2019; 56:12-17. [PMID: 31785505 PMCID: PMC7126932 DOI: 10.1016/j.jcrc.2019.10.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 03/25/2019] [Revised: 10/10/2019] [Accepted: 10/31/2019] [Indexed: 11/10/2022]
Abstract
Purpose This study investigated the feasibility and efficacy of continuous noninvasive ventilation (NIV) support with 100% oxygen using a specially designed face mask, for reducing desaturation during fiberoptic bronchoscopy (FOB)-guided intubation in critically ill patients with respiratory failure. Materials and methods This was a single-center prospective randomized study. All patients undergoing FOB-guided nasal tracheal intubation were randomized to bag-valve-mask ventilation or NIV for preoxygenation followed by intubation. The NIV group were intubated through a sealed hole in a specially designed face mask during continuous NIV support with 100% oxygen. Control patients were intubated with removal of the mask and no ventilatory support. Results We enrolled 106 patients, including 53 in each group. Pulse oxygen saturation (SpO2) after preoxygenation (99% (96%–100%) vs. 96% (90%–99%), p = .001) and minimum SpO2 during intubation (95% (87%–100%) vs. 83% (74%–91%), p < .01) were both significantly higher in the NIV compared with the control group. Severe hypoxemic events (SpO2 < 80%) occurred less frequently in the NIV group than in controls (7.4% vs. 37.7%, respectively; p < .01). Conclusions Continuous NIV support during FOB-guided nasal intubation can prevent severe desaturation during intubation in critically ill patients with respiratory failure. Trial registration: ClinicalTrials.gov, NCT02462668. Registered on 25 May 2015, https://www.clinicaltrials.gov/ct2/results?term=NCT02462668. Our study is the first to evaluate NIV during FOB-guided nasotracheal intubation. NIV support during FOB-guided nasotracheal intubation was effectively prevented severe desaturation during intubation. We used a specially-designed intubation face mask to ensure that there was no interruption of NIV support during intubation.
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Affiliation(s)
- Lingbo Nong
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Lab of Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Weibo Liang
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Lab of Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yuheng Yu
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Lab of Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yin Xi
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Lab of Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Dongdong Liu
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Lab of Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jie Zhang
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Lab of Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jing Zhou
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Lab of Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Chun Yang
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Lab of Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Weiqun He
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Lab of Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiaoqing Liu
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Lab of Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yimin Li
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Lab of Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Rongchang Chen
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Lab of Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
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198
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Tams C, Stephan PJ, Euliano NR, Martin AD, Patel R, Ataya A, Gabrielli A. Breathing variability predicts the suggested need for corrective intervention due to the perceived severity of patient-ventilator asynchrony during NIV. J Clin Monit Comput 2019; 34:1035-1042. [PMID: 31664660 DOI: 10.1007/s10877-019-00408-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 10/21/2019] [Indexed: 10/25/2022]
Abstract
Patient-ventilator asynchrony is associated with intolerance to noninvasive ventilation (NIV) and worsened outcomes. Our goal was to develop a tool to determine a patient needs for intervention by a practitioner due to the presence of patient-ventilator asynchrony. We postulated that a clinician can determine when a patient needs corrective intervention due to the perceived severity of patient-ventilator asynchrony. We hypothesized a new measure, patient breathing variability, would indicate when corrective intervention is suggested by a bedside practitioner due to the perceived severity of patient-ventilator asynchrony. With IRB approval data was collected on 78 NIV patients. A panel of experts reviewed retrospective data from a development set of 10 NIV patients to categorize them into one of the three categories. The three categories were; "No to mild asynchrony-no intervention needed", "moderate asynchrony-non-emergent corrective intervention required", and "severe asynchrony-immediate intervention required". A stepwise regression with a F-test forward selection criterion was used to develop a positive linear logic model predicting the expert panel's categorizations of the need for corrective intervention. The model was incorporated into a software tool for clinical implementation. The tool was implemented prospectively on 68 NIV patients simultaneous to a bedside practitioner scoring the need for corrective intervention due to the perceived severity of patient-ventilator asynchrony. The categories from the tool and the practitioner were compared with the rate of agreement, sensitivity, specificity, and receiver operator characteristic analyses. The rate of agreement in categorizing the suggested need for clinical intervention due to the perceived presence of patient-ventilator asynchrony between the tool and experienced bedside practitioners was 95% with a Kappa score of 0.85 (p < 0.001). Further analysis found a specificity of 84% and sensitivity of 99%. The tool appears to accurately match the suggested need for corrective intervention by a bedside practitioner. Application of the tool allows for continuous, real time, and non-invasive monitoring of patients receiving NIV, and may enable early corrective interventions to ameliorate potential patient-ventilator asynchrony.
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Affiliation(s)
- Carl Tams
- Convergent Engineering, 107 SW 140th Terrace, STE 1, Newberry, FL, 32669, USA
| | - Paul J Stephan
- Convergent Engineering, 107 SW 140th Terrace, STE 1, Newberry, FL, 32669, USA
| | - Neil R Euliano
- Convergent Engineering, 107 SW 140th Terrace, STE 1, Newberry, FL, 32669, USA.
| | - A Daniel Martin
- Department of Physical Therapy, College of Public Health & Health Professions, University of Florida, Gainesville, FL, 32610, USA
| | - Rohit Patel
- Department of Anesthesiology and Department of Emergency Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, PO Box 100254, Gainesville, FL, 32610, USA
| | - Ali Ataya
- Department of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Gainesville, FL, 32610, USA
| | - Andrea Gabrielli
- Department of Anesthesiology Perioperative Medicine and Pain Management, University of Miami Health System, 1611 NW 12th Ave (C-301), Miami, FL, 33136, USA
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199
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Wilson ME, Mittal A, Karki B, Dobler CC, Wahab A, Curtis JR, Erwin PJ, Majzoub AM, Montori VM, Gajic O, Murad MH. Do-not-intubate orders in patients with acute respiratory failure: a systematic review and meta-analysis. Intensive Care Med 2019; 46:36-45. [PMID: 31659387 PMCID: PMC7223954 DOI: 10.1007/s00134-019-05828-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 08/26/2019] [Accepted: 10/07/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE To assess the rates and variability of do-not-intubate orders in patients with acute respiratory failure. METHODS We conducted a systematic review of observational studies that enrolled adult patients with acute respiratory failure requiring noninvasive ventilation or high-flow nasal cannula oxygen from inception to 2019. RESULTS Twenty-six studies evaluating 10,755 patients were included. The overall pooled rate of do-not-intubate orders was 27%. The pooled rate of do-not-intubate orders in studies from North America was 14% (range 9-22%), from Europe was 28% (range 13-58%), and from Asia was 38% (range 9-83%), p = 0.001. Do-not-intubate rates were higher in studies with higher patient age and in studies where do-not-intubate decisions were made without reported patient/family input. There were no significant differences in do-not-intubate orders according to illness severity, observed mortality, malignancy comorbidity, or methodological quality. Rates of do-not-intubate orders increased over time from 9% in 2000-2004 to 32% in 2015-2019. Only 12 studies (46%) reported information about do-not-intubate decision-making processes. Only 4 studies (15%) also reported rates of do-not-resuscitate. CONCLUSIONS One in four patients with acute respiratory failure (who receive noninvasive ventilation or high-flow nasal cannula oxygen) has a do-not-intubate order. The rate of do-not-intubate orders has increased over time. There is high inter-study variability in do-not-intubate rates-even when accounting for age and illness severity. There is high variability in patient/family involvement in do-not-intubate decision making processes. Few studies reported differences in rates of do-not-resuscitate and do-not-intubate-even though recovery is very different for acute respiratory failure and cardiac arrest.
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Affiliation(s)
- Michael E Wilson
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. .,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA. .,Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA.
| | - Aniket Mittal
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Bibek Karki
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Claudia C Dobler
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, USA.,Institute for Evidence-Based Healthcare, Bond University and Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Abdul Wahab
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - J Randall Curtis
- Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
| | | | - Abdul M Majzoub
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, USA
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA.,Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - M Hassan Murad
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, USA.,Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Wilkins JV Jr, Gardner MT, Walenga R, Hosseini S, Longest PW, Golshahi L. Mechanistic Understanding of High Flow Nasal Cannula Therapy and Pressure Support with an In Vitro Infant Model. Ann Biomed Eng 2020; 48:624-33. [PMID: 31598892 DOI: 10.1007/s10439-019-02377-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 09/26/2019] [Indexed: 10/25/2022]
Abstract
Despite the increased use of high flow nasal cannula therapy, little has been done to predict airway pressures for a full breath cycle. A 3-month-old infant in vitro model was developed, which included the entire upper airway and the first three bifurcations of the lungs. A breathing simulator was used to create a realistic breath pattern, and high flow was provided using a Vapotherm unit. Four cannulas of varying sizes were used to assess the effects of the inner diameter and nasal occlusion of the cannulas on airway pressures. At 8 L min-1, end expiratory pressures of 0.821-1.306 cm H2O and 0.828-1.133 cm H2O were produced in the nasopharynx and trachea, respectively. Correlations were developed to predict full breath cycle airway pressures, based on the gas flow rate delivered, cannula dimensions, as well as the breathing flow rate, for the nasopharynx and trachea. Pearson correlation coefficients for the nasopharynx and trachea correlations were 0.991 and 0.992, respectively. The developed correlations could be used to determine the flow rate necessary for a cannula to produce pressures similar to CPAP settings. The proposed correlations accurately predict the regional airway pressure up to and including 7 cm H2O of support for the entire breath cycle.
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