Acute dyspnea in the emergency department: a clinical review

Enhancing Nursing Practices in Critical Care for Older Adults: A Systematic Review of Age-Friendly Nursing Interventions

OBJECTIVES

To synthesize evidence on the implementation and effectiveness of age-friendly interventions in intensive care units (ICUs) to optimize care for older adults.

DESIGN

Systematic review of studies published up to February 2024, focusing on interventions tailored to meet the needs of older adults in ICU settings.

SETTING AND PARTICIPANTS

Comparative studies conducted in ICUs worldwide, involving older adults receiving critical care, were reviewed.

METHODS

A systematic search of databases including Embase, MEDLINE, and Cochrane was performed. The quality of studies was assessed using the ROSVIS-II tool, and findings were synthesized narratively and thematically.

RESULTS

Out of 1200 articles initially identified, 45 studies met inclusion criteria. Age-friendly interventions (eg, geriatric assessment teams, multimodal care bundles) demonstrated significant benefits, including a 19% reduction in major in-hospital complications and shorter hospital stays by an average of 3 days.

CONCLUSIONS AND IMPLICATIONS

The review supports the effectiveness of age-friendly interventions in improving clinical outcomes for older ICU patients. However, consistent reporting of effect sizes was lacking, and more high-quality comparative effectiveness research is needed. Implications for practice include integrating these interventions into standard ICU protocols to enhance older adult care. Policy implications involve advocating for health care policies that support the dissemination and implementation of effective age-friendly practices. Further research should focus on establishing a robust evidence base to guide implementation and policy decisions.

Point-of-care ultrasound in nephrology: A private practice viewpoint

Point-of-care ultrasound (POCUS) is a limited ultrasound examination performed by the clinician at the bedside, emerging as a complement to physical examination across various medical specialties. In the field of nephrology, its integration has been gradual, primarily limited to guiding procedures like temporary dialysis catheter placement or, in some cases, diagnostic kidney ultrasounds. In reality, the assessment of hemodynamic status at the bedside holds immense value for nephrologists, yet there exists limited awareness among practitioners regarding its implementation. While there is a growing trend towards incorporating multi-organ POCUS training in fellowship programs, private practice nephrologists remain relatively uninformed. This discussion explores the untapped potential of POCUS as a valuable diagnostic tool in everyday nephrology practice, demonstrating its effectiveness in diverse clinical settings, ranging from medical wards to outpatient dialysis units. Additionally, we delve into the challenges hindering its widespread adoption and consider the future trajectory of this innovative approach.

Automatic B-lines: a tool for minimizing time to diuretic administration in pulmonary edema patients in the emergency department of a developing country

BACKGROUND

Effective management of pulmonary edema in the emergency department (ED) is crucial given its significant global impact on health. This study aimed to investigate the hypothesis: "Does the utilization of Automatic B-lines via ultrasonography in patients with pulmonary edema facilitate faster diuretic administration in a developing country?"

METHODS

This retrospective observational study was conducted at a tertiary academic center in Thailand. Patients with pulmonary edema admitted to the ED between January 2023 and June 2024 were enrolled. Ultrasound documentation and electronic ED medical records were compared to assess the time of diuretic administration between patients who had lung ultrasounds utilizing automatic B-lines and those who had manual B-lines counted by physician eye inspection. Multivariate logistic regression was employed to examine the relationship between the use of automatic B-lines and early diuretic administration.

RESULTS

The study included 134 patients with pulmonary edema. The time to diuretic administration was significantly shorter in the automatic B-lines group (median time [Q1-Q3], 55 min; range, 35-110 min) compared to the non-automatic B-lines group (median time, 100 min; range, 75-145 min). In the multivariable logistic regression analysis, early diuretic administration within 60 min of triage was significantly more likely in the automatic B-lines group (adjusted odds ratio, 1.45; 95% confidence interval, 1.10-2.45) than in the non-automatic B-lines group.

CONCLUSIONS

In a developing country, patients with pulmonary edema who had lung ultrasound evaluation with automated B lines experienced a fastest diuresis compared to those who utilized ultrasonography without automatic B lines. Implementing automatic B-lines as an early screening protocol could enhance clinical practice in the ED.

Non-invasive respiratory support in elderly hospitalized patients

INTRODUCTION

The proportion of elderly people among hospitalized patients is rapidly growing. Between 7% to 25% of ICU patients are aged 85 and over and noninvasive respiratory support is often offered to avoid the risks of invasive mechanical ventilation or in patients with a 'do-not-intubate' order. However, while noninvasive respiratory support has been extensively studied in the general population, there is limited data available on its efficacy in elderly patients with ARF.

AREAS COVERED

PubMed/Medline, Web of Science, Scopus and Embase online databases were searched for studies that assessed clinical efficacy of high flow nasal cannula, continuous positive airway pressure and noninvasive ventilation in patients ≥ 65 years old with acute de novo ARF, showing that short to mid-term benefits provided by noninvasive respiratory support in elderly patients in terms of reduction of mechanical ventilation risk and mortality are similar to younger patients, if adjusted for the severity of comorbidities and respiratory failure.

EXPERT OPINION

Noninvasive support strategies can represent an effective opportunity in elderly patients with ARF, especially in patients too frail to undergo endotracheal intubation and in whom received or decided for a 'do not intubate' order. Indeed, noninvasive support has a different impact, depending on the setting.

The occurrence mechanism, assessment, and non-pharmacological treatment of dyspnea

Dyspnea is a subjective sensation often described as a feeling of respiratory effort, tightness, or air hunger. The underlying mechanisms of this symptom are multifaceted and involve factors such as respiratory centers, cardiovascular system, airways, neuromuscular components, and metabolic factors, although not fully elucidated. The classical theory of imbalance between inspiratory neural drive (IND) and the simultaneous dynamic responses of the respiratory system posits that the disruption of a normal and harmonious relationship fundamentally shapes the expression of respiratory discomfort. Assessment and comprehensive treatment of dyspnea are crucial for patient rehabilitation, including subjective self-reporting and objective clinical measurements. Non-pharmacological interventions, such as pulmonary rehabilitation, fan therapy, exercise, chest wall vibration, virtual reality technology, traditional Chinese medicine (acupuncture and acupressure), and yoga, have shown promise in alleviating dyspnea symptoms. Additionally, oxygen therapy, has demonstrated short-term benefits for patients with pre-hospital respiratory distress and hypoxemia. This review provides a comprehensive overview of dyspnea, emphasizing the importance of a multifaceted approach for its assessment and management, with a focus on non-pharmacological interventions that contribute to enhanced patient outcomes and quality of life.

Non-invasive positive pressure ventilation can reduce perioperative mortality in acute aortic dissection patients with hypoxemia

Background

Hypoxemia is a common critical respiratory complication in patients with acute aortic dissection (AAD) before operation and results in adverse outcomes. This study aimed to identify the optimal oxygenation treatment for AAD patients with hypoxemia in the emergency department (ED).

Methods

This was a retrospective, observational, cohort study. We retrospectively collected data from 187 adult patients with AAD and hypoxemia who had been admitted to our ED. All patients were divided into nasal cannula group (n=91), Venturi mask group (n=60), and non-invasive positive pressure ventilation (NIPPV) group (n=36). The primary outcome was overall mortality in ED; the secondary outcomes were preoperative intubation rate and postoperative mortality, length of intensive care unit (ICU) stay, length of hospital stay, and length of intubation.

Results

Among all patients, those who received NIPPV treatment showed the lowest ED intubation rate (2.78%, P=0.004), shortest postoperative length of ICU stay (median 2.31, P<0.001), postoperative length of intubation (median 25.10, P<0.001), and post-operative length of hospital stay (median 21.00, P<0.001). Kaplan-Meier analysis showed the highest 3-day survival (log-rank 7.387, P=0.03) and 5-day survival (log-rank 14.710, P=0.001) in the NIPPV group. After adjustment, NIPPV therapy was independently associated with the reduced 3-day [adjusted hazard ratio (HR) 0.102, 95% confidence interval (CI): 0.013-0.791, P=0.03] and 5-day (adjusted HR 0.057, 95% CI: 0.008-0.427, P=0.005) mortality in ED.

Conclusions

Early utilization of NIPPV in AAD patients with hypoxemia in the ED can effectively decrease pre-operative intubation rate and perioperative mortality, and improve postoperative outcomes.

Respiratory Acidosis as a Diagnostic Clue in Symptomatic Epilepsy With Stroke Mimics: A Case Report

Stroke mimics are difficult to differentiate from each other. Symptomatic epilepsy can also occur, but it is necessary to perform a magnetic resonance imaging (MRI) scan to distinguish it from a stroke. Although respiratory acidosis has been reported to occur with partial-onset seizures due to prolonged apnea, respiratory acidosis is rarely suspected to be a sign of epilepsy. We report a case in which respiratory acidosis helped to diagnose symptomatic epilepsy with stroke mimics. The patient was a 52-year-old female who was brought to the emergency room with the chief complaint of difficulty in talking. When she visited the hospital, sensory aphasia was observed, and a computed tomography (CT) scan was performed. She vomited after the CT scan, and an arterial blood gas analysis showed a pH of 7.26 with a PaCO2 level of 71 mmHg, indicating respiratory acidosis. After the administration of diazepam, the seizures abated and her sensory aphasia improved. Later, an investigation of the patient's history revealed symptomatic epilepsy and discontinuation of antiepileptic drugs. If unexplained respiratory acidosis is noted in a patient with stroke mimics, a further investigation of the patient's history and physical examination may help to diagnose symptomatic epilepsy.