Obesity hypoventilation syndrome in the critically ill

Noninvasive Mechanical Ventilation in Acute Ventilatory Failure: Rationale and Current Applications

Noninvasive ventilation plays a pivotal role in acute ventilator failure and has been shown, in certain disease processes such as acute exacerbation of chronic obstructive pulmonary disease, to prevent and shorten the duration of invasive mechanical ventilation, reducing the risks and complications associated with it. The application of noninvasive ventilation is relatively simple and well tolerated by patients and in the right setting can change the course of their illness.

IL-8 predicts early mortality in patients with acute hypercapnic respiratory failure treated with noninvasive positive pressure ventilation

Background

Patients with Acute Hypercapnic Respiratory Failure (AHRF) who are unresponsive to appropriate medical treatment, are often treated with Noninvasive Positive Pressure Ventilation (NPPV). Clinical predictors of the outcome of this treatment are scarce. Therefore, we evaluated the role of the biomarkers IL-8 and GDF-15 in predicting 28-day mortality in patients with AHRF who receive treatment with NPPV.

Methods

The study population were 46 patients treated with NPPV for AHRF. Clinical and background data was registered and blood samples taken for analysis of inflammatory biomarkers. IL-8 and GDF-15 were selected for analysis, and related to risk of 28-day mortality (primary endpoint) using Cox proportional hazard models adjusted for gender, age and various clinical parameters.

Results

Of the 46 patients, there were 3 subgroup in regards to primary diagnosis: Acute Exacerbation of COPD (AECOPD, n = 34), Acute Heart Failure (AHF, n = 8) and Acute Exacerbation in Obesity Hypoventilation Syndrome (AEOHS, n = 4). There was significant difference in the basic characteristic of the subgroups, but not in the clinical parameters that were used in treatment decisions. 13 patients died within 28 days of admission (28%). The Hazard Ratio for 28-days mortality per 1-SD increment of IL-8 was 3.88 (95% CI 1.86–8.06, p < 0.001). When IL-8 values were divided into tertiles, the highest tertile had a significant association with 28 days mortality, HR 10.02 (95% CI 1.24–80.77, p for trend 0.03), compared with the lowest tertile. This correlation was maintained when the largest subgroup with AECOPD was analyzed. GDF-15 was correlated in the same way, but when put into the same model as IL-8, the significance disappeared.

Conclusion

IL-8 is a target to explore further as a predictor of 28 days mortality, in patients with AHRF treated with NPPV.

Sepsis in Special Populations

Sepsis is recognized by the presence of physiologic and laboratory changes that reflect the inflammatory response to infection on cellular and systemic levels. Comorbid conditions, such as cirrhosis, end-stage renal disease, and obesity, alter patients' susceptibility to infection and their response to it once present. Baseline changes in vital signs and chronic medications often mask clues to the severity of illness. The physiologic, hematologic, and biochemical adjustments that accompany pