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Zhu Q, Tan D, Wang H, Zhao R, Ling B. High-flow nasal cannula oxygen therapy for mild-moderate acute respiratory failure in patients with blunt chest trauma: An exploratory descriptive study. Am J Emerg Med 2024; 83:76-81. [PMID: 38981159 DOI: 10.1016/j.ajem.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 06/04/2024] [Accepted: 07/02/2024] [Indexed: 07/11/2024] Open
Abstract
OBJECTIVE The use of high-flow nasal cannula (HFNC) oxygen therapy is gaining popularity for the treatment of acute respiratory failure (ARF). However, limited evidence exists regarding the effectiveness of HFNC for hypoxemic ARF in patients with blunt chest trauma (BCT). METHODS This retrospective analysis focused on BCT patients with mild-moderate hypoxemic ARF who were treated with either HFNC or non-invasive ventilation (NIV) in the emergency medicine department from January 2021 to December 2022. The primary endpoint was treatment failure, defined as either invasive ventilation, or a switch to the other study treatment (NIV for patients in the NFNC group, and vice-versa). RESULTS A total of 157 patients with BCT (72 in the HFNC group and 85 in the NIV group) were included in this study. The treatment failure rate in the HFNC group was 11.1% and 16.5% in the NIV group - risk difference of 5.36% (95% CI, -5.94-16.10%; P = 0.366). The most common cause of failure in the HFNC group was aggravation of respiratory distress. While in the NIV group, the most common reason for failure was treatment intolerance. Treatment intolerance in the HFNC group was significantly lower than that in the NIV group (1.4% vs 9.4%, 95% CI 0.40-16.18; P = 0.039). Univariate logistic regression analysis showed that chronic respiratory disease, abbreviated injury scale score (chest) (≥3), Acute Physiology and Chronic Health Evaluation II score (≥15), partial arterial oxygen tension /fraction of inspired oxygen (≤200) at 1 h of treatment and respiratory rate (≥32 /min) at 1 h of treatment were risk factors associated with HFNC failure. CONCLUSION In BCT patients with mild-moderate hypoxemic ARF, the usage of HFNC did not lead to higher rate of treatment failure when compared to NIV. HFNC was found to offer better comfort and tolerance than NIV, suggesting it may be a promising new respiratory support therapy for BCT patients with mild-moderate ARF.
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Affiliation(s)
- Qingcheng Zhu
- Department of Emergency Medicine, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou 225001, China
| | - Dingyu Tan
- Department of Emergency Medicine, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou 225001, China
| | - Huihui Wang
- Department of Emergency Medicine, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou 225001, China
| | - Runmin Zhao
- Department of Emergency Medicine, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou 225001, China
| | - Bingyu Ling
- Department of Emergency Medicine, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou 225001, China.
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2
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Westhoff M, Neumann P, Geiseler J, Bickenbach J, Arzt M, Bachmann M, Braune S, Delis S, Dellweg D, Dreher M, Dubb R, Fuchs H, Hämäläinen N, Heppner H, Kluge S, Kochanek M, Lepper PM, Meyer FJ, Neumann B, Putensen C, Schimandl D, Schönhofer B, Schreiter D, Walterspacher S, Windisch W. [Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]. Pneumologie 2024; 78:453-514. [PMID: 37832578 DOI: 10.1055/a-2148-3323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.
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Affiliation(s)
- Michael Westhoff
- Klinik für Pneumologie, Lungenklinik Hemer - Zentrum für Pneumologie und Thoraxchirurgie, Hemer
| | - Peter Neumann
- Abteilung für Klinische Anästhesiologie und Operative Intensivmedizin, Evangelisches Krankenhaus Göttingen-Weende gGmbH
| | - Jens Geiseler
- Medizinische Klinik IV - Pneumologie, Beatmungs- und Schlafmedizin, Paracelsus-Klinik Marl, Marl
| | - Johannes Bickenbach
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen
| | - Michael Arzt
- Schlafmedizinisches Zentrum der Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg
| | - Martin Bachmann
- Klinik für Atemwegs-, Lungen- und Thoraxmedizin, Beatmungszentrum Hamburg-Harburg, Asklepios Klinikum Harburg, Hamburg
| | - Stephan Braune
- IV. Medizinische Klinik: Akut-, Notfall- und Intensivmedizin, St. Franziskus-Hospital, Münster
| | - Sandra Delis
- Klinik für Pneumologie, Palliativmedizin und Geriatrie, Helios Klinikum Emil von Behring GmbH, Berlin
| | - Dominic Dellweg
- Klinik für Innere Medizin, Pneumologie und Gastroenterologie, Pius-Hospital Oldenburg, Universitätsmedizin Oldenburg
| | - Michael Dreher
- Klinik für Pneumologie und Internistische Intensivmedizin, Uniklinik RWTH Aachen
| | - Rolf Dubb
- Akademie der Kreiskliniken Reutlingen GmbH, Reutlingen
| | - Hans Fuchs
- Zentrum für Kinder- und Jugendmedizin, Neonatologie und pädiatrische Intensivmedizin, Universitätsklinikum Freiburg
| | | | - Hans Heppner
- Klinik für Geriatrie und Geriatrische Tagesklinik Klinikum Bayreuth, Medizincampus Oberfranken Friedrich-Alexander-Universität Erlangen-Nürnberg, Bayreuth
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Matthias Kochanek
- Klinik I für Innere Medizin, Hämatologie und Onkologie, Universitätsklinikum Köln, Köln
| | - Philipp M Lepper
- Klinik für Innere Medizin V - Pneumologie, Allergologie und Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg
| | - F Joachim Meyer
- Lungenzentrum München - Bogenhausen-Harlaching) München Klinik gGmbH, München
| | - Bernhard Neumann
- Klinik für Neurologie, Donauisar Klinikum Deggendorf, und Klinik für Neurologie der Universitätsklinik Regensburg am BKH Regensburg, Regensburg
| | - Christian Putensen
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Bonn
| | - Dorit Schimandl
- Klinik für Pneumologie, Beatmungszentrum, Zentralklinik Bad Berka GmbH, Bad Berka
| | - Bernd Schönhofer
- Klinik für Innere Medizin, Pneumologie und Intensivmedizin, Evangelisches Klinikum Bethel, Universitätsklinikum Ost Westphalen-Lippe, Bielefeld
| | | | - Stephan Walterspacher
- Medizinische Klinik - Sektion Pneumologie, Klinikum Konstanz und Lehrstuhl für Pneumologie, Universität Witten-Herdecke, Witten
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Lehrstuhl für Pneumologie Universität Witten/Herdecke, Köln
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Girault C, Artaud-Macari E, Jolly G, Carpentier D, Cuvelier A, Béduneau G. [High-flow nasal oxygen therapy and hypercapnic acute respiratory failure]. Rev Mal Respir 2024:S0761-8425(24)00228-6. [PMID: 38926023 DOI: 10.1016/j.rmr.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 05/23/2024] [Indexed: 06/28/2024]
Abstract
Humidified high-flow nasal oxygen therapy (HFNO) has, in recent years, come to assume a key role in the management of hypoxemic acute respiratory failure (ARF). While non-invasive ventilation (NIV) currently represents the first-line ventilatory strategy in patients exhibiting hypercapnic ARF, the operating principles and physiological effects of HFNO could be interesting and useful in the initial management of hypercapnic ARF and/or after extubation, particularly in acute exacerbations of chronic obstructive pulmonary disease. Under these conditions, HFNO could be used either alone continuously or in combination with NIV during breaks in spontaneous breathing, depending on the severity and etiology of the underlying hypercapnic ARF.
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Affiliation(s)
- C Girault
- Service de médecine intensive et réanimation, GRHVN UR-3830, CHU-hôpitaux de Rouen, Normandie univ, 76000 Rouen, France.
| | - E Artaud-Macari
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, GRHVN UR-3830, CHU-hôpitaux de Rouen, Normandie univ, 76000 Rouen, France
| | - G Jolly
- Service de médecine intensive et réanimation, CHU-hôpitaux de Rouen, 76000 Rouen, France
| | - D Carpentier
- Service de médecine intensive et réanimation, CHU-hôpitaux de Rouen, 76000 Rouen, France
| | - A Cuvelier
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, GRHVN UR-3830, CHU-hôpitaux de Rouen, Normandie univ, 76000 Rouen, France
| | - G Béduneau
- Service de médecine intensive et réanimation, GRHVN UR-3830, CHU-hôpitaux de Rouen, Normandie univ, 76000 Rouen, France
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LoMauro A, De Luca A, Scarpazza P, Aliverti A. In Vivo Measurement of Tidal Volume During Non-invasive Respiratory Support by Continuous-Flow Helmet CPAP. Ann Biomed Eng 2024:10.1007/s10439-024-03545-6. [PMID: 38886251 DOI: 10.1007/s10439-024-03545-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 05/08/2024] [Indexed: 06/20/2024]
Abstract
Recently, the interest in the Helmet interface during non-invasive respiratory support (NIRS) has increased due to the COVID-19 pandemic. During NIRS, positive end-expiratory pressure (PEEP) can be given as continuous positive airway pressure (CPAP), which maintains a positive airway pressure throughout the whole respiratory cycle with Helmet as an interface (H-CPAP). The main disadvantage of the H-CPAP is the inability to measure tidal volume (VT). Opto-electronic plethysmography (OEP) is a non-invasive technique that is not sensitive to gas compression/expansion inside the helmet. OEP acquisitions were performed on 28 healthy volunteers (14 females and 14 males) at baseline and during Helmet CPAP. The effect of posture (semi-recumbent vs. prone), flow (50 vs. 60 L/min), and PEEP (0 vs. 5 vs. 10 cmH2O) on the ventilatory and thoracic-abdominal pattern and the operational volumes were investigated. Prone position limited vital capacity, abdominal expansion and chest wall recruitment. A constant flow of 60 L/min reduced the need for the subject to ventilate while having a slight recruitment effect (100 mL) in the semi-recumbent position. A progressive increasing recruitment was found with higher PEEP but limited by the prone position. It is possible to accurately measure tidal volume during H-CPAP to deliver non-invasive ventilatory support using opto-electronic plethysmography during different clinical settings.
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Affiliation(s)
- A LoMauro
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, P.zza L. da Vinci, 32, 20133, Milan, Italy.
| | - A De Luca
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, P.zza L. da Vinci, 32, 20133, Milan, Italy
| | - P Scarpazza
- Pneumology Unit, Ospedale Civile, Vimercate, Milan, Italy
| | - A Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, P.zza L. da Vinci, 32, 20133, Milan, Italy
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Rodríguez-Leal CM, González-Corralejo C, Candel FJ, Salavert M. Candent issues in pneumonia. Reflections from the Fifth Annual Meeting of Spanish Experts 2023. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2024; 37:221-251. [PMID: 38436606 PMCID: PMC11094633 DOI: 10.37201/req/018.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 03/05/2024]
Abstract
Pneumonia is a multifaceted illness with a wide range of clinical manifestations, degree of severity and multiple potential causing microorganisms. Despite the intensive research of recent decades, community-acquired pneumonia remains the third-highest cause of mortality in developed countries and the first due to infections; and hospital-acquired pneumonia is the main cause of death from nosocomial infection in critically ill patients. Guidelines for management of this disease are available world wide, but there are questions which generate controversy, and the latest advances make it difficult to stay them up to date. A multidisciplinary approach can overcome these limitations and can also aid to improve clinical results. Spanish medical societies involved in diagnosis and treatment of pneumonia have made a collaborative effort to actualize and integrate last expertise about this infection. The aim of this paper is to reflect this knowledge, communicated in Fifth Pneumonia Day in Spain. It reviews the most important questions about this disorder, such as microbiological diagnosis, advances in antibiotic and sequential therapy, management of beta-lactam allergic patient, preventive measures, management of unusual or multi-resistant microorganisms and adjuvant or advanced therapies in Intensive Care Unit.
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Affiliation(s)
| | | | - F J Candel
- Francisco Javier Candel, Clinical Microbiology Service. Hospital Clínico San Carlos. IdISSC and IML Health Research Institutes. 28040 Madrid. Spain.
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6
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Zhu Q, Zhou W, Ling B, Wang H, Tan D. High-flow nasal cannula oxygen therapy is equally effective to noninvasive ventilation for mild-moderate acute respiratory distress syndrome in patients with acute pancreatitis: A single-center, retrospective cohort study. Saudi J Gastroenterol 2024:00936815-990000000-00084. [PMID: 38813712 DOI: 10.4103/sjg.sjg_24_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 05/02/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND The use of high-flow nasal cannula (HFNC) oxygen therapy is gaining popularity for the treatment of acute hypoxic respiratory failure. However, limited evidence exists regarding the effectiveness of HFNC for acute respiratory distress syndrome (ARDS) in patients with acute pancreatitis (AP). METHODS This retrospective analysis focused on AP patients with mild-moderate ARDS, who were treated with either HFNC or noninvasive ventilation (NIV) in the emergency medicine department, from January 2020 to December 2022. The primary endpoint was treatment failure, defined as either invasive ventilation or a switch to any other study treatment (NIV for patients in the NFNC group and vice versa). RESULTS A total of 146 patients with AP (68 in the HFNC group and 78 in the NIV group) were included in this study. The treatment failure rate in the HFNC group was 17.6% and 19.2% in the NIV group - a risk difference of -1.6% (95% CI, -11.3 to 14.0%; P = 0.806). The most common causes of failure in the HFNC group were aggravation of respiratory distress and hypoxemia. However, in the NIV group, the most common reasons for failure were treatment intolerance and exacerbation of respiratory distress. Treatment intolerance in the HFNC group was significantly lower than that in the NIV group (16.7% vs 60.0%, 95% CI -66.8 to -6.2; P = 0.023). Multivariate logistic regression analysis showed that body mass index (≥28), acute physiology and chronic health evaluation II score (≥15), partial arterial oxygen tension/fraction of inspired oxygen (≤200), and respiratory rate (≥32/min) at 1 hour were independent predictors of HFNC failure. CONCLUSION In AP patients with mild-moderate ARDS, the usage of HFNC did not lead to a higher rate of treatment failure when compared to NIV. HFNC is an ideal choice of respiratory support for patients with NIV intolerance, but clinical application should pay attention to the influencing factors of its treatment failure.
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Affiliation(s)
- Qingcheng Zhu
- Department of Emergency Medicine, Clinical Medical College, Yangzhou University (Northern Jiangsu People's Hospital), Yangzhou, China
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7
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Chen X, Ma B, Yang Y, Zhang M, Xu F. Predicting the potentially exacerbation of severe viral pneumonia in hospital by MuLBSTA score joint CD4 + and CD8 +T cell counts: construction and verification of risk warning model. BMC Pulm Med 2024; 24:261. [PMID: 38811907 PMCID: PMC11137986 DOI: 10.1186/s12890-024-03073-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/22/2024] [Indexed: 05/31/2024] Open
Abstract
PURPOSE This study mainly focuses on the immune function and introduces CD4+, CD8+ T cells and their ratios based on the MuLBSTA score, a previous viral pneumonia mortality risk warning model, to construct an early warning model of severe viral pneumonia risk. METHODS A retrospective single-center observational study was operated from January 2021 to December 2022 at the People's Hospital of Liangjiang New Area, Chongqing, China. A total of 138 patients who met the criteria for viral pneumonia in hospital were selected and their data, including demographic data, comorbidities, laboratory results, CT scans, immunologic and pathogenic tests, treatment regimens, and clinical outcomes, were collected and statistically analyzed. RESULTS Forty-one patients (29.7%) developed severe or critical illness. A viral pneumonia severe risk warning model was successfully constructed, including eight parameters: age, bacterial coinfection, CD4+, CD4+/CD8+, multiple lung lobe infiltrations, smoking, hypertension, and hospital admission days. The risk score for severe illness in patients was set at 600 points. The model had good predictive performance (AUROC = 0.94397), better than the original MuLBSTA score (AUROC = 0.8241). CONCLUSION A warning system constructed based on immune function has a good warning effect on the risk of severe conversion in patients with viral pneumonia.
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Affiliation(s)
- Xi Chen
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China
- Department of Critical Care Medicine, People's Hospital of Chongqing Liangjiang New Area, Chongqing, 401120, China
| | - Bei Ma
- Department of Critical Care Medicine, People's Hospital of Chongqing Liangjiang New Area, Chongqing, 401120, China
| | - Yu Yang
- Department of Critical Care Medicine, People's Hospital of Chongqing Liangjiang New Area, Chongqing, 401120, China
| | - Mu Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China.
| | - Fang Xu
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China.
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Groff P. High flow Nasal Cannula oxygen therapy: the Columbus egg that helps us understand the clinical meaning of dyspnea. Intern Emerg Med 2024:10.1007/s11739-024-03538-2. [PMID: 38801632 DOI: 10.1007/s11739-024-03538-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/11/2024] [Indexed: 05/29/2024]
Affiliation(s)
- Paolo Groff
- Emergency Department, Santa Maria della Misericordia Hospital, Piazzale Menghini 1, 06129, Perugia, Italy.
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Ball L, Talmor D, Pelosi P. Transpulmonary pressure monitoring in critically ill patients: pros and cons. Crit Care 2024; 28:177. [PMID: 38796447 PMCID: PMC11127359 DOI: 10.1186/s13054-024-04950-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 05/10/2024] [Indexed: 05/28/2024] Open
Abstract
The use of transpulmonary pressure monitoring based on measurement of esophageal pressure has contributed importantly to the personalization of mechanical ventilation based on respiratory pathophysiology in critically ill patients. However, esophageal pressure monitoring is still underused in the clinical practice. This technique allows partitioning of the respiratory mechanics between the lungs and the chest wall, provides information on lung recruitment and risk of barotrauma, and helps titrating mechanical ventilation settings in patients with respiratory failure. In assisted ventilation modes and during non-invasive respiratory support, esophageal pressure monitoring provides important information on the inspiratory effort and work of breathing. Nonetheless, several controversies persist on technical aspects, interpretation and clinical decision-making based on values derived from this monitoring technique. The aim of this review is to summarize the physiological bases of esophageal pressure monitoring, discussing the pros and cons of its clinical applications and different interpretations in critically ill patients undergoing invasive and non-invasive respiratory support.
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Affiliation(s)
- Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Viale Benedetto XV 16, Genoa, Italy.
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy.
| | - Daniel Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Viale Benedetto XV 16, Genoa, Italy
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
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10
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Estenssoro E, González I, Plotnikow GA. Post-pandemic acute respiratory distress syndrome: A New Global Definition with extension to lower-resource regions. Med Intensiva 2024; 48:272-281. [PMID: 38644108 DOI: 10.1016/j.medine.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 01/27/2024] [Indexed: 04/23/2024]
Abstract
Acute respiratory distress syndrome (ARDS), first described in 1967, is characterized by acute respiratory failure causing profound hypoxemia, decreased pulmonary compliance, and bilateral CXR infiltrates. After several descriptions, the Berlin definition was adopted in 2012, which established three categories of severity according to hypoxemia (mild, moderate and severe), specified temporal aspects for diagnosis, and incorporated the use of non-invasive ventilation. The COVID-19 pandemic led to changes in ARDS management, focusing on continuous monitoring of oxygenation and on utilization of high-flow oxygen therapy and lung ultrasound. In 2021, a New Global Definition based on the Berlin definition of ARDS was proposed, which included a category for non-intubated patients, considered the use of SpO2, and established no particular requirement for oxygenation support in regions with limited resources. Although debates persist, the continuous evolution seeks to adapt to clinical and epidemiological needs, and to the search of personalized treatments.
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Affiliation(s)
- Elisa Estenssoro
- Escuela de Gobierno en Salud, Ministerio de Salud, Buenos Aires, Argentina; Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Buenos Aires, Argentina.
| | - Iván González
- Servicio de Rehabilitación, Área de Kinesiología Crítica, Hospital Británico de Buenos Aires, CABA, Argentina
| | - Gustavo A Plotnikow
- Servicio de Rehabilitación, Área de Kinesiología Crítica, Hospital Británico de Buenos Aires, CABA, Argentina; Facultad de Medicina y Ciencias de la Salud, Universidad Abierta Interamericana, Argentina
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11
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Busani S, Coloretti I, Baciarello M, Bellini V, Sarti M, Biagioni E, Tonelli R, Marchioni A, Clini E, Guaraldi G, Mussini C, Meschiari M, Tonetti T, Pisani L, Nava S, Bignami E, Ranieri MV, Girardis M. Association between respiratory distress time and invasive mechanical ventilation in COVID-19 patients: A multicentre regional cohort study. Pulmonology 2024; 30:282-286. [PMID: 35501277 PMCID: PMC8958102 DOI: 10.1016/j.pulmoe.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 02/25/2022] [Accepted: 03/17/2022] [Indexed: 11/17/2022] Open
Abstract
AIM To determine whether the duration of respiratory distress symptoms in severe COVID-19 pneumonia affects the need for invasive mechanical ventilation and clinical outcomes. MATERIALS AND METHODS An observational multicentre cohort study of patients hospitalised in five COVID-19-designated ICUs of the University Hospitals of Emilia-Romagna Region. Patients included were adults with pneumonia due to SARS-CoV-2 with PaO₂/FiO₂ ratio <300 mmHg, respiratory distress symptoms, and need for mechanical ventilation (invasive or non-invasive). Exclusion criteria were an uncertain time of respiratory distress, end-of-life decision, and mechanical respiratory support before hospital admission. MEASUREMENTS AND MAIN RESULTS We analysed 171 patients stratified into tertiles according to respiratory distress duration (distress time, DT) before application of mechanical ventilation support. The rate of patients requiring invasive mechanical ventilation was significantly different (p < 0.001) among the tertiles: 17/57 patients in the shortest duration, 29/57 in the intermediate duration, and 40/57 in the longest duration. The respiratory distress time significantly increased the risk of invasive ventilation in the univariate analysis (OR 5.5 [CI 2.48-12.35], p = 0.003). Multivariable regression analysis confirmed this association (OR 10.7 [CI 2.89-39.41], p < 0.001). Clinical outcomes (mortality and hospital stay) did not show significant differences between DT tertiles. DISCUSSION Albeit preliminary and retrospective, our data raised the hypothesis that the duration of respiratory distress symptoms may play a role in COVID-19 patients' need for invasive mechanical ventilation. Furthermore, our observations suggested that specific strategies may be directed towards identifying and managing early symptoms of respiratory distress, regardless of the levels of hypoxemia and the severity of the dyspnoea itself.
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Affiliation(s)
- S Busani
- Anesthesia and Intensive Care Unit, University Hospital of Modena Policlinico, University of Modena and Reggio Emilia, Modena, Italy.
| | - I Coloretti
- Anesthesia and Intensive Care Unit, University Hospital of Modena Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - M Baciarello
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - V Bellini
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - M Sarti
- Anesthesia and Intensive Care Unit, University Hospital of Modena Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - E Biagioni
- Anesthesia and Intensive Care Unit, University Hospital of Modena Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - R Tonelli
- Respiratory Diseases Unit, University Hospital of Modena Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - A Marchioni
- Respiratory Diseases Unit, University Hospital of Modena Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - E Clini
- Respiratory Diseases Unit, University Hospital of Modena Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - G Guaraldi
- Infectious Disease Unit, University Hospital of Modena Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - C Mussini
- Infectious Disease Unit, University Hospital of Modena Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - M Meschiari
- Infectious Disease Unit, University Hospital of Modena Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - T Tonetti
- Anesthesia and Intensive Care Medicine, University Hospital of Bologna Sant'Orsola, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - L Pisani
- Pneumology and Respiratory Critical Care, University Hospital of Bologna Sant'Orsola, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - S Nava
- Pneumology and Respiratory Critical Care, University Hospital of Bologna Sant'Orsola, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - E Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - M V Ranieri
- Anesthesia and Intensive Care Medicine, University Hospital of Bologna Sant'Orsola, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - M Girardis
- Anesthesia and Intensive Care Unit, University Hospital of Modena Policlinico, University of Modena and Reggio Emilia, Modena, Italy
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12
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Roca O, Li J, Mauri T. High-flow nasal cannula: evolving practices and novel clinical and physiological insights. Intensive Care Med 2024; 50:758-761. [PMID: 38573402 DOI: 10.1007/s00134-024-07386-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 03/06/2024] [Indexed: 04/05/2024]
Affiliation(s)
- Oriol Roca
- Servei de Medicina Intensiva, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Institut de Recerca Part Taulí-I3PT, Parc del Taulí 1, 08028, Sabadell, Spain.
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain.
- Ciber Enfermedades Respiratorias (Ciberes), Instituto de Salud Carlos III, Madrid, Spain.
| | - Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University, 600 S Paulina St, Suite 765, Chicago, IL, 60612, USA
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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13
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Choudhary T, Upadhyaya P, Davis CM, Yang P, Tallowin S, Lisboa FA, Schobel SA, Coopersmith CM, Elster EA, Buchman TG, Dente CJ, Kamaleswaran R. Derivation and Validation of Generalized Sepsis-induced Acute Respiratory Failure Phenotypes Among Critically Ill Patients: A Retrospective Study. RESEARCH SQUARE 2024:rs.3.rs-4307475. [PMID: 38746442 PMCID: PMC11092838 DOI: 10.21203/rs.3.rs-4307475/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Background Septic patients who develop acute respiratory failure (ARF) requiring mechanical ventilation represent a heterogenous subgroup of critically ill patients with widely variable clinical characteristics. Identifying distinct phenotypes of these patients may reveal insights about the broader heterogeneity in the clinical course of sepsis. We aimed to derive novel phenotypes of sepsis-induced ARF using observational clinical data and investigate their generalizability across multi-ICU specialties, considering multi-organ dynamics. Methods We performed a multi-center retrospective study of ICU patients with sepsis who required mechanical ventilation for ≥24 hours. Data from two different high-volume academic hospital systems were used as a derivation set with N=3,225 medical ICU (MICU) patients and a validation set with N=848 MICU patients. For the multi-ICU validation, we utilized retrospective data from two surgical ICUs at the same hospitals (N=1,577). Clinical data from 24 hours preceding intubation was used to derive distinct phenotypes using an explainable machine learning-based clustering model interpreted by clinical experts. Results Four distinct ARF phenotypes were identified: A (severe multi-organ dysfunction (MOD) with a high likelihood of kidney injury and heart failure), B (severe hypoxemic respiratory failure [median P/F=123]), C (mild hypoxia [median P/F=240]), and D (severe MOD with a high likelihood of hepatic injury, coagulopathy, and lactic acidosis). Patients in each phenotype showed differences in clinical course and mortality rates despite similarities in demographics and admission co-morbidities. The phenotypes were reproduced in external validation utilizing an external MICU from second hospital and SICUs from both centers. Kaplan-Meier analysis showed significant difference in 28-day mortality across the phenotypes (p<0.01) and consistent across both centers. The phenotypes demonstrated differences in treatment effects associated with high positive end-expiratory pressure (PEEP) strategy. Conclusion The phenotypes demonstrated unique patterns of organ injury and differences in clinical outcomes, which may help inform future research and clinical trial design for tailored management strategies.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Eric A Elster
- Uniformed Services University of the Health Sciences
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14
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Hume J, Goertzen L, Avent Y, Steiner ME, McArthur J. Timing of intubation of pediatric hematopoietic cell transplant patients: an international survey. Front Oncol 2024; 14:1400635. [PMID: 38741778 PMCID: PMC11089206 DOI: 10.3389/fonc.2024.1400635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 04/15/2024] [Indexed: 05/16/2024] Open
Abstract
Introduction Retrospective data suggest that pediatric hematopoietic cell transplant (HCT) patients placed on non-invasive ventilation (NIV) prior to intubation have increased risk of mortality compared to patients who are intubated earlier in their course. The HCT-CI subgroup of the PALISI Network set out to gain a better understanding of factors that influence clinician's decisions surrounding timing of intubation of pediatric HCT patients. Methods We validated and distributed a brief survey exploring potential factors that may influence clinician's decisions around timing of intubation of pediatric HCT patients with acute lung injury (ALI). Results One hundred and four of the 869 PALISI Network's members responded to the survey; 97 of these respondents acknowledged caring for HCT patients and were offered the remainder of the survey. The majority of respondents were PICU physicians (96%), with a small number of Advanced Practice Providers and HCT physicians. As expected, poor prognosis categories were perceived as a factors that delay timing to intubation whereas need for invasive procedures was perceived as a factor shortening timing to intubation. Concerns for oxygen toxicity or NIV-associated lung injury were not believed to influence timing of intubation. Discussion Our survey indicates increased risk of ALI from prolonged NIV and oxygen toxicity in HCT patients are not a concern for most clinicians. Further education of pediatric ICU clinicians around these risk factors could lead to improvement in outcomes and demands further study. Additionally, clinicians identified concerns for the patient's poor prognosis as a common reason for delayed intubation.
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Affiliation(s)
- Janet Hume
- Department of Pediatrics, Division of Critical Care Medicine, University of Minnesota/Masonic Children’s Hospital, Minneapolis, MN, United States
| | - Lexie Goertzen
- Department of Pediatrics, Division of Critical Care Medicine, University of Minnesota/Masonic Children’s Hospital, Minneapolis, MN, United States
| | - Yvonne Avent
- Department of Pediatrics, Division of Critical Care and Pulmonary Medicine, St Jude Children’s Research Hospital, Memphis, TN, United States
| | - Marie E. Steiner
- Department of Pediatrics, Division of Critical Care Medicine, University of Minnesota/Masonic Children’s Hospital, Minneapolis, MN, United States
- Department of Pediatrics, Division of Hematology/Oncology, University of Minnesota/Masonic Children’s Hospital, Minneapolis, MN, United States
| | - Jennifer McArthur
- Department of Pediatrics, Division of Critical Care and Pulmonary Medicine, St Jude Children’s Research Hospital, Memphis, TN, United States
- Department of Pediatrics, Division of Critical Care Medicine, University of Tennessee Health Sciences Center, Memphis, TN, United States
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15
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Simon Machado R, Mathias K, Joaquim L, de Quadros RW, Rezin GT, Petronilho F. Hyperoxia and brain: the link between necessity and injury from a molecular perspective. Neurotox Res 2024; 42:25. [PMID: 38619632 DOI: 10.1007/s12640-024-00702-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 11/15/2023] [Accepted: 03/25/2024] [Indexed: 04/16/2024]
Abstract
Oxygen (O2) supplementation is commonly used to treat hypoxia in patients with respiratory failure. However, indiscriminate use can lead to hyperoxia, a condition detrimental to living tissues, particularly the brain. The brain is sensitive to reactive oxygen species (ROS) and inflammation caused by high concentrations of O2, which can result in brain damage and mitochondrial dysfunction, common features of neurodegenerative disorders. Hyperoxia leads to increased production of ROS, causing oxidative stress, an imbalance between oxidants and antioxidants, which can damage tissues. The brain is particularly vulnerable to oxidative stress due to its lipid composition, high O2 consumption rate, and low levels of antioxidant enzymes. Moreover, hyperoxia can cause vasoconstriction and decreased O2 supply to the brain, posing a challenge to redox balance and neurodegenerative processes. Studies have shown that the severity of hyperoxia-induced brain damage varies with inspired O2 concentration and duration of exposure. Therefore, careful evaluation of the balance between benefits and risks of O2 supplementation, especially in clinical settings, is crucial.
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Affiliation(s)
- Richard Simon Machado
- Laboratory of Experimental Neurology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina, Criciuma, SC, Brazil.
- Laboratory of Neurobiology of Inflammatory and Metabolic Processes, Graduate Program in Health Sciences, Health Sciences Unit, University of South Santa Catarina, Tubarão, SC, Brazil.
| | - Khiany Mathias
- Laboratory of Experimental Neurology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina, Criciuma, SC, Brazil
| | - Larissa Joaquim
- Laboratory of Experimental Neurology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina, Criciuma, SC, Brazil
| | | | - Gislaine Tezza Rezin
- Laboratory of Neurobiology of Inflammatory and Metabolic Processes, Graduate Program in Health Sciences, Health Sciences Unit, University of South Santa Catarina, Tubarão, SC, Brazil
| | - Fabricia Petronilho
- Laboratory of Experimental Neurology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina, Criciuma, SC, Brazil
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Asif H, McNeer JL, Ghanayem NS, Cursio JF, Kane JM. First-Line Respiratory Support for Children With Hematologic Malignancy and Acute Respiratory Failure. Crit Care Explor 2024; 6:e1076. [PMID: 38601458 PMCID: PMC11005899 DOI: 10.1097/cce.0000000000001076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024] Open
Abstract
OBJECTIVES To characterize trends in noninvasive ventilation (NIV) and invasive mechanical ventilation (IMV) use over time in children with hematologic malignancy admitted to the PICU with acute respiratory failure (ARF), and to identify risk factors associated with NIV failure requiring transition to IMV. DESIGN Retrospective cohort analysis using the Virtual Pediatric Systems (VPS, LLC) between January 1, 2010 and December 31, 2019. SETTING One hundred thirteen North American PICUs participating in VPS. PATIENTS Two thousand four hundred eighty children 0-21 years old with hematologic malignancy admitted to participating PICUs for ARF requiring respiratory support. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 3013 total encounters, of which 868 (28.8%) received first-line NIV alone (NIV only), 1544 (51.2%) received first-line IMV (IMV only), and 601 (19.9%) required IMV after a failed NIV trial (NIV failure). From 2010 to 2019, the NIV only group increased from 9.6% to 43.1% and the IMV only group decreased from 80.1% to 34.2% (p < 0.001). The NIV failure group had the highest mortality compared with NIV only and IMV only (36.6% vs. 8.1%, vs. 30.5%, p < 0.001). However, risk-of-mortality (ROM) was highest in the IMV only group compared with NIV only and NIV failure (median Pediatric Risk of Mortality III ROM 8.1% vs. 2.8% vs. 5.5%, p < 0.001). NIV failure patients also had the longest median PICU length of stay compared with the other two study groups (15.2 d vs. 6.1 and 9.0 d, p < 0.001). Higher age was associated with significantly decreased odds of NIV failure, and diagnosis of non-Hodgkin lymphoma was associated with significantly increased odds of NIV failure compared with acute lymphoid leukemia. CONCLUSIONS For children with hematologic malignancy admitted to the PICU with ARF, NIV has replaced IMV as the most common initial therapy. NIV failure rate remains high with high-observed mortality despite lower PICU admission ROM.
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Affiliation(s)
- Hassaan Asif
- Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Jennifer L McNeer
- Department of Pediatrics, Section of Pediatric Hematology/Oncology, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Nancy S Ghanayem
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, University of Chicago, Comer Children's Hospital, Chicago, IL
| | - John F Cursio
- Department of Public Health Sciences, University of Chicago, Chicago, IL
| | - Jason M Kane
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, University of Chicago, Comer Children's Hospital, Chicago, IL
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17
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Ferrer M, De Pascale G, Tanzarella ES, Antonelli M. Severe Community-Acquired Pneumonia: Noninvasive Mechanical Ventilation, Intubation, and HFNT. Semin Respir Crit Care Med 2024; 45:169-186. [PMID: 38604188 DOI: 10.1055/s-0043-1778140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
Severe acute respiratory failure (ARF) is a major issue in patients with severe community-acquired pneumonia (CAP). Standard oxygen therapy is the first-line therapy for ARF in the less severe cases. However, respiratory supports may be delivered in more severe clinical condition. In cases with life-threatening ARF, invasive mechanical ventilation (IMV) will be required. Noninvasive strategies such as high-flow nasal therapy (HFNT) or noninvasive ventilation (NIV) by either face mask or helmet might cover the gap between standard oxygen and IMV. The objective of all the supporting measures for ARF is to gain time for the antimicrobial treatment to cure the pneumonia. There is uncertainty regarding which patients with severe CAP are most likely to benefit from each noninvasive support strategy. HFNT may be the first-line approach in the majority of patients. While NIV may be relatively contraindicated in patients with excessive secretions, facial hair/structure resulting in air leaks or poor compliance, NIV may be preferable in those with increased work of breathing, respiratory muscle fatigue, and congestive heart failure, in which the positive pressure of NIV may positively impact hemodynamics. A trial of NIV might be considered for select patients with hypoxemic ARF if there are no contraindications, with close monitoring by an experienced clinical team who can intubate patients promptly if they deteriorate. In such cases, individual clinician judgement is key to choose NIV, interface, and settings. Due to the paucity of studies addressing IMV in this population, the protective mechanical ventilation strategies recommended by guidelines for acute respiratory distress syndrome can be reasonably applied in patients with severe CAP.
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Affiliation(s)
- Miquel Ferrer
- Unitat de Vigilancia Intensiva Respiratoria, Servei de Pneumologia, Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- Departament de Medicina, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigacion Biomedica En Red-Enfermedades Respiratorias (CIBERES-CB060628), Barcelona, Spain
| | - Gennaro De Pascale
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Eloisa S Tanzarella
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimo Antonelli
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Roca O, Telias I, Grieco DL. Bedside-available strategies to minimise P-SILI and VILI during ARDS. Intensive Care Med 2024; 50:597-601. [PMID: 38498168 DOI: 10.1007/s00134-024-07366-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/17/2024] [Indexed: 03/20/2024]
Affiliation(s)
- Oriol Roca
- Servei de Medicina Intensiva, Parc Taulí Hospital Universitari, Institut de Recerca Part Taulí - I3PT, Parc del Taulí 1, 08028, Sabadell, Spain.
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain.
- Ciber Enfermedades Respiratorias (Ciberes), Instituto de Salud Carlos III, Madrid, Spain.
| | - Irene Telias
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Canada
| | - Domenico L Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy
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Parrilla-Gómez FJ, Marin-Corral J, Castellví-Font A, Pérez-Terán P, Picazo L, Ravelo-Barba J, Campano-García M, Festa O, Restrepo M, Masclans JR. Switches in non-invasive respiratory support strategies during acute hypoxemic respiratory failure: Need to monitoring from a retrospective observational study. Med Intensiva 2024; 48:200-210. [PMID: 37985338 DOI: 10.1016/j.medine.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/02/2023] [Accepted: 10/17/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE To explore combined non-invasive-respiratory-support (NIRS) patterns, reasons for NIRS switching, and their potential impact on clinical outcomes in acute-hypoxemic-respiratory-failure (AHRF) patients. DESIGN Retrospective, single-center observational study. SETTING Intensive Care Medicine. PATIENTS AHRF patients (cardiac origin and respiratory acidosis excluded) underwent combined NIRS therapies such as non-invasive-ventilation (NIV) and High-Flow-Nasal-Cannula (HFNC). INTERVENTIONS Patients were classified based on the first NIRS switch performed (HFNC-to-NIV or NIV-to-HFNC), and further specific NIRS switching strategies (NIV trial-like vs. Non-NIV trial-like and single vs. multiples switches) were independently evaluated. MAIN VARIABLES OF INTEREST Reasons for switching, NIRS failure and mortality rates. RESULTS A total of 63 patients with AHRF were included, receiving combined NIRS, 58.7% classified in the HFNC-to-NIV group and 41.3% in the NIV-to-HFNC group. Reason for switching from HFNC to NIV was AHRF worsening (100%), while from NIV to HFNC was respiratory improvement (76.9%). NIRS failure rates were higher in the HFNC-to-NIV than in NIV-to-HFNC group (81% vs. 35%, p < 0.001). Among HFNC-to-NIV patients, there was no difference in the failure rate between the NIV trial-like and non-NIV trial-like groups (86% vs. 78%, p = 0.575) but the mortality rate was significantly lower in NIV trial-like group (14% vs. 52%, p = 0.02). Among NIV to HFNC patients, NIV failure was lower in the single switch group compared to the multiple switches group (15% vs. 53%, p = 0.039), with a shorter length of stay (5 [2-8] vs. 12 [8-30] days, p = 0.001). CONCLUSIONS NIRS combination is used in real life and both switches' strategies, HFNC to NIV and NIV to HFNC, are common in AHRF management. Transitioning from HFNC to NIV is suggested as a therapeutic escalation and in this context performance of a NIV-trial could be beneficial. Conversely, switching from NIV to HFNC is suggested as a de-escalation strategy that is deemed safe if there is no NIRS failure.
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Affiliation(s)
- Francisco José Parrilla-Gómez
- Critical Care Department, Hospital del Mar de Barcelona. Critical illness research group (GREPAC), Hospital del Mar Research Institute (IMIM); Department of Medicine and Life Sciences (MELIS), UPF, Barcelona, Spain.
| | - Judith Marin-Corral
- Critical Care Department, Hospital del Mar de Barcelona. Critical illness research group (GREPAC), Hospital del Mar Research Institute (IMIM); Division of Pulmonary & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, San Antonio, TX, USA
| | - Andrea Castellví-Font
- Critical Care Department, Hospital del Mar de Barcelona. Critical illness research group (GREPAC), Hospital del Mar Research Institute (IMIM)
| | - Purificación Pérez-Terán
- Critical Care Department, Hospital del Mar de Barcelona. Critical illness research group (GREPAC), Hospital del Mar Research Institute (IMIM); Department of Medicine and Life Sciences (MELIS), UPF, Barcelona, Spain
| | - Lucía Picazo
- Critical Care Department, Hospital del Mar de Barcelona. Critical illness research group (GREPAC), Hospital del Mar Research Institute (IMIM)
| | - Jorge Ravelo-Barba
- Critical Care Department, Hospital del Mar de Barcelona. Critical illness research group (GREPAC), Hospital del Mar Research Institute (IMIM)
| | - Marta Campano-García
- Critical Care Department, Hospital del Mar de Barcelona. Critical illness research group (GREPAC), Hospital del Mar Research Institute (IMIM)
| | - Olimpia Festa
- Anaesthesia and Reanimation Department, Hospital General de Sant Boi, Barcelona, Spain
| | - Marcos Restrepo
- Division of Pulmonary & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, San Antonio, TX, USA; Division of Pulmonary Diseases & Critical Care Medicine, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Joan Ramón Masclans
- Critical Care Department, Hospital del Mar de Barcelona. Critical illness research group (GREPAC), Hospital del Mar Research Institute (IMIM); Department of Medicine and Life Sciences (MELIS), UPF, Barcelona, Spain
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20
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Brusić J, Grubešić A, Jarić F, Vučković T, Lekić A, Šustić A, Protić A. Use of CPAP Ventilation in Non-ICU Wards May Influence Outcomes in Patients with Severe Respiratory COVID-19. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:582. [PMID: 38674228 PMCID: PMC11052437 DOI: 10.3390/medicina60040582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 03/22/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024]
Abstract
Background and Objectives: The COVID-19 disease has significantly burdened the healthcare system, including all units of severe patient treatment. Non-intensive care units were established to rationalize the capacity within the Intensive Care Unit (ICU) and to create a unit where patients with Acute Respiratory Distress Syndrome (ARDS) could be treated with non-invasive Continuous Positive Air Pressure (CPAP) outside the ICU. This unicentric retrospective study aimed to assess the efficacy of NIV Treatment in Patients of the fourth pandemic wave and how its application affects the frequency and mortality of ICU-treated patients at University Hospital Rijeka compared to earlier waves of the COVID-19 pandemic. Furthermore, the study showcases the effect of the Patient/Nurse ratio (P/N ratio) on overall mortality in the ICU. Materials and Methods: The study was conducted on two groups of patients with respiratory insufficiency in the second and third pandemic waves, treated in the COVID Respiratory Centre (CRC) (153 patients). We also reviewed a cohort of patients from the fourth pandemic wave who were initially hospitalized in a COVID-6 non-intensive unit from 1 October 2021 to 1 November 2022 (102 patients), and some of them escalated to CRC. Results: The introduction of the CPAP non-invasive ventilation method as a means of hypoxic respiratory failure treatment in non-intensive care units has decreased the strain, overall number of admissions, and CRC patient mortality. The overall fourth wave mortality was 29.4%, compared to the 58.2% overall mortality of the second and third waves. Conclusions: As a result, this has decreased CRC patient admissions and, by itself, overall mortality.
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Affiliation(s)
- Josip Brusić
- Department of Anesthesiology, Intensive Care and Pain Treatment, Clinical Hospital Center Rijeka, Krešimirova 42, 51 000 Rijeka, Croatia; (J.B.); (A.P.)
- Department of Nursing, Faculty of Health Studies, University of Rijeka, Viktora Cara Emina 5, 51000 Rijeka, Croatia
| | - Aron Grubešić
- Department of Hematology, Clinical Hospital Center Rijeka, Krešimirova 42, 51000 Rijeka, Croatia
- Department of Internal Medicine, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
| | - Filip Jarić
- Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia; (F.J.); (T.V.)
| | - Tin Vučković
- Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia; (F.J.); (T.V.)
| | - Andrica Lekić
- Department of Basic Medical Sciences, Faculty of Health Studies, University of Rijeka, Viktora Cara Emina 5, 51000 Rijeka, Croatia;
| | - Alan Šustić
- Department of Anesthesiology, Intensive Care and Pain Treatment, Clinical Hospital Center Rijeka, Krešimirova 42, 51 000 Rijeka, Croatia; (J.B.); (A.P.)
- Department of Nursing, Faculty of Health Studies, University of Rijeka, Viktora Cara Emina 5, 51000 Rijeka, Croatia
- Department of Anesthesiology, Reanimatology, Emergency and Intensive Medicine, Faculty of Medicine, University of Rijeka, Tome Strižića 3, 51000 Rijeka, Croatia
| | - Alen Protić
- Department of Anesthesiology, Intensive Care and Pain Treatment, Clinical Hospital Center Rijeka, Krešimirova 42, 51 000 Rijeka, Croatia; (J.B.); (A.P.)
- Department of Nursing, Faculty of Health Studies, University of Rijeka, Viktora Cara Emina 5, 51000 Rijeka, Croatia
- Department of Anesthesiology, Reanimatology, Emergency and Intensive Medicine, Faculty of Medicine, University of Rijeka, Tome Strižića 3, 51000 Rijeka, Croatia
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Torregiani C, Baratella E, Segalotti A, Ruaro B, Salton F, Confalonieri P, Tavano S, Lapadula G, Bozzi C, Confalonieri M, Dellaca’ RL, Veneroni C. Oscillometry Longitudinal Data on COVID-19 Acute Respiratory Syndrome Treated with Non-Invasive Respiratory Support. J Clin Med 2024; 13:1868. [PMID: 38610633 PMCID: PMC11012861 DOI: 10.3390/jcm13071868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 03/02/2024] [Accepted: 03/16/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Oscillometry allows for the non-invasive measurements of lung mechanics. In COVID-19 ARDS patients treated with Non-Invasive Oxygen Support (NI-OS), we aimed to (1) observe lung mechanics at the patients' admission and their subsequent changes, (2) compare lung mechanics with clinical and imaging data, and (3) evaluate whether lung mechanics helps to predict clinical outcomes. Methods: We retrospectively analyzed the data from 37 consecutive patients with moderate-severe COVID-19 ARDS. Oscillometry was performed on their 1st, 4th, and 7th day of hospitalization. Resistance (R5), reactance (X5), within-breath reactance changes (ΔX5), and the frequency dependence of the resistance (R5-R19) were considered. Twenty-seven patients underwent computed tomographic pulmonary angiography (CTPA): collapsed, poorly aerated, and normally inflated areas were quantified. Adverse outcomes were defined as intubation or death. Results: Thirty-two patients were included in this study. At the first measurement, only 44% of them had an abnormal R5 or X5. In total, 23 patients had measurements performed on their 3rd day and 7 on their 7th day of hospitalization. In general, their R5, R5-R19, and ΔX decreased with time, while their X5 increased. Collapsed areas on the CTPA correlated with the X5 z-score (ρ = -0.38; p = 0.046), while poorly aerated areas did not. Seven patients had adverse outcomes but did not present different oscillometry parameters on their 1st day of hospitalization. Conclusions: Our study confirms the feasibility of oscillometry in critically ill patients with COVID-19 pneumonia undergoing NI-OS. The X5 z-scores indicates collapsed but not poorly aerated lung areas in COVID-19 pneumonia. Our data, which show a severe impairment of gas exchange despite normal reactance in most patients with COVID-19 ARDS, support the hypothesis of a composite COVID-19 ARDS physiopathology.
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Affiliation(s)
- Chiara Torregiani
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University of Trieste, Hospital of Cattinara, 34149 Trieste, Italy
| | - Elisa Baratella
- Radiology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, 34149 Trieste, Italy
| | - Antonio Segalotti
- Radiology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, 34149 Trieste, Italy
| | - Barbara Ruaro
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University of Trieste, Hospital of Cattinara, 34149 Trieste, Italy
| | - Francesco Salton
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University of Trieste, Hospital of Cattinara, 34149 Trieste, Italy
| | - Paola Confalonieri
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University of Trieste, Hospital of Cattinara, 34149 Trieste, Italy
| | - Stefano Tavano
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University of Trieste, Hospital of Cattinara, 34149 Trieste, Italy
| | - Giulia Lapadula
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University of Trieste, Hospital of Cattinara, 34149 Trieste, Italy
| | - Chiara Bozzi
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University of Trieste, Hospital of Cattinara, 34149 Trieste, Italy
| | - Marco Confalonieri
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University of Trieste, Hospital of Cattinara, 34149 Trieste, Italy
| | - Raffaele L. Dellaca’
- Department of Electronics, Information and Biomedical Engineering (DEIB), TechRes Lab, Politecnico di Milano University, 20122 Milano, Italy; (R.L.D.); (C.V.)
| | - Chiara Veneroni
- Department of Electronics, Information and Biomedical Engineering (DEIB), TechRes Lab, Politecnico di Milano University, 20122 Milano, Italy; (R.L.D.); (C.V.)
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Li YH, Lei GY, Guo J, Yi M, Fu YJ, Wang GY. Effect of maternal oxygen supplementation for parturient undergoing elective cesarean section by high-flow nasal oxygen compared with room air on fetal acidemia: study protocol for a randomized controlled trial. Trials 2024; 25:73. [PMID: 38254137 PMCID: PMC10802011 DOI: 10.1186/s13063-024-07927-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Maternal oxygen supplementation is usually used as an intrauterine resuscitation technique to prevent fetal hypoxia and acidemia during delivery. However, there has been a great deal of controversy regarding the effects of prophylactic maternal oxygen during cesarean section, during which the incidence of fetal acidemia seems to be higher compared with that during labor. High-flow nasal oxygen (HFNO) can improve oxygenation better in patients with high-flow oxygen airflow. The purpose of this study is to determine whether maternal oxygen supplementation with HFNO has a positive effect on fetal acidemia during cesarean section through umbilical arterial blood gas analysis. METHOD This prospective, single-center, randomized, double-blinded trial will enroll 120 patients undergoing cesarean section. Participants will be randomly assigned to the HFNO group or air group at a 1:1 ratio. For parturients in the HFNO group, the flow rate is 40L/min, and the oxygen is heated to 37℃ with humidity 100% oxygen concentration through the Optiflow high-flow nasal oxygen system. And for the air group, the flow rate is 2 L/min with an air pattern through the same device. The primary outcome was umbilical artery (UA) lactate. Secondary outcomes include UA pH, PO2, PCO2, BE, the incidence of pH < 7.20 and pH < 7.10, Apgar scores at 1 and 5 min, and neonatal adverse outcomes. DISCUSSION Our study is the first trial investigating whether maternal oxygen supplementation with HFNO can reduce the umbilical artery lactate levels and the incidence of fetal acidemia in cesarean section under combined spinal-epidural anesthesia. TRIAL REGISTRATION ClinicalTrials.gov NCT05921955. Registered on 27 June 2023.
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Affiliation(s)
- Yun-Hui Li
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Gui-Yu Lei
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Jun Guo
- Department of Gynecologic and Obstetric, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Meng Yi
- Department of Gynecologic and Obstetric, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Yu-Jing Fu
- Department of Gynecologic and Obstetric, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Gu-Yan Wang
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China.
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23
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Hernández FLC, Virguez JV, Vesga JFG, Castellanos ML, Beltrán GR, Toquica LDL, Gomez CNS, Ríos MVS, Bolívar YRC, Sanchez JIA. Effect of COVID-19 on infections associated with medical devices in critical care. BMC Infect Dis 2024; 24:110. [PMID: 38254034 PMCID: PMC10801999 DOI: 10.1186/s12879-023-08934-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/19/2023] [Indexed: 01/24/2024] Open
Abstract
OBJECTIVES This study explores the hypothesis that COVID-19 patients are at a heightened risk of healthcare-associated infections (HAIs) associated with medical device usage compared to non-COVID-19 patients. Our primary objective was to investigate the correlation between COVID-19 infection in ICU patients and subsequent HAIs following invasive medical device insertion. Additionally, we aim to assess the impact of SARS-CoV-2 infection on onset times concerning specific microorganisms and the type of medical device, providing valuable insights into this intricate relationship in intensive care settings. METHODOLOGY A retrospective cohort study was conducted using ICU patient records at our hospital from 2020 to 2022. This investigation entailed evaluating the timing of HAIs while distinguishing between patients with and without SARS-CoV-2 infection. We identified and analyzed the type of isolation and infection attributed to the medical device while controlling for ICU duration and ventilator days using Cox regression. RESULTS Our study included 127 patients without SARS-CoV-2 infection and 140 patients with SARS-CoV-2 infection. The findings indicated a higher incidence of HAI caused by various microorganisms associated with any medical device in patients with SARS-CoV-2 (HR = 6.86; 95% CI-95%: 3.26-14.43; p < 0.01). After adjusting for ICU duration and ventilator days, a heightened frequency of HAIs persisted in SARS-CoV-2-infected individuals. However, a detailed examination of HAIs revealed that only ventilation-associated pneumonia (VAP) displayed a significant association (HR = 6.69; 95% CI: 2.59-17.31; p < 0.01). A statistically significant correlation between SARS-CoV-2 infection and the isolation of S. aureus was also observed (p = 0.034). The prevalence of S. aureus infection was notably higher in patients with SARS-CoV-2 (RR = 8.080; 95% CI: 1.052-62.068; p < 0.01). CONCLUSIONS The frequency of pathogen isolates in invasive medical devices exhibited an association with SARS-CoV-2 infection. Critically ill patients with SARS-CoV-2 are more prone to developing early-onset VAP than those without SARS-CoV-2 infection.
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24
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Cao S, Li H, Xin J, Jin Z, Zhang Z, Li J, Zhu Y, Su L, Huang P, Jiang L, Du M, Christiani DC. Identification of genetic profile and biomarkers involved in acute respiratory distress syndrome. Intensive Care Med 2024; 50:46-55. [PMID: 37922010 PMCID: PMC11167213 DOI: 10.1007/s00134-023-07248-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 10/08/2023] [Indexed: 11/05/2023]
Abstract
PURPOSE The purpose of this study was to profile genetic causal factors of acute respiratory distress syndrome (ARDS) and early predict patients at high ARDS risk. METHODS We performed a phenome-wide Mendelian Randomization analysis through summary statistics of an ARDS genome-wide association study (1250 cases and 1583 controls of European ancestry) and 33,150 traits. Transcriptomic data from human blood and lung tissues of a preclinical mouse model were used to validate biomarkers, which were further used to construct a prediction model and nomogram. RESULTS A total of 1736 traits, including 1223 blood RNA, 159 plasma proteins, and 354 non-gene phenotypes (classified by Biochemistry, Anthropometry, Disease, Nutrition and Habit, Immunology, and Treatment), exhibited a potentially causal relationship with ARDS development, which were accessible through a user-friendly interface platform called CARDS (Causal traits for Acute Respiratory Distress Syndrome). Regarding candidate blood RNA, four genes were validated, namely TMEM176B, SLC2A5, CDC45, and VSIG8, showing differential expression in blood of ARDS patients compared to controls, as well as dynamic expression in mouse lung tissues. Importantly, the addition of four blood genes and five immune cell proportions significantly improved the prediction performance of ARDS development, with 0.791 of the area under the curve from receiver-operator characteristic, compared to 0.725 for the basic model consisting of Acute Physiology and Chronic Health Evaluation (APACHE) III Score, sex, body mass index, bacteremia, and sepsis. A model-based nomogram was also developed for the clinical practice. CONCLUSION This study identifies a wide range of ARDS relevant factors and develops a promising prediction model, enhancing early clinical management and intervention for ARDS development.
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Affiliation(s)
- Shurui Cao
- School of Medicine, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Huiqin Li
- Department of Biostatistics, Center for Global Health, School of Public Health, Nanjing Medical University, 101 Longmian Avenue, Nanjing, 211166, Jiangsu, China
| | - Junyi Xin
- Department of Bioinformatics, School of Biomedical Engineering and Informatics, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zhenghao Jin
- School of Medicine, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zhengyu Zhang
- School of Medicine, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jiawei Li
- School of Medicine, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yukun Zhu
- School of Medicine, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Li Su
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 655 Huntington Avenue, Boston, MA, 02115, USA
| | - Peipei Huang
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 655 Huntington Avenue, Boston, MA, 02115, USA
- Department of Emergency, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Lei Jiang
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 655 Huntington Avenue, Boston, MA, 02115, USA
- Department of Emergency, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Mulong Du
- Department of Biostatistics, Center for Global Health, School of Public Health, Nanjing Medical University, 101 Longmian Avenue, Nanjing, 211166, Jiangsu, China.
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 655 Huntington Avenue, Boston, MA, 02115, USA.
| | - David C Christiani
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 655 Huntington Avenue, Boston, MA, 02115, USA.
- Pulmonary and Critical Care Unit, Department of Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA.
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25
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Xu Z, Zhu L, Zhan J, Feng H, Deana C, Vetrugno L, Liu L, Lu J. Effect of high-flow nasal cannula oxygen therapy in combination with non-invasive ventilation on critically ill patients with acute respiratory failure: a retrospective study. J Thorac Dis 2023; 15:6821-6830. [PMID: 38249858 PMCID: PMC10797400 DOI: 10.21037/jtd-23-1014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/17/2023] [Indexed: 01/23/2024]
Abstract
Background Acute respiratory failure (ARF) is a respiratory disease in which ventilation dysfunction of the lungs occurs at rest due to various factors, resulting in oxygen deprivation and carbon dioxide (CO2) retention. In recent years, high-flow nasal cannula (HFNC), as a new type of oxygen therapy, has attracted increasing attention. Compared with traditional oxygen therapy, HFNC adopts nasal catheter to make it more in line with the physiological and respiratory characteristics of the human body, and thus can provide a higher and more constant inhalation of oxygen. This retrospective study was conducted to explore the clinical effect of HFNC combined with non-invasive ventilation (NIV) in the treatment of critically ill patients with ARF. Methods A total of 532 critically ill patients with ARF treated in our hospital from January 2019 to December 2020 were screened for the suitability for being included in the study. Of these, 261 patients in this study received NIV. In total, 151 patients were included after applying the inclusion and exclusion criteria. NIV was generally given intermittently, and the daily duration of application was determined according to the patient's condition. The NIV-treated patients were assigned into two groups according to the oxygen inhalation mode during intermittent NIV: (I) standard group: normal oxygen inhalation was applied at the NIV interval; and (II) research group: patients treated with HFNC at the NIV interval. The respective basic data and outcome observation indices were collected. Results In terms of the clinical outcome, the number of NIV treatment days in the research group was lower (P<0.05). At 30 min, 1 h, and 24 h after treatment, the partial pressure of arterial oxygen (PaO2), arterial oxygen saturation (SaO2), oxygenation index (P/F) indices in the research group were higher, while the CO2 partial pressure (PaCO2) was lower (P<0.05). Finally, the 28- and 90-day survival rates were compared between the groups and the results indicated no significant difference in the 28-day survival rates, but the 90-day survival rates of the research group were considerably higher (P<0.05). Conclusions The use of HFNC combined with NIV to treat ARF in critically ill patients can effectively improve the ARF-related respiratory indicators in critically ill patients.
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Affiliation(s)
- Zhiping Xu
- Department of Emergency and Critical Care Medicine, the Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Lingxia Zhu
- Department of Emergency and Critical Care Medicine, the Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jingye Zhan
- Department of Emergency and Critical Care Medicine, the Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Hui Feng
- Department of Emergency and Critical Care Medicine, the Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Cristian Deana
- Department of Anesthesia and Intensive Care, ASUFC-Academic Hospital of Udine, Udine, Italy
| | - Luigi Vetrugno
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, Chieti, Italy
| | - Lijun Liu
- Department of Emergency and Critical Care Medicine, the Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Juan Lu
- Department of Emergency and Critical Care Medicine, the Second Affiliated Hospital of Soochow University, Suzhou, China
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26
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Ortac Ersoy E, Erdemir B, Halacli B, Guven G, Yildirim M, Geldigitti IT, Yazdali Koylu N, Topeli A. Effect of Awake Prone Positioning on ROX Index in Critically-ill Patients With Respiratory Failure due to COVID-19. J Intensive Care Med 2023; 38:1158-1164. [PMID: 37611188 DOI: 10.1177/08850666231186956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
COVID-19 pneumonia causes acute respiratory distress syndrome (ARDS). Prone positioning (PP) is beneficial to pulmonary physiology and improves oxygenation in patients with ARDS. We aimed to investigate the effect of the PP on oxygenation, respiratory rate (RR) and ROX index in non-intubated patients with COVID-19 associated respiratory failure and to determine whether ROX index predicts intubation. Awake critically-ill patients with confirmed diagnosis of COVID-19 who underwent PP were enrolled in the retrospective, single-center study. Oxygenation parameters were recorded 1 h before PP, during PP and 1 h after return to supine position (after PP). Intubation was defined as the endpoint. Seventy-one patients with a median age of 64 [55-73] years were enrolled in the study. PaO2/FiO2 and SpO2/FiO2 improved during PP, this improvement did not persist after PP. RR improved during and after PP in both intubated and non-intubated patients (for all P < .001). ROX index improved only in non-intubated patients (P < .001) but not in intubated patients (P = .07). Area under the curve (AUC) of ROX index for intubation before PP, during PP and after PP were 0.74 [0.61-0.88] (P = .002), 0.76 [0.62-0.91] (P = .001), and 0.76 [0.64-0.89] (P = .001), respectively. ROX index >6.83 before PP had a negative predictive value (NPV) of 0.85; ROX index >8.28 during PP had a NPV of 0.88 and ROX index >7.48 after PP had a NPV of 0.85. In logistic regression adjusted for APACHE II score, ROX index ≤6.83 before PP had an odds ratio (OR) 4.47 [1.39-14.38], ROX index ≤8.28 during PP had an OR 7.96 [2.29-27.64] and ROX index ≤7.48 had an OR 3.98 [1.25-12.61] for prediction of intubation. In conclusion, awake PP improves oxygenation and decreases RR. ROX index improved only in non- intubated patients and a higher ROX index predicts lower risk of progressing to mechanical ventilation with intubation.
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Affiliation(s)
- Ebru Ortac Ersoy
- Department of Internal Medicine, Division of Intensive Care, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Begüm Erdemir
- Department of Internal Medicine, Division of Intensive Care, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Burcin Halacli
- Department of Internal Medicine, Division of Intensive Care, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Goksel Guven
- Department of Internal Medicine, Division of Intensive Care, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Mehmet Yildirim
- Diskapi Training and Research Hospital, Intensive Care Unit, University of Health Sciences, Ankara, Turkey
| | - Ismail Tuna Geldigitti
- Department of Internal Medicine, Division of Intensive Care, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Nur Yazdali Koylu
- Department of Internal Medicine, Division of Intensive Care, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Arzu Topeli
- Department of Internal Medicine, Division of Intensive Care, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Mauri T, Furfaro D, Kassis EB. Physiology-Based Indications to Improve Outcome of Awake Extracorporeal Membrane Oxygenation. Crit Care Med 2023; 51:1840-1843. [PMID: 37971344 DOI: 10.1097/ccm.0000000000006053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Affiliation(s)
- Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - David Furfaro
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Elias Baedorf Kassis
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
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28
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Zhou X, Luo X, Li Q, Chen G, Tong J, Deng W. Prone versus lateral position in acute hypoxemic respiratory failure patients with HFNO therapy: study protocol for a multicentre randomised controlled open-label trial. Trials 2023; 24:762. [PMID: 38012708 PMCID: PMC10683165 DOI: 10.1186/s13063-023-07761-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 10/28/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND High-flow nasal oxygen (HFNO) therapy is a leading treatment technique for acute hypoxemic respiratory failure (AHRF), but its treatment failure rate remains high. The awake prone position (APP) has been proven to increase oxygenation and reduce the endotracheal intubation rate in patients with COVID-19-induced AHRF. However, the APP is poorly tolerated in patients, and its performance in improving prognoses is controversial. The lateral position has a similar mechanism and effect to the prone position, but it is more tolerable than the prone position. Therefore, it is worth exploring whether the lateral position is better for awake patients with AHRF. METHODS This is a protocol for a three-arm parallel-group multicentre randomised controlled open-label exploratory trial. A total of 583 patients from two hospitals in Chongqing, China, will be randomised to take the semi-recumbent position, lateral position, or prone position at a ratio of 1:1:1. Patients are all diagnosed with AHRF secondary to non-COVID-19 pneumonia or lung infection and receiving HFNO therapy. The primary outcome is ventilator-free days in 28 days. The secondary outcomes are the 28-day intubation rate, 28-day all-cause mortality, total position change time, the incidence of adverse events, number of hours using HFNO therapy, length of hospital and intensive care unit (ICU) stay, and others. We will conduct subgroup analyses on the arterial partial pressure of oxygen to the fraction of inspiration oxygen (PaO2/FiO2) ratio (> 200 mmHg or ≤ 200 mmHg), time from admission to intervention implementation (< 24 h or ≥ 24 h), position changing time, and different diagnoses. DISCUSSION This trial will explore the prognostic effects of the APP with that of the lateral position in awake patients with non-COVID-19AHRF and compare the differences between them. To provide evidence for clinical decision-making and further research on position management. TRIAL REGISTRATION This trial was registered in the Chinese Clinical Trial Registry. The registration number is ChiCTR2200055822 . Registered on January 20, 2022.
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Affiliation(s)
- Xixin Zhou
- The Second Clinical College, Chongqing Medical University, Chongqing, China
- Department of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaoqing Luo
- Department of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qin Li
- Department of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Guihua Chen
- Nursing Department, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Jin Tong
- Department of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wang Deng
- Department of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Essex K, Mullen J, Lauria MJ, Braude DA. Management of Hantavirus Cardiopulmonary Syndrome in Critical Care Transport: A Review. Air Med J 2023; 42:483-487. [PMID: 37996187 DOI: 10.1016/j.amj.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/19/2023] [Accepted: 07/31/2023] [Indexed: 11/25/2023]
Abstract
In 1993, the Southwest found itself staring down a disease then known as "unexplained adult respiratory syndrome." During the outbreak, 12 of 23 known patients died. What we now recognize as hantavirus cardiopulmonary syndrome still remains a rare and deadly disease. Although no cure exists, modern supportive techniques such as extracorporeal membrane oxygenation have increased survival among these patients. Early diagnosis has become the primary factor in patient survival. The initial presentation of hantavirus is similar to acute respiratory distress syndrome, necessitating a high index of suspicion to afford the patient the best chance of survival. Diagnosis is further complicated by prolonged and nonspecific incubation periods making it difficult to pinpoint an exposure. Familiarizing oneself with common clinical presentations, diagnostic strategies, and testing is the best way to increase patient survival. Because hantavirus has a predilection for rural areas, transport to a tertiary facility is paramount to provide the resources necessary to care for these complex patients. Rapid sequence intubation, although common in airway-compromised patients, could prove fatal in the setting of the severe hemodynamic instability found in hantavirus cardiopulmonary syndrome. Anticipation of significant pressor use and fluid administration could likely mean the difference in patient mortality during transport.
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Affiliation(s)
- Kyle Essex
- AIT Airmed, Albuquerque, New Mexico; American Medical Response, Las Cruces, New Mexico.
| | | | - Michael J Lauria
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM; Lifeguard Air Emergency Services, Albuquerque, NM
| | - Darren A Braude
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM; Lifeguard Air Emergency Services, Albuquerque, NM
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Vetrugno L, Castaldo N, Fantin A, Deana C, Cortegiani A, Longhini F, Forfori F, Cammarota G, Grieco DL, Isola M, Navalesi P, Maggiore SM, Bassetti M, Chetta A, Confalonieri M, De Martino M, Ferrari G, Francisi D, Luzzati R, Meini S, Scozzafava M, Sozio E, Tascini C, Bassi F, Patruno V, De Robertis E, Aldieri C, Ball L, Baratella E, Bartoletti M, Boscolo A, Burgazzi B, Catalanotti V, Confalonieri P, Corcione S, De Rosa FG, De Simoni A, Bono VD, Tria RD, Forlani S, Giacobbe DR, Granozzi B, Labate L, Lococo S, Lupia T, Matellon C, Mehrabi S, Morosi S, Mongodi S, Mura M, Nava S, Pol R, Pettenuzzo T, Quyen NH, Rescigno C, Righi E, Ruaro B, Salton F, Scabini S, Scarda A, Sibani M, Tacconelli E, Tartaglione G, Tazza B, Vania E, Viale P, Vianello A, Visentin A, Zuccon U, Meroi F, Buonsenso D. Ventilatory associated barotrauma in COVID-19 patients: A multicenter observational case control study (COVI-MIX-study). Pulmonology 2023; 29:457-468. [PMID: 36669936 PMCID: PMC9684110 DOI: 10.1016/j.pulmoe.2022.11.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/25/2022] [Accepted: 11/02/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The risk of barotrauma associated with different types of ventilatory support is unclear in COVID-19 patients. The primary aim of this study was to evaluate the effect of the different respiratory support strategies on barotrauma occurrence; we also sought to determine the frequency of barotrauma and the clinical characteristics of the patients who experienced this complication. METHODS This multicentre retrospective case-control study from 1 March 2020 to 28 February 2021 included COVID-19 patients who experienced barotrauma during hospital stay. They were matched with controls in a 1:1 ratio for the same admission period in the same ward of treatment. Univariable and multivariable logistic regression (OR) were performed to explore which factors were associated with barotrauma and in-hospital death. RESULTS We included 200 cases and 200 controls. Invasive mechanical ventilation was used in 39.3% of patients in the barotrauma group, and in 20.1% of controls (p<0.001). Receiving non-invasive ventilation (C-PAP/PSV) instead of conventional oxygen therapy (COT) increased the risk of barotrauma (OR 5.04, 95% CI 2.30 - 11.08, p<0.001), similarly for invasive mechanical ventilation (OR 6.24, 95% CI 2.86-13.60, p<0.001). High Flow Nasal Oxygen (HFNO), compared with COT, did not significantly increase the risk of barotrauma. Barotrauma frequency occurred in 1.00% [95% CI 0.88-1.16] of patients; these were older (p=0.022) and more frequently immunosuppressed (p=0.013). Barotrauma was shown to be an independent risk for death (OR 5.32, 95% CI 2.82-10.03, p<0.001). CONCLUSIONS C-PAP/PSV compared with COT or HFNO increased the risk of barotrauma; otherwise HFNO did not. Barotrauma was recorded in 1.00% of patients, affecting mainly patients with more severe COVID-19 disease. Barotrauma was independently associated with mortality. TRIAL REGISTRATION this case-control study was prospectively registered in clinicaltrial.gov as NCT04897152 (on 21 May 2021).
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Affiliation(s)
- Luigi Vetrugno
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy; Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, Chieti, Italy.
| | - Nadia Castaldo
- Pulmonology Unit, Department of Cardiothoracic Surgery, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Alberto Fantin
- Pulmonology Unit, Department of Cardiothoracic Surgery, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Cristian Deana
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - 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, Palermo, Italy
| | - Federico Longhini
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Francesco Forfori
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, AOUP-Pisa, Italy
| | - Gianmaria Cammarota
- Anesthesia and Intensive Care Service 2, University Hospital of Perugia, Perugia, Italy; Department of Medicine and Surgery, Universiy of Perugia, Perugia, Italy
| | - Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Department of Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Miriam Isola
- Department of Medicine, University of Udine, Udine, Italy
| | - Paolo Navalesi
- Institute of Anaesthesia and Intensive Care, Padua University Hospital, Padua, Italy; Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - Salvatore Maurizio Maggiore
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy; Department of Innovative Technologies in Medicine and Dentistry, Gabriele d'Annunzio University of Chieti Pescara, Chieti, Italy
| | - Matteo Bassetti
- Infectious Diseases Unit, Ospedale Policlinico San Martino - IRCCS, Genoa, Italy; Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Alfredo Chetta
- Respiratory Disease and Lung Function Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Marco Confalonieri
- Department of Pulmonology, University Hospital of Cattinara, Trieste, Italy; University of Trieste, Trieste, Italy
| | | | - Giovanni Ferrari
- Pneumologia e Unità di Terapia Semi Intensiva Respiratoria, AO Umberto I Mauriziano, Turin, Italy
| | - Daniela Francisi
- Department of Infectious Disease "S. Maria della Misericordia" Hospital, University of Perugia, Perugia, Italy
| | - Roberto Luzzati
- Infectious Disease Unit, University of Trieste, Trieste, Italy
| | - Simone Meini
- U.O. Medicina Interna, Felice Lotti Hospital, Azienda USL Toscana Nord-Ovest, Pontedera, Italy
| | | | - Emanuela Sozio
- Infectious Diseases Division, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Carlo Tascini
- Department of Medicine, University of Udine, Udine, Italy; Infectious Diseases Division, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Flavio Bassi
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Vincenzo Patruno
- Pulmonology Unit, Department of Cardiothoracic Surgery, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Edoardo De Robertis
- Anesthesia and Intensive Care Service 2, University Hospital of Perugia, Perugia, Italy; Department of Medicine and Surgery, Universiy of Perugia, Perugia, Italy
| | - Chiara Aldieri
- Division of Infectious Diseases, Department of Medicine, Hospital Santa Croce e Carle, Cuneo, Italy
| | - Lorenzo Ball
- Anesthesia and Intensive Care, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Elisa Baratella
- Department of Pulmonology, University Hospital of Cattinara, Trieste, Italy; University of Trieste, Trieste, Italy
| | - Michele Bartoletti
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy
| | - Annalisa Boscolo
- Institute of Anaesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Barbara Burgazzi
- Respiratory Disease and Lung Function Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Vito Catalanotti
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy
| | - Paola Confalonieri
- Department of Pulmonology, University Hospital of Cattinara, Trieste, Italy; University of Trieste, Trieste, Italy
| | - Silvia Corcione
- Department of Medical Sciences, University of Turin, Infectious Diseases, City of Health and Sciences, Turin, Italy
| | - Francesco Giuseppe De Rosa
- Infectious Diseases Unit, Cardinal Massaia Hospital, Asti, Italy; Infectious Diseases Unit, Cardinal Massaia Hospital, Asti, Italy
| | - Alessandro De Simoni
- Respiratory Disease and Lung Function Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Valerio Del Bono
- Division of Infectious Diseases, Department of Medicine, Hospital Santa Croce e Carle, Cuneo, Italy
| | - Roberta Di Tria
- Pneumologia e Unità di Terapia Semi Intensiva Respiratoria, AO Umberto I Mauriziano, Turin, Italy
| | - Sara Forlani
- Pulmonary Medicine Unit, Lodi General Hospital, Lodi, Italy
| | - Daniele Roberto Giacobbe
- Infectious Diseases Unit, Ospedale Policlinico San Martino - IRCCS, Genoa, Italy; Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Bianca Granozzi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy
| | - Laura Labate
- Infectious Diseases Unit, Ospedale Policlinico San Martino - IRCCS, Genoa, Italy; Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Sara Lococo
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Tommaso Lupia
- Infectious Diseases Unit, Cardinal Massaia Hospital, Asti, Italy
| | - Carola Matellon
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Sara Mehrabi
- Infectious Diseases Division, Diagnostics and Public Health Department, University of Verona, Verona, Italy
| | - Sabrina Morosi
- Department of Infectious Disease "S. Maria della Misericordia" Hospital, University of Perugia, Perugia, Italy
| | - Silvia Mongodi
- Anaesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maddalena Mura
- U.O. Medicina Interna, Felice Lotti Hospital, Azienda USL Toscana Nord-Ovest, Pontedera, Italy
| | - Stefano Nava
- Department of Clinical, Integrated and Experimental Medicine (DIMES), University of Bologna, Bologna, Italy; Respiratory and Critical Care Unit, Sant Orsola University Hospital, Bologna, Italy
| | - Riccardo Pol
- Infectious Disease Unit, University of Trieste, Trieste, Italy
| | - Tommaso Pettenuzzo
- Institute of Anaesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Nguyen Hoang Quyen
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Carolina Rescigno
- UOC Malattie Infettive ad Indirizzo Neurologico, AORN Ospedali dei Colli, P.O. "D. Cotugno", Naples, Italy
| | - Elda Righi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Barbara Ruaro
- Department of Pulmonology, University Hospital of Cattinara, Trieste, Italy; University of Trieste, Trieste, Italy
| | - Francesco Salton
- Department of Pulmonology, University Hospital of Cattinara, Trieste, Italy; University of Trieste, Trieste, Italy
| | - Silvia Scabini
- Department of Medical Sciences, University of Turin, Infectious Diseases, City of Health and Sciences, Turin, Italy
| | - Angelo Scarda
- Respiratory Disease Unit, "Santa Maria degli Angeli" Hospital, Pordenone, Italy
| | - Marcella Sibani
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Evelina Tacconelli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Gennaro Tartaglione
- Respiratory Disease Unit, "Santa Maria degli Angeli" Hospital, Pordenone, Italy
| | - Beatrice Tazza
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy
| | - Eleonora Vania
- Infectious Diseases Division, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola, Bologna, Italy
| | - Andrea Vianello
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Alessandro Visentin
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Umberto Zuccon
- Respiratory Disease Unit, "Santa Maria degli Angeli" Hospital, Pordenone, Italy
| | | | - Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Giosa L, Collins PD, Sciolla M, Cerrone F, Di Blasi S, Macrì MM, Davicco L, Laguzzi A, Gorgonzola F, Penso R, Steinberg I, Muraccini M, Perboni A, Russotto V, Camporota L, Bellani G, Caironi P. Effects of CPAP and FiO 2 on respiratory effort and lung stress in early COVID-19 pneumonia: a randomized, crossover study. Ann Intensive Care 2023; 13:103. [PMID: 37847454 PMCID: PMC10581975 DOI: 10.1186/s13613-023-01202-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/06/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND in COVID-19 acute respiratory failure, the effects of CPAP and FiO2 on respiratory effort and lung stress are unclear. We hypothesize that, in the compliant lungs of early Sars-CoV-2 pneumonia, the application of positive pressure through Helmet-CPAP may not decrease respiratory effort, and rather worsen lung stress and oxygenation when compared to higher FiO2 delivered via oxygen masks. METHODS In this single-center (S.Luigi Gonzaga University-Hospital, Turin, Italy), randomized, crossover study, we included patients receiving Helmet-CPAP for early (< 48 h) COVID-19 pneumonia without additional cardiac or respiratory disease. Healthy subjects were included as controls. Participants were equipped with an esophageal catheter, a non-invasive cardiac output monitor, and an arterial catheter. The protocol consisted of a random sequence of non-rebreather mask (NRB), Helmet-CPAP (with variable positive pressure and FiO2) and Venturi mask (FiO2 0.5), each delivered for 20 min. Study outcomes were changes in respiratory effort (esophageal swing), total lung stress (dynamic + static transpulmonary pressure), gas-exchange and hemodynamics. RESULTS We enrolled 28 COVID-19 patients and 7 healthy controls. In all patients, respiratory effort increased from NRB to Helmet-CPAP (5.0 ± 3.7 vs 8.3 ± 3.9 cmH2O, p < 0.01). However, Helmet's pressure decreased by a comparable amount during inspiration (- 3.1 ± 1.0 cmH2O, p = 0.16), therefore dynamic stress remained stable (p = 0.97). Changes in static and total lung stress from NRB to Helmet-CPAP were overall not significant (p = 0.07 and p = 0.09, respectively), but showed high interpatient variability, ranging from - 4.5 to + 6.1 cmH2O, and from - 5.8 to + 5.7 cmH2O, respectively. All findings were confirmed in healthy subjects, except for an increase in dynamic stress (p < 0.01). PaO2 decreased from NRB to Helmet-CPAP with FiO2 0.5 (107 ± 55 vs 86 ± 30 mmHg, p < 0.01), irrespective of positive pressure levels (p = 0.64). Conversely, with Helmet's FiO2 0.9, PaO2 increased (p < 0.01), but oxygen delivery remained stable (p = 0.48) as cardiac output decreased (p = 0.02). When PaO2 fell below 60 mmHg with VM, respiratory effort increased proportionally (p < 0.01, r = 0.81). CONCLUSIONS In early COVID-19 pneumonia, Helmet-CPAP increases respiratory effort without altering dynamic stress, while the effects upon static and total stress are variable, requiring individual assessment. Oxygen masks with higher FiO2 provide better oxygenation with lower respiratory effort. Trial registration Retrospectively registered (13-May-2021): clinicaltrials.gov (NCT04885517), https://clinicaltrials.gov/ct2/show/NCT04885517 .
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Affiliation(s)
- Lorenzo Giosa
- Department of Critical Care Medicine, Guy's and St. Thomas' National Health Service Foundation Trust, St. Thomas' Hospital, Westminster Bridge Road, London, SE17EH, UK.
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK.
| | - Patrick Duncan Collins
- Department of Critical Care Medicine, Guy's and St. Thomas' National Health Service Foundation Trust, St. Thomas' Hospital, Westminster Bridge Road, London, SE17EH, UK
| | - Martina Sciolla
- Department of Pulmonary Medicine, AOU S. Luigi Gonzaga, Orbassano, Turin, Italy
| | | | - Salvatore Di Blasi
- Department of Anesthesia and Critical Care, AOU S. Luigi Gonzaga, Orbassano, Turin, Italy
| | - Matteo Maria Macrì
- Department of Anesthesia and Critical Care, AOU S. Luigi Gonzaga, Orbassano, Turin, Italy
| | - Luca Davicco
- Department of Anesthesia and Critical Care, AOU S. Luigi Gonzaga, Orbassano, Turin, Italy
| | - Andrea Laguzzi
- Department of Anesthesia and Critical Care, AOU S. Luigi Gonzaga, Orbassano, Turin, Italy
| | - Fabiana Gorgonzola
- Department of Pulmonary Medicine, AOU S. Luigi Gonzaga, Orbassano, Turin, Italy
| | - Roberto Penso
- Department of Anesthesia and Critical Care, AOU S. Luigi Gonzaga, Orbassano, Turin, Italy
| | - Irene Steinberg
- Department of Surgical Sciences, University of Turin, Turin, Italy
- Department of Anaesthesia, Intensive Care and Emergency, Città della Salute e della Scienza University Hospital, Turin, Italy
| | | | - Alberto Perboni
- Department of Pulmonary Medicine, AOU S. Luigi Gonzaga, Orbassano, Turin, Italy
| | - Vincenzo Russotto
- Department of Anesthesia and Critical Care, AOU S. Luigi Gonzaga, Orbassano, Turin, Italy
- Department of Oncology, University of Turin, Turin, Italy
| | - Luigi Camporota
- Department of Critical Care Medicine, Guy's and St. Thomas' National Health Service Foundation Trust, St. Thomas' Hospital, Westminster Bridge Road, London, SE17EH, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
| | - Giacomo Bellani
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento, Trento, Italy
| | - Pietro Caironi
- Department of Anesthesia and Critical Care, AOU S. Luigi Gonzaga, Orbassano, Turin, Italy
- Department of Oncology, University of Turin, Turin, Italy
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García-Fernández JJ, Sánchez-Nicolás JA, Galicia-Puyol S, Gil-Rosa I, Guerras-Conesa JJ, Bernal-Morell E, Cinesi-Gómez C. Failure of Non-Invasive Respiratory Support in Patients with SARS-CoV-2. J Clin Med 2023; 12:6537. [PMID: 37892675 PMCID: PMC10607690 DOI: 10.3390/jcm12206537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/06/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
INTRODUCTION The objective of this study is to assess the failure of therapies with HFNO (high-flow nasal oxygen), CPAP, Bilevel, or combined therapy in patients with hypoxemic acute respiratory failure due to SARS-CoV-2 during their hospitalization. METHODS This was a retrospective and observational study of SARS-CoV-2-positive patients who required non-invasive respiratory support (NIRS) at the Reina Sofía General University Hospital of Murcia between March 2020 and May 2021. RESULTS Of 7355 patients, 197 (11.8%) were included; 95 of them failed this therapy (48.3%). We found that during hospitalization in the ward, the combined therapy of HFNO and CPAP had an overall lower failure rate and the highest treatment with Bilevel (p = 0.005). In the comparison of failure in therapy without two levels of airway pressure, HFNO, CPAP, and combined therapy of HFNO with CPAP, (35.6% of patients) presented with 24.2% failure, compared to those who had two levels of pressure with Bilevel and combined therapy of HFNO with Bilevel (64.4% of patients), with 75.8% associated failure (OR: 0, 374; CI 95%: 0.203-0.688. p = 0.001). CONCLUSIONS The use of NIRS during conventional hospitalization is safe and effective in patients with respiratory failure secondary to SARS-CoV-2 infection. The therapeutic strategy of Bilevel increases the probability of failure, with the combined therapy strategy of CPAP and HFNO being the most promising option.
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Affiliation(s)
- Juan Javier García-Fernández
- Health Sciences PhD Program, Catholic University of Murcia UCAM, Campus de los Jerónimos nº135, Guadalupe, 30107 Murcia, Spain;
| | | | - Sonia Galicia-Puyol
- Emergency Department, Los Arcos del Mar Menor General University Hospital, 30739 Murcia, Spain
| | - Isabel Gil-Rosa
- Emergency Department, Reina Sofía General University Hospital, 30003 Murcia, Spain (C.C.-G.)
| | | | - Enrique Bernal-Morell
- Infectious Diseases Department, Reina Sofía General University Hospital, 30003 Murcia, Spain
| | - César Cinesi-Gómez
- Emergency Department, Reina Sofía General University Hospital, 30003 Murcia, Spain (C.C.-G.)
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Pitre T, Zeraatkar D, Kachkovski GV, Leung G, Shligold E, Dowhanik S, Angriman F, Ferreyro BL, Scales DC, Rochwerg B. Noninvasive Oxygenation Strategies in Adult Patients With Acute Hypoxemic Respiratory Failure: A Systematic Review and Network Meta-Analysis. Chest 2023; 164:913-928. [PMID: 37085046 DOI: 10.1016/j.chest.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 03/27/2023] [Accepted: 04/10/2023] [Indexed: 04/23/2023] Open
Abstract
BACKGROUND Several recently published randomized controlled trials have evaluated various noninvasive oxygenation strategies for the treatment of acute hypoxemic respiratory failure. RESEARCH QUESTION Which available noninvasive oxygen strategies are effective for acute hypoxic respiratory failure? STUDY DESIGN AND METHODS A systematic review of Medline, Embase, Cochrane CENTRAL, CINAHL, Web of Science, MedRxiv, and Research Square was conducted from inception to October 1, 2022. A random effects frequentist network meta-analysis was performed, and the results are presented using absolute risk difference per 1,000 patients. The Grading of Recommendations, Assessment, Development and Evaluation framework was used to rate the certainty of the evidence. Mortality, invasive mechanical ventilation, duration of hospitalization and ICU stay, ventilator-free days, and level of comfort are reported. RESULTS Thirty-six trials (7,046 patients) were included. It was found that helmet CPAP probably reduces mortality compared with standard oxygen therapy (SOT) (231 fewer deaths per 1,000; 95% CI, 126-273 fewer) (moderate certainty). A high-flow nasal cannula (HFNC) probably reduces the need for invasive mechanical ventilation (103.5 fewer events per 1,000; 95% CI, 40.5-157.5 fewer) (moderate certainty). All noninvasive oxygenation strategies may reduce the duration of hospitalization as compared with SOT (low certainty). Helmet bilevel ventilation (4.84 days fewer; 95% CI, 2.33-7.36 days fewer) and helmet CPAP (1.74 days fewer; 95% CI, 4.49 fewer-1.01 more) may reduce the duration of ICU stay as compared with SOT (both low certainty). SOT may be more comfortable than face mask noninvasive ventilation and no different in comfort compared with an HFNC (both low certainty). INTERPRETATION A helmet interface for noninvasive ventilation probably reduces mortality and the risk of mechanical ventilation, as well as the duration of hospital and ICU stay. An HFNC probably reduces the risk of invasive mechanical ventilation and may be as comfortable as SOT. Further research is necessary to understand the role of these interfaces in acute hypoxemic respiratory failure.
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Affiliation(s)
- Tyler Pitre
- Department of Medicine, McMaster University, Hamilton, ON, Canada.
| | - Dena Zeraatkar
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Anesthesiology, McMaster University, Hamilton, ON, Canada
| | - George V Kachkovski
- Faculty of Health Sciences, Michael G. DeGroote School of Medicine, Hamilton, ON, Canada
| | - Gareth Leung
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Erica Shligold
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sebastian Dowhanik
- Faculty of Health Sciences, Michael G. DeGroote School of Medicine, Hamilton, ON, Canada
| | - Federico Angriman
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; 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, ON, Canada
| | - 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, ON, Canada; Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
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Simioli F, Annunziata A, Coppola A, Imitazione P, Mirizzi AI, Marotta A, D’Angelo R, Fiorentino G. The role of dexmedetomidine in ARDS: an approach to non-intensive care sedation. Front Med (Lausanne) 2023; 10:1224242. [PMID: 37720511 PMCID: PMC10502206 DOI: 10.3389/fmed.2023.1224242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/17/2023] [Indexed: 09/19/2023] Open
Abstract
Introduction Severe COVID-19 is a life-threatening condition characterized by complications such as interstitial pneumonia, hypoxic respiratory failure, and acute respiratory distress syndrome (ARDS). Non-pharmacological intervention with mechanical ventilation plays a key role in treating COVID-19-related ARDS but is influenced by a high risk of failure in more severe patients. Dexmedetomidine is a new generation highly selective α2-adrenergic receptor (α2-AR) agonist that provides sedative effects with preservation of respiratory function. The aim of this study is to assess how dexmedetomidine influences gas exchange during non-invasive ventilation (NIV) and high-flow nasal cannula (HFNC) in moderate to severe ARDS caused by COVID-19 in a non-intensive care setting. Methods This is a single center retrospective cohort study. We included patients who showed moderate to severe respiratory distress. All included subjects had indication to NIV and were suitable for a non-intensive setting of care. A total of 170 patients were included, divided in a control group (n = 71) and a treatment group (DEX group, n = 99). Results A total of 170 patients were hospitalized for moderate to severe ARDS and COVID-19. The median age was 71 years, 29% females. The median Charlson comorbidity index (CCI) was 2.5. Obesity affected 21% of the study population. The median pO2/FiO2 was 82 mmHg before treatment. After treatment, the increase of pO2/FiO2 ratio was clinically and statistically significant in the DEX group compared to the controls (125 mmHg [97-152] versus 94 mmHg [75-122]; ***p < 0.0001). A significative reduction of NIV duration was observed in DEX group (10 [7-16] days vs. 13 [10-17] days; *p < 0.02). Twenty four patients required IMV in control group (n = 71) and 16 patients in DEX group (n = 99) with a reduction of endotracheal intubation of 62% (OR 0.38; **p < 0.008). A higher incidence of sinus bradycardia was observed in the DEX group. Conclusion Dexmedetomidine provides a "calm and arousal" status which allows spontaneous ventilation in awake patients treated with NIV and HFNC. The adjunctive therapy with dexmedetomidine is associated with a higher pO2/FiO2, lower duration of NIV, and a lower risk of NIV failure. A higher incidence of sinus bradycardia needs to be considered.
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Affiliation(s)
- Francesca Simioli
- Department of Respiratory Pathophysiology and Rehabilitation, Monaldi Hospital, A.O. dei Colli, Naples, Italy
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Yau CE, Lee DYX, Vasudevan A, Goh KJ, Wong E, Ho AFW, Lim DYZ. Performance of the ROX index in predicting high flow nasal cannula failure in COVID-19 patients: a systematic review and meta-analysis. Crit Care 2023; 27:320. [PMID: 37605238 PMCID: PMC10441756 DOI: 10.1186/s13054-023-04567-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/07/2023] [Indexed: 08/23/2023] Open
Abstract
COVID-19 patients with acute hypoxemic respiratory failure (AHRF) benefit from high flow nasal cannula (HFNC) oxygen therapy. However, delays in initiating invasive ventilation after HFNC failure are associated with poorer outcomes. The respiratory oxygenation (ROX) index, combining SpO2/FiO2 and respiratory rate, can predict HFNC failure. This meta-analysis evaluated the optimal ROX index cut-offs in predicting HFNC failure among COVID-19 patients at different measurement timings and clinical settings. Three databases were searched for eligible papers. From each study, we reconstructed the confusion matrices at different cut-offs, fitted linear mixed models to estimate the ROX index distribution function, and derived the area under the summary receiver operator characteristic curve (sAUC) and optimal cut-offs to predict HFNC failure. 24 studies containing 4790 patients were included. Overall sAUC was 0.771 (95% CI: 0.666-0.847) (optimal cut-off: 5.23, sensitivity: 0.732, specificity: 0.690). The cut-off values to achieve 80%, 90% sensitivity, 80%, 90% specificity were 5.70, 6.69, 4.45, 3.37, respectively. We stratified the analysis by ROX measurement time and estimated optimal cut-offs and cut-offs to achieve 80% sensitivity and specificity. For 2-6 h and 6-12 h post-HFNC initiation, we propose the use of 80% specific cut-offs to rule in HFNC failure of < 5.33 and < 3.69, respectively. For 12-24 h post-HFNC initiation, we propose the use of the 80% sensitive cut-off of > 6.07 to rule out HFNC failure. Our analysis confirms the overall utility of the ROX index in risk stratification of COVID-19 patients with AHRF receiving HFNC and provides potentially useful cut-offs for different times from HFNC initiation.
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Affiliation(s)
- Chun En Yau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Dawn Yi Xin Lee
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Adithi Vasudevan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ken Junyang Goh
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Evelyn Wong
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore.
- Pre-Hospital and Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore, Singapore.
- Centre for Population Health Research and Implementation, SingHealth Regional Health System, Singapore, Singapore.
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.
| | - Daniel Yan Zheng Lim
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore.
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Grieco DL, Delle Cese L, Menga LS, Rosà T, Michi T, Lombardi G, Cesarano M, Giammatteo V, Bello G, Carelli S, Cutuli SL, Sandroni C, De Pascale G, Pesenti A, Maggiore SM, Antonelli M. Physiological effects of awake prone position in acute hypoxemic respiratory failure. Crit Care 2023; 27:315. [PMID: 37592288 PMCID: PMC10433569 DOI: 10.1186/s13054-023-04600-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/05/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND The effects of awake prone position on the breathing pattern of hypoxemic patients need to be better understood. We conducted a crossover trial to assess the physiological effects of awake prone position in patients with acute hypoxemic respiratory failure. METHODS Fifteen patients with acute hypoxemic respiratory failure and PaO2/FiO2 < 200 mmHg underwent high-flow nasal oxygen for 1 h in supine position and 2 h in prone position, followed by a final 1-h supine phase. At the end of each study phase, the following parameters were measured: arterial blood gases, inspiratory effort (ΔPES), transpulmonary driving pressure (ΔPL), respiratory rate and esophageal pressure simplified pressure-time product per minute (sPTPES) by esophageal manometry, tidal volume (VT), end-expiratory lung impedance (EELI), lung compliance, airway resistance, time constant, dynamic strain (VT/EELI) and pendelluft extent through electrical impedance tomography. RESULTS Compared to supine position, prone position increased PaO2/FiO2 (median [Interquartile range] 104 mmHg [76-129] vs. 74 [69-93], p < 0.001), reduced respiratory rate (24 breaths/min [22-26] vs. 27 [26-30], p = 0.05) and increased ΔPES (12 cmH2O [11-13] vs. 9 [8-12], p = 0.04) with similar sPTPES (131 [75-154] cmH2O s min-1 vs. 105 [81-129], p > 0.99) and ΔPL (9 [7-11] cmH2O vs. 8 [5-9], p = 0.17). Airway resistance and time constant were higher in prone vs. supine position (9 cmH2O s arbitrary units-3 [4-11] vs. 6 [4-9], p = 0.05; 0.53 s [0.32-61] vs. 0.40 [0.37-0.44], p = 0.03). Prone position increased EELI (3887 arbitrary units [3414-8547] vs. 1456 [959-2420], p = 0.002) and promoted VT distribution towards dorsal lung regions without affecting VT size and lung compliance: this generated lower dynamic strain (0.21 [0.16-0.24] vs. 0.38 [0.30-0.49], p = 0.004). The magnitude of pendelluft phenomenon was not different between study phases (55% [7-57] of VT in prone vs. 31% [14-55] in supine position, p > 0.99). CONCLUSIONS Prone position improves oxygenation, increases EELI and promotes VT distribution towards dependent lung regions without affecting VT size, ΔPL, lung compliance and pendelluft magnitude. Prone position reduces respiratory rate and increases ΔPES because of positional increases in airway resistance and prolonged expiratory time. Because high ΔPES is the main mechanistic determinant of self-inflicted lung injury, caution may be needed in using awake prone position in patients exhibiting intense ΔPES. Clinical trail registeration: The study was registered on clinicaltrials.gov (NCT03095300) on March 29, 2017.
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Affiliation(s)
- Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Luca Delle Cese
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Luca S. Menga
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Tommaso Rosà
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Teresa Michi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Gianmarco Lombardi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Melania Cesarano
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Valentina Giammatteo
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Giuseppe Bello
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Simone Carelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Salvatore L. Cutuli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Claudio Sandroni
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Gennaro De Pascale
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Antonio Pesenti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Salvatore M. Maggiore
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
- University Department of Innovative Technologies in Medicine and Dentistry, Gabriele d’Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
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Santus P, Radovanovic D, Saad M, Zilianti C, Coppola S, Chiumello DA, Pecchiari M. Acute dyspnea in the emergency department: a clinical review. Intern Emerg Med 2023; 18:1491-1507. [PMID: 37266791 PMCID: PMC10235852 DOI: 10.1007/s11739-023-03322-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/22/2023] [Indexed: 06/03/2023]
Abstract
Acute dyspnea represents one of the most frequent symptoms leading to emergency room evaluation. Its significant prognostic value warrants a careful evaluation. The differential diagnosis of dyspnea is complex due to the lack of specificity and the loose association between its intensity and the severity of the underlying pathological condition. The initial assessment of dyspnea calls for prompt diagnostic evaluation and identification of optimal monitoring strategy and provides information useful to allocate the patient to the most appropriate setting of care. In recent years, accumulating evidence indicated that lung ultrasound, along with echocardiography, represents the first rapid and non-invasive line of assessment that accurately differentiates heart, lung or extra-pulmonary involvement in patients with dyspnea. Moreover, non-invasive respiratory support modalities such as high-flow nasal oxygen and continuous positive airway pressure have aroused major clinical interest, in light of their efficacy and practicality to treat patients with dyspnea requiring ventilatory support, without using invasive mechanical ventilation. This clinical review is focused on the pathophysiology of acute dyspnea, on its clinical presentation and evaluation, including ultrasound-based diagnostic workup, and on available non-invasive modalities of respiratory support that may be required in patients with acute dyspnea secondary or associated with respiratory failure.
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Affiliation(s)
- Pierachille Santus
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milan, Italy.
- Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milan, Italy.
| | - Dejan Radovanovic
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milan, Italy
- Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milan, Italy
| | - Marina Saad
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milan, Italy
| | - Camilla Zilianti
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
| | - Silvia Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, Ospedale Universitario San Paolo, Milan, Italy
| | - Davide Alberto Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, Ospedale Universitario San Paolo, Milan, Italy
- Department of Health Sciences, Università Degli Studi Di Milano, Milan, Italy
- Coordinated Research Center On Respiratory Failure, Università Degli Studi Di Milano, Milan, Italy
| | - Matteo Pecchiari
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
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de Beaufort E, Carteaux G, Morin F, Lesimple A, Haudebourg AF, Fresnel E, Duval D, Broc A, Mercat A, Brochard L, Savary D, Beloncle F, Mekontso Dessap A, Richard JC. A new reservoir-based CPAP with low oxygen consumption: the Bag-CPAP. Crit Care 2023; 27:262. [PMID: 37403149 DOI: 10.1186/s13054-023-04542-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 06/22/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Several noninvasive ventilatory supports rely in their design on high oxygen consumption which may precipitate oxygen shortage, as experienced during the COVID-19 pandemic. In this bench-to-bedside study, we assessed the performance of a new continuous positive airway pressure (CPAP) device integrating a large reservoir ("Bag-CPAP") designed to minimize oxygen consumption, and compared it with other CPAP devices. METHODS First, a bench study compared the performances of Bag-CPAP and four CPAP devices with an intensive care unit ventilator. Two FiO2 targets (40-60% and 80-100%) at a predefined positive end expiratory pressure (PEEP) level between 5 and 10 cm H2O were tested and fraction of inspired oxygen (FiO2) and oxygen consumption were measured. Device-imposed work of breathing (WOB) was also evaluated. Second, an observational clinical study evaluated the new CPAP in 20 adult patients with acute respiratory failure in two hospitals in France. Actual FiO2, PEEP, peripheral oxygen saturation, respiratory rate, and dyspnea score were assessed. RESULTS All six systems tested in the bench study reached the minimal FiO2 target of 40% and four reached at least 80% FiO2 while maintaining PEEP in the predefined range. Device-delivered FiO2/consumed oxygen ratio was the highest with the new reservoir-based CPAP irrespective of FiO2 target. WOB induced by the device was higher with Bag-CPAP. In the clinical study, Bag-CPAP was well tolerated and could reach high (> 90%) and moderate (> 50%) FiO2 with an oxygen flow rate of 15 [15-16] and 8 [7-9] L/min, respectively. Dyspnea score improved significantly after introduction of Bag-CPAP, and SpO2 increased. CONCLUSIONS In vitro, Bag-CPAP exhibited the highest oxygen saving properties albeit had increased WOB. It was well accepted clinically and reduced dyspnea. Bag-CPAP may be useful to treat patients with acute respiratory failure in the field, especially when facing constraints in oxygen delivery.
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Affiliation(s)
- Eloïse de Beaufort
- Université Paris Est-Créteil, Faculté de Santé, Groupe de Recherche Clinique CARMAS, 94010, Créteil, France
- Med2Lab Laboratory, ALMS, Antony, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil, France
| | - Guillaume Carteaux
- Université Paris Est-Créteil, Faculté de Santé, Groupe de Recherche Clinique CARMAS, 94010, Créteil, France.
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, 1 rue Gustave Eiffel, 94010, Créteil Cedex, France.
- INSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil, France.
| | - François Morin
- Centre Hospitalier Universitaire d'Angers, Département de Médecine d'Urgence, Université d'Angers, Faculté de Santé, Vent'Lab, Angers, France
| | - Arnaud Lesimple
- Med2Lab Laboratory, ALMS, Antony, France
- CNRS, INSERM 1083, MITOVASC, Université d'Angers, Angers, France
- Centre Hospitalier Universitaire d'Angers, Département de Médecine Intensive-Réanimation et Médecine Hyperbare, Vent'Lab, Université d'Angers, Faculté de Santé, Angers, France
| | - Anne-Fleur Haudebourg
- Université Paris Est-Créteil, Faculté de Santé, Groupe de Recherche Clinique CARMAS, 94010, Créteil, France
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, 1 rue Gustave Eiffel, 94010, Créteil Cedex, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil, France
| | | | - Damien Duval
- Centre Hospitalier Universitaire d'Angers, Département de Médecine d'Urgence, Université d'Angers, Faculté de Santé, Vent'Lab, Angers, France
| | | | - Alain Mercat
- Centre Hospitalier Universitaire d'Angers, Département de Médecine Intensive-Réanimation et Médecine Hyperbare, Vent'Lab, Université d'Angers, Faculté de Santé, Angers, France
| | - Laurent Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Dominique Savary
- Centre Hospitalier Universitaire d'Angers, Département de Médecine d'Urgence, Université d'Angers, Faculté de Santé, Vent'Lab, Angers, France
| | - François Beloncle
- Centre Hospitalier Universitaire d'Angers, Département de Médecine Intensive-Réanimation et Médecine Hyperbare, Vent'Lab, Université d'Angers, Faculté de Santé, Angers, France
| | - Armand Mekontso Dessap
- Université Paris Est-Créteil, Faculté de Santé, Groupe de Recherche Clinique CARMAS, 94010, Créteil, France
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, 1 rue Gustave Eiffel, 94010, Créteil Cedex, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil, France
| | - Jean-Christophe Richard
- Med2Lab Laboratory, ALMS, Antony, France
- Centre Hospitalier Universitaire d'Angers, Département de Médecine Intensive-Réanimation et Médecine Hyperbare, Vent'Lab, Université d'Angers, Faculté de Santé, Angers, France
- INSERM, UMR 1066, Créteil, France
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Taxbro K, Hammarskjöld F, Nilsson M, Persson M, Chew MS, Sunnergren O. Factors related to COVID-19 mortality among three Swedish intensive care units-A retrospective study. Acta Anaesthesiol Scand 2023; 67:788-796. [PMID: 36915957 DOI: 10.1111/aas.14232] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 02/15/2023] [Accepted: 03/07/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Mortality due to acute hypoxemic respiratory failure (AHRF) in patients with coronavirus disease-19 (COVID-19) differs across units, regions, and countries. These variations may be attributed to several factors, including comorbidities, acute physiological derangement, disease severity, treatment, ethnicity, healthcare system strain, and socioeconomic status. This study aimed to explore the features of patient characteristics, clinical management, and staffing that may be related to mortality among three intensive care units (ICUs) within the same hospital system in South Sweden. METHODS We retrospectively analyzed ICU patients with COVID-19 and AHRF in Region Jönköping County, Sweden. The primary outcome was the 90-day mortality rate. We used univariate and multivariable logistic regression analyses to investigate the relationship of predictors with outcomes. RESULTS Between March 15, 2020, and May 31, 2021, 331 patients with AHRF and COVID-19 were admitted to the three ICUs. There were differences in disease severity, treatments, process-related factors, and socioeconomic factors between the units. These factors were related to 90-day mortality. After multivariable adjustment, age, severity of acute respiratory distress syndrome, and the number of nurses per ICU-bed independently predicted 90-day mortality. CONCLUSION Age, disease severity, and nurse staffing, but not treatment or socioeconomic status, were independently associated with 90-day mortality among critically ill patients with AHRF due to COVID-19. We also identified variations in care related processes, which may be a modifiable risk factor and warrants future investigation.
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Affiliation(s)
- Knut Taxbro
- Department of Anaesthesia and Intensive Care Medicine, Ryhov County Hospital, Jönköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Fredrik Hammarskjöld
- Department of Anaesthesia and Intensive Care Medicine, Ryhov County Hospital, Jönköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Mats Nilsson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Futurum, Academy of Health and Care, Region Jönköping County, Jönköping, Sweden
| | - Magnus Persson
- Department of Anaesthesia and Intensive Care Medicine, Värnamo Hospital, Värnamo, Sweden
| | - Michelle S Chew
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Anaesthesia and Intensive Care Medicine, Linköping University Hospital, Linköping, Sweden
| | - Ola Sunnergren
- Department of Otorhinolaryngology, Region Jönköping County, Jönköping, Sweden
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Grieco DL, Munshi L, Piquilloud L. Personalized noninvasive respiratory support for acute hypoxemic respiratory failure. Intensive Care Med 2023; 49:840-843. [PMID: 37115260 PMCID: PMC10140708 DOI: 10.1007/s00134-023-07048-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 03/23/2023] [Indexed: 04/29/2023]
Affiliation(s)
- Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.Go F. Vito, 00168, Rome, Italy.
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Division of Respirology, University Health Network/Sinai Health System, Toronto, Canada
| | - Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
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Poopipatpab S, Nuchpramool P, Phairatwet P, Lertwattanachai T, Trongtrakul K. The use of respiratory rate-oxygenation index to predict failure of high-flow nasal cannula in patients with coronavirus disease 2019-associated acute respiratory distress syndrome: A retrospective study. PLoS One 2023; 18:e0287432. [PMID: 37343046 DOI: 10.1371/journal.pone.0287432] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 06/06/2023] [Indexed: 06/23/2023] Open
Abstract
Patients with mild-to-moderate coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome (ARDS) can be treated with a high-flow nasal cannula (HFNC). The use of the respiratory rate-oxygenation (ROX) index, calculated as the ratio of oxygen saturation (SpO2)/fractional oxygen (FiO2) to respiratory rate, in the first few hours after HFNC initiation can help identify patients who fail HFNC therapy later. However, few studies have documented the use of the ROX index during the period of HFNC therapy. Therefore, we aimed to demonstrate the diagnostic performance of the ROX index when calculated throughout the HFNC therapy period and to determine the best cut-off point for predicting HFNC failure. We conducted a retrospective study of patients with COVID-19-associated ARDS who commenced HFNC at the Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Thailand, between April 1 and August 30, 2021. We calculated the ROX index every 4 h throughout the HFNC therapy period and defined HFNC failure as a subsequent endotracheal tube intubation. The performance of the ROX index was analyzed using the area under the receiver operating characteristic curve (AUC). We applied the ROX index ≤ 4.88 to predict HFNC failure and obtained a new ROX cut-off point using Youden's method. In total, 212 patients with COVID-19 treated with HFNC were included in the study. Of these, 81 patients (38.2%) experienced HFNC failure. The ROX index ≤ 4.88 demonstrated a reasonable performance in predicting HFNC failure (AUC, 0.77; 95% confidence interval [CI], 0.72-0.83; p<0.001). However, compared with the original cut-off point of ≤ 4.88, the new ROX index cut-off point of ≤ 5.84 delivered optimal performance (AUC, 0.84; 95% CI, 0.79-0.88; p<0.001), with a significantly better discriminative ability (p = 0.007). In conclusion, a ROX index ≤ 5.84 was found to be optimal for predicting HFNC failure in patients with COVID-19-associated ARDS.
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Affiliation(s)
- Sujaree Poopipatpab
- Department of Anesthesiology, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Pruchwilai Nuchpramool
- Department of Anesthesiology, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Piyarat Phairatwet
- Department of Internal Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Todspol Lertwattanachai
- Department of Pharmacology, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Konlawij Trongtrakul
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Cutuli SL, Grieco DL, Michi T, Cesarano M, Rosà T, Pintaudi G, Menga LS, Ruggiero E, Giammatteo V, Bello G, De Pascale G, Antonelli M. Personalized Respiratory Support in ARDS: A Physiology-to-Bedside Review. J Clin Med 2023; 12:4176. [PMID: 37445211 DOI: 10.3390/jcm12134176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/19/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a leading cause of disability and mortality worldwide, and while no specific etiologic interventions have been shown to improve outcomes, noninvasive and invasive respiratory support strategies are life-saving interventions that allow time for lung recovery. However, the inappropriate management of these strategies, which neglects the unique features of respiratory, lung, and chest wall mechanics may result in disease progression, such as patient self-inflicted lung injury during spontaneous breathing or by ventilator-induced lung injury during invasive mechanical ventilation. ARDS characteristics are highly heterogeneous; therefore, a physiology-based approach is strongly advocated to titrate the delivery and management of respiratory support strategies to match patient characteristics and needs to limit ARDS progression. Several tools have been implemented in clinical practice to aid the clinician in identifying the ARDS sub-phenotypes based on physiological peculiarities (inspiratory effort, respiratory mechanics, and recruitability), thus allowing for the appropriate application of personalized supportive care. In this narrative review, we provide an overview of noninvasive and invasive respiratory support strategies, as well as discuss how identifying ARDS sub-phenotypes in daily practice can help clinicians to deliver personalized respiratory support and potentially improve patient outcomes.
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Affiliation(s)
- Salvatore Lucio Cutuli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Teresa Michi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Melania Cesarano
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Tommaso Rosà
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Gabriele Pintaudi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Luca Salvatore Menga
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Ersilia Ruggiero
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Valentina Giammatteo
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giuseppe Bello
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Gennaro De Pascale
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Michi T, Mattana C, Menga LS, Bocci MG, Cesarano M, Rosà T, Gualano MR, Montomoli J, Spadaro S, Tosato M, Rota E, Landi F, Cutuli SL, Tanzarella ES, Pintaudi G, Piervincenzi E, Bello G, Tonetti T, Rucci P, De Pascale G, Maggiore SM, Grieco DL, Conti G, Antonelli M. Long-term outcome of COVID-19 patients treated with helmet noninvasive ventilation vs. high-flow nasal oxygen: a randomized trial. J Intensive Care 2023; 11:21. [PMID: 37208787 DOI: 10.1186/s40560-023-00669-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/10/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Long-term outcomes of patients treated with helmet noninvasive ventilation (NIV) are unknown: safety concerns regarding the risk of patient self-inflicted lung injury and delayed intubation exist when NIV is applied in hypoxemic patients. We assessed the 6-month outcome of patients who received helmet NIV or high-flow nasal oxygen for COVID-19 hypoxemic respiratory failure. METHODS In this prespecified analysis of a randomized trial of helmet NIV versus high-flow nasal oxygen (HENIVOT), clinical status, physical performance (6-min-walking-test and 30-s chair stand test), respiratory function and quality of life (EuroQoL five dimensions five levels questionnaire, EuroQoL VAS, SF36 and Post-Traumatic Stress Disorder Checklist for the DSM) were evaluated 6 months after the enrollment. RESULTS Among 80 patients who were alive, 71 (89%) completed the follow-up: 35 had received helmet NIV, 36 high-flow oxygen. There was no inter-group difference in any item concerning vital signs (N = 4), physical performance (N = 18), respiratory function (N = 27), quality of life (N = 21) and laboratory tests (N = 15). Arthralgia was significantly lower in the helmet group (16% vs. 55%, p = 0.002). Fifty-two percent of patients in helmet group vs. 63% of patients in high-flow group had diffusing capacity of the lungs for carbon monoxide < 80% of predicted (p = 0.44); 13% vs. 22% had forced vital capacity < 80% of predicted (p = 0.51). Both groups reported similar degree of pain (p = 0.81) and anxiety (p = 0.81) at the EQ-5D-5L test; the EQ-VAS score was similar in the two groups (p = 0.27). Compared to patients who successfully avoided invasive mechanical ventilation (54/71, 76%), intubated patients (17/71, 24%) had significantly worse pulmonary function (median diffusing capacity of the lungs for carbon monoxide 66% [Interquartile range: 47-77] of predicted vs. 80% [71-88], p = 0.005) and decreased quality of life (EQ-VAS: 70 [53-70] vs. 80 [70-83], p = 0.01). CONCLUSIONS In patients with COVID-19 hypoxemic respiratory failure, treatment with helmet NIV or high-flow oxygen yielded similar quality of life and functional outcome at 6 months. The need for invasive mechanical ventilation was associated with worse outcomes. These data indicate that helmet NIV, as applied in the HENIVOT trial, can be safely used in hypoxemic patients. Trial registration Registered on clinicaltrials.gov NCT04502576 on August 6, 2020.
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Affiliation(s)
- Teresa Michi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Chiara Mattana
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Luca S Menga
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Maria Grazia Bocci
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Melania Cesarano
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Tommaso Rosà
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Maria Rosaria Gualano
- Department of Hygiene and Public Health, UniCamillus University, Rome, Italy
- Leadership in Medicine Research Center, Catholic University of The Sacred Heart, Rome , Italy
| | - Jonathan Montomoli
- Department of Anaesthesia and Intensive Care, Infermi Hospital, Rimini, Italy
| | - Savino Spadaro
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliera-Universitaria Arcispedale Sant'Anna, University of Ferrara, Ferrara, Italy
| | - Matteo Tosato
- Geriatrics Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Elisabetta Rota
- Geriatrics Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Landi
- Geriatrics Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Salvatore L Cutuli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Eloisa S Tanzarella
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Gabriele Pintaudi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Edoardo Piervincenzi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Giuseppe Bello
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Tommaso Tonetti
- Department of Medical and Surgical Sciences, Anesthesia and Intensive Care Medicine, Alma Mater Studiorum, Policlinico Di Sant'Orsola, Università Di Bologna, Bologna, Italy
| | - Paola Rucci
- Department of Biomedical and Neuromotor Science, Alma Mater Studiorum-Università Di Bologna, Bologna, Italy
| | - Gennaro De Pascale
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Salvatore M Maggiore
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
| | - Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy.
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy.
| | - Giorgio Conti
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
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Jalil Y, Ferioli M, Dres M. The COVID-19 Driving Force: How It Shaped the Evidence of Non-Invasive Respiratory Support. J Clin Med 2023; 12:jcm12103486. [PMID: 37240592 DOI: 10.3390/jcm12103486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 05/03/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
During the COVID-19 pandemic, the use of non-invasive respiratory support (NIRS) became crucial in treating patients with acute hypoxemic respiratory failure. Despite the fear of viral aerosolization, non-invasive respiratory support has gained attention as a way to alleviate ICU overcrowding and reduce the risks associated with intubation. The COVID-19 pandemic has led to an unprecedented increased demand for research, resulting in numerous publications on observational studies, clinical trials, reviews, and meta-analyses in the past three years. This comprehensive narrative overview describes the physiological rationale, pre-COVID-19 evidence, and results of observational studies and randomized control trials regarding the use of high-flow nasal oxygen, non-invasive mechanical ventilation, and continuous positive airway pressure in adult patients with COVID-19 and associated acute hypoxemic respiratory failure. The review also highlights the significance of guidelines and recommendations provided by international societies and the need for further well-designed research to determine the optimal use of NIRS in treating this population.
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Affiliation(s)
- Yorschua Jalil
- INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, 75006 Paris, France
- Service de Médecine Intensive-Réanimation (Département "R3S"), AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, 75013 Paris, France
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile
- Departamento de Ciencias de la Salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile
| | - Martina Ferioli
- INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, 75006 Paris, France
- Service de Médecine Intensive-Réanimation (Département "R3S"), AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, 75013 Paris, France
- Respiratory and Critical Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Clinical, Integrated and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, 40136 Bologna, Italy
| | - Martin Dres
- INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, 75006 Paris, France
- Service de Médecine Intensive-Réanimation (Département "R3S"), AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, 75013 Paris, France
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Menga LS, Delle Cese L, Rosà T, Cesarano M, Scarascia R, Michi T, Biasucci DG, Ruggiero E, Dell’Anna AM, Cutuli SL, Tanzarella ES, Pintaudi G, De Pascale G, Sandroni C, Maggiore SM, Grieco DL, Antonelli M. Respective Effects of Helmet Pressure Support, Continuous Positive Airway Pressure, and Nasal High-Flow in Hypoxemic Respiratory Failure: A Randomized Crossover Clinical Trial. Am J Respir Crit Care Med 2023; 207:1310-1323. [PMID: 36378814 PMCID: PMC10595442 DOI: 10.1164/rccm.202204-0629oc] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 11/15/2022] [Indexed: 11/16/2022] Open
Abstract
Rationale: The respective effects of positive end-expiratory pressure (PEEP) and pressure support delivered through the helmet interface in patients with hypoxemia need to be better understood. Objectives: To assess the respective effects of helmet pressure support (noninvasive ventilation [NIV]) and continuous positive airway pressure (CPAP) compared with high-flow nasal oxygen (HFNO) on effort to breathe, lung inflation, and gas exchange in patients with hypoxemia (PaO2/FiO2 ⩽ 200). Methods: Fifteen patients underwent 1-hour phases (constant FiO2) of HFNO (60 L/min), helmet NIV (PEEP = 14 cm H2O, pressure support = 12 cm H2O), and CPAP (PEEP = 14 cm H2O) in randomized sequence. Measurements and Main Results: Inspiratory esophageal (ΔPES) and transpulmonary pressure (ΔPL) swings were used as surrogates for inspiratory effort and lung distension, respectively. Tidal Volume (Vt) and end-expiratory lung volume were assessed with electrical impedance tomography. ΔPES was lower during NIV versus CPAP and HFNO (median [interquartile range], 5 [3-9] cm H2O vs. 13 [10-19] cm H2O vs. 10 [8-13] cm H2O; P = 0.001 and P = 0.01). ΔPL was not statistically different between treatments. PaO2/FiO2 ratio was significantly higher during NIV and CPAP versus HFNO (166 [136-215] and 175 [158-281] vs. 120 [107-149]; P = 0.002 and P = 0.001). NIV and CPAP similarly increased Vt versus HFNO (mean change, 70% [95% confidence interval (CI), 17-122%], P = 0.02; 93% [95% CI, 30-155%], P = 0.002) and end-expiratory lung volume (mean change, 198% [95% CI, 67-330%], P = 0.001; 263% [95% CI, 121-407%], P = 0.001), mostly due to increased aeration/ventilation in dorsal lung regions. During HFNO, 14 of 15 patients had pendelluft involving >10% of Vt; pendelluft was mitigated by CPAP and further by NIV. Conclusions: Compared with HFNO, helmet NIV, but not CPAP, reduced ΔPES. CPAP and NIV similarly increased oxygenation, end-expiratory lung volume, and Vt, without affecting ΔPL. NIV, and to a lesser extent CPAP, mitigated pendelluft. Clinical trial registered with clinicaltrials.gov (NCT04241861).
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Affiliation(s)
- Luca S. Menga
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Luca Delle Cese
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Tommaso Rosà
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Melania Cesarano
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Roberta Scarascia
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Teresa Michi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Daniele G. Biasucci
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Ersilia Ruggiero
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Antonio M. Dell’Anna
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Salvatore L. Cutuli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Eloisa S. Tanzarella
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Gabriele Pintaudi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Gennaro De Pascale
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Claudio Sandroni
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Salvatore Maurizio Maggiore
- University Department of Innovative Technologies in Medicine and Dentistry, Gabriele d’Annunzio University of Chieti-Pescara, Chieti, Italy; and
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
| | - Domenico L. Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
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He Y, Zhuang X, Liu H, Ma W. Comparison of the efficacy and comfort of high-flow nasal cannula with different initial flow settings in patients with acute hypoxemic respiratory failure: a systematic review and network meta-analysis. J Intensive Care 2023; 11:18. [PMID: 37165464 PMCID: PMC10171174 DOI: 10.1186/s40560-023-00667-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 05/01/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND High-flow nasal cannula (HFNC) has been proven effective in improving patients with acute hypoxemic respiratory failure (AHRF), but a discussion of its use for initial flow settings still need to be provided. We aimed to compare the effectiveness and comfort evaluation of HFNC with different initial flow settings in patients with AHRF. METHODS Studies published by October 10, 2022, were searched exhaustively in PubMed, Embase, Web of Science, Cochrane Library (CENTRAL), and the China National Knowledge Infrastructure (CNKI) database. Network meta-analysis (NMA) was performed with STATA 17.0 and R software (version 4.2.1). A Bayesian framework was applied for this NMA. Comparisons of competing models based on the deviance information criterion (DIC) were used to select the best model for NMA. The primary outcome is the intubation at day 28. Secondary outcomes included short-term and long-term mortality, comfort score, length of ICU or hospital stay, and 24-h PaO2/FiO2. RESULTS This NMA included 23 randomized controlled trials (RCTs) with 5774 patients. With NIV as the control, the HFNC_high group was significantly associated with lower intubation rates (odds ratio [OR] 0.72 95% credible interval [CrI] 0.56 to 0.93; moderate quality evidence) and short-term mortality (OR 0.81 95% CrI 0.69 to 0.96; moderate quality evidence). Using HFNC_Moderate (Mod) group (mean difference [MD] - 1.98 95% CrI -3.98 to 0.01; very low quality evidence) as a comparator, the HFNC_Low group had a slight advantage in comfort scores but no statistically significant difference. Of all possible interventions, the HFNC_High group had the highest probability of being the best in reducing intubation rates (73.04%), short-term (82.74%) and long-term mortality (67.08%). While surface under the cumulative ranking curve value (SUCRA) indicated that the HFNC_Low group had the highest probability of being the best in terms of comfort scores. CONCLUSIONS The high initial flow settings (50-60 L/min) performed better in decreasing the occurrence of intubation and mortality, albeit with poor comfort scores. Treatment of HFNC for AHRF patients ought to be initiated from moderate flow rates (30-40 L/min), and individualized flow settings can make HFNC more sensible in clinical practice.
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Affiliation(s)
- Yuewen He
- Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, People's Republic of China
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, 12 Jichang Road, Guangzhou, Guangdong, 510405, People's Republic of China
| | - Xuhui Zhuang
- Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, People's Republic of China
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, 12 Jichang Road, Guangzhou, Guangdong, 510405, People's Republic of China
| | - Hao Liu
- Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, People's Republic of China
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, 12 Jichang Road, Guangzhou, Guangdong, 510405, People's Republic of China
| | - Wuhua Ma
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, 12 Jichang Road, Guangzhou, Guangdong, 510405, People's Republic of China.
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Carrié C, Rieu B, Benard A, Trin K, Petit L, Massri A, Jurcison I, Rousseau G, Tran Van D, Reynaud Salard M, Bourenne J, Levrat A, Muller L, Marie D, Dahyot-Fizelier C, Pottecher J, David JS, Godet T, Biais M. Early non-invasive ventilation and high-flow nasal oxygen therapy for preventing endotracheal intubation in hypoxemic blunt chest trauma patients: the OptiTHO randomized trial. Crit Care 2023; 27:163. [PMID: 37101272 PMCID: PMC10131545 DOI: 10.1186/s13054-023-04429-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/04/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND The benefit-risk ratio of prophylactic non-invasive ventilation (NIV) and high-flow nasal oxygen therapy (HFNC-O2) during the early stage of blunt chest trauma remains controversial because of limited data. The main objective of this study was to compare the rate of endotracheal intubation between two NIV strategies in high-risk blunt chest trauma patients. METHODS The OptiTHO trial was a randomized, open-label, multicenter trial over a two-year period. Every adult patients admitted in intensive care unit within 48 h after a high-risk blunt chest trauma (Thoracic Trauma Severity Score ≥ 8), an estimated PaO2/FiO2 ratio < 300 and no evidence of acute respiratory failure were eligible for study enrollment (Clinical Trial Registration: NCT03943914). The primary objective was to compare the rate of endotracheal intubation for delayed respiratory failure between two NIV strategies: i) a prompt association of HFNC-O2 and "early" NIV in every patient for at least 48 h with vs. ii) the standard of care associating COT and "late" NIV, indicated in patients with respiratory deterioration and/or PaO2/FiO2 ratio ≤ 200 mmHg. Secondary outcomes were the occurrence of chest trauma-related complications (pulmonary infection, delayed hemothorax or moderate-to-severe ARDS). RESULTS Study enrollment was stopped for futility after a 2-year study period and randomization of 141 patients. Overall, 11 patients (7.8%) required endotracheal intubation for delayed respiratory failure. The rate of endotracheal intubation was not significantly lower in patients treated with the experimental strategy (7% [5/71]) when compared to the control group (8.6% [6/70]), with an adjusted OR = 0.72 (95%IC: 0.20-2.43), p = 0.60. The occurrence of pulmonary infection, delayed hemothorax or delayed ARDS was not significantly lower in patients treated by the experimental strategy (adjusted OR = 1.99 [95%IC: 0.73-5.89], p = 0.18, 0.85 [95%IC: 0.33-2.20], p = 0.74 and 2.14 [95%IC: 0.36-20.77], p = 0.41, respectively). CONCLUSION A prompt association of HFNC-O2 with preventive NIV did not reduce the rate of endotracheal intubation or secondary respiratory complications when compared to COT and late NIV in high-risk blunt chest trauma patients with non-severe hypoxemia and no sign of acute respiratory failure. CLINICAL TRIAL REGISTRATION NCT03943914, Registered 7 May 2019.
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Affiliation(s)
- Cédric Carrié
- Surgical and Trauma Intensive Care Unit, Anesthesiology and Critical Care Department, Hôpital Pellegrin, CHU Bordeaux, Bordeaux University Hospital, Place Amélie Raba Léon, 33076, Bordeaux Cedex, France.
| | - Benjamin Rieu
- Anesthesiology and Critical Care Department, Clermont - Ferrand University Hospital, Clermont - Ferrand, France
| | - Antoine Benard
- Pôle de Santé Publique, Service d'information Médicale, Clinical Epidemiology Unit (USMR), CHU Bordeaux, Bordeaux, France
| | - Kilian Trin
- Pôle de Santé Publique, Service d'information Médicale, Clinical Epidemiology Unit (USMR), CHU Bordeaux, Bordeaux, France
| | - Laurent Petit
- Surgical and Trauma Intensive Care Unit, Anesthesiology and Critical Care Department, Hôpital Pellegrin, CHU Bordeaux, Bordeaux University Hospital, Place Amélie Raba Léon, 33076, Bordeaux Cedex, France
| | - Alexandre Massri
- Anesthesiology and Critical Care Department, Pau Hospital, Pau, France
| | - Igor Jurcison
- Anesthesiology and Critical Care Department, Beaujon University Hospital, Paris, France
| | - Guillaume Rousseau
- Anesthesiology and Critical Care Department, Beaujon University Hospital, Paris, France
| | - David Tran Van
- Anesthesiology and Critical Care Department, Robert Picqué Hospital, Bordeaux, France
| | - Marie Reynaud Salard
- Anesthesiology and Critical Care Department, Saint Etienne University Hospital, Saint Etienne, France
| | - Jeremy Bourenne
- Emergency and Critical Care Department, Hôpital de La Timone, Marseille University Hospital, Marseille, France
| | - Albrice Levrat
- Anesthesiology and Critical Care Department, Annecy Hospital, Annecy, France
| | - Laurent Muller
- Anesthesiology and Critical Care Department, Nimes University Hospital, Nimes, France
| | - Damien Marie
- Anesthesiology and Critical Care Department, Poitiers University Hospital, Poitiers, France
| | - Claire Dahyot-Fizelier
- Anesthesiology and Critical Care Department, Poitiers University Hospital, Poitiers, France
| | - Julien Pottecher
- Anesthesiology and Critical Care Department, Strasbourg University Hospital, Strasbourg, France
| | - Jean-Stéphane David
- Department of Anesthesia and Intensive Care, Groupe Hospitalier Sud, Hospices Civils de Lyon (HCL), Lyon, France
- Research On Healthcare Performance (RESHAPE), INSERM U1290, University Claude Bernard Lyon 1, Lyon, France
| | - Thomas Godet
- Anesthesiology and Critical Care Department, Clermont - Ferrand University Hospital, Clermont - Ferrand, France
| | - Matthieu Biais
- Surgical and Trauma Intensive Care Unit, Anesthesiology and Critical Care Department, Hôpital Pellegrin, CHU Bordeaux, Bordeaux University Hospital, Place Amélie Raba Léon, 33076, Bordeaux Cedex, France
- INSERM U1034, Biology of Cardiovascular Diseases, Bordeaux University, Pessac, France
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Ramji HF, Hafiz M, Altaq HH, Hussain ST, Chaudry F. Acute Respiratory Distress Syndrome; A Review of Recent Updates and a Glance into the Future. Diagnostics (Basel) 2023; 13:diagnostics13091528. [PMID: 37174920 PMCID: PMC10177247 DOI: 10.3390/diagnostics13091528] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/14/2023] [Accepted: 04/15/2023] [Indexed: 05/15/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a rapidly progressive form of respiratory failure that accounts for 10% of admissions to the ICU and is associated with approximately 40% mortality in severe cases. Despite significant mortality and healthcare burden, the mainstay of management remains supportive care. The recent pandemic of SARS-CoV-2 has re-ignited a worldwide interest in exploring the pathophysiology of ARDS, looking for innovative ideas to treat this disease. Recently, many trials have been published utilizing different pharmacotherapy targets; however, the long-term benefits of these agents remain unknown. Metabolomics profiling and stem cell transplantation offer strong enthusiasm and may completely change the outlook of ARDS management in the near future.
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Affiliation(s)
- Husayn F Ramji
- University of Oklahoma College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
- Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Maida Hafiz
- Department of Sleep Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Hiba Hammad Altaq
- Department of Pulmonary, Critical Care & Sleep Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Syed Talal Hussain
- Department of Pulmonary, Critical Care & Sleep Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Fawad Chaudry
- Department of Pulmonary, Critical Care & Sleep Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
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Slobod D, Spinelli E, Crotti S, Lissoni A, Galazzi A, Grasselli G, Mauri T. Effects of an asymmetrical high flow nasal cannula interface in hypoxemic patients. Crit Care 2023; 27:145. [PMID: 37072854 PMCID: PMC10111067 DOI: 10.1186/s13054-023-04441-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/12/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Optimal noninvasive respiratory support for patients with hypoxemic respiratory failure should minimize work of breathing without increasing the transpulmonary pressure. Recently, an asymmetrical high flow nasal cannula (HFNC) interface (Duet, Fisher & Paykel Healthcare Ltd), in which the caliber of each nasal prong is different, was approved for clinical use. This system might reduce work of breathing by lowering minute ventilation and improving respiratory mechanics. METHODS We enrolled 10 patients ≥ 18 years of age who were admitted to the Ospedale Maggiore Policlinico ICU in Milan, Italy, and had a PaO2/FiO2 < 300 mmHg during HFNC support with a conventional cannula. We investigated whether the asymmetrical interface, compared to a conventional high flow nasal cannula, reduces minute ventilation and work of breathing. Each patient underwent support with the asymmetrical interface and the conventional interface, applied in a randomized sequence. Each interface was provided at a flow rate of 40 l/min followed by 60 l/min. Patients were continuously monitored with esophageal manometry and electrical impedance tomography. RESULTS Application of the asymmetrical interface resulted in a -13.5 [-19.4 to (-4.5)] % change in minute ventilation at a flow rate of 40 l/min, p = 0.006 and a -19.6 [-28.0 to (-7.5)] % change at 60 l/min, p = 0.002, that occurred despite no change in PaCO2 (35 [33-42] versus 35 [33-43] mmHg at 40 l/min and 35 [32-41] versus 36 [32-43] mmHg at 60 l/min). Correspondingly, the asymmetrical interface lowered the inspiratory esophageal pressure-time product from 163 [118-210] to 140 [84-159] (cmH2O*s)/min at a flow rate of 40 l/min, p = 0.02 and from 142 [123-178] to 117 [90-137] (cmH2O*s)/min at a flow rate of 60 l/min, p = 0.04. The asymmetrical cannula did not have any impact on oxygenation, the dorsal fraction of ventilation, dynamic lung compliance, or end-expiratory lung impedance, suggesting no major effect on PEEP, lung mechanics, or alveolar recruitment. CONCLUSIONS An asymmetrical HFNC interface reduces minute ventilation and work of breathing in patients with mild-to-moderate hypoxemic respiratory failure supported with a conventional interface. This appears to be primarily driven by increased ventilatory efficiency due to enhanced CO2 clearance from the upper airway.
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Affiliation(s)
- Douglas Slobod
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
- Department of Critical Care Medicine, McGill University, Montreal, Canada
| | - Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Stefania Crotti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Alfredo Lissoni
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Alessandro Galazzi
- Department of Healthcare Professions, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
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50
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Gorder K, Young W, Kapur NK, Henry TD, Garcia S, Guddeti RR, Smith TD. Mechanical Circulatory Support in COVID-19. Heart Fail Clin 2023; 19:205-211. [PMID: 36863812 PMCID: PMC9973539 DOI: 10.1016/j.hfc.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Despite aggressive care, patients with cardiopulmonary failure and COVID-19 experience unacceptably high mortality rates. The use of mechanical circulatory support devices in this population offers potential benefits but confers significant morbidity and novel challenges for the clinician. Thoughtful application of this complex technology is of the utmost importance and should be done in a multidisciplinary fashion by teams familiar with mechanical support devices and aware of the particular challenges provided by this complex patient population.
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Affiliation(s)
- Kari Gorder
- The Christ Hospital Heart and Vascular Institute, 2139 Auburn Avenue, Cincinnati OH 45219, USA.
| | - Wesley Young
- The Christ Hospital Heart and Vascular Institute, 2139 Auburn Avenue, Cincinnati OH 45219, USA. https://twitter.com/wesyoungpa
| | - Navin K Kapur
- Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
| | - Timothy D Henry
- The Christ Hospital Heart and Vascular Institute, 2139 Auburn Avenue, Cincinnati OH 45219, USA; The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, OH 45219, USA. https://twitter.com/HenrytTimothy
| | - Santiago Garcia
- Minneapolis Heart Institute, 800 East, 28th Street, Minneapolis, MN 55407, USA
| | - Raviteja R Guddeti
- Minneapolis Heart Institute, 800 East, 28th Street, Minneapolis, MN 55407, USA. https://twitter.com/RavitejaGuddeti
| | - Timothy D Smith
- The Christ Hospital Heart and Vascular Institute, 2139 Auburn Avenue, Cincinnati OH 45219, USA. https://twitter.com/TimDSmithMD
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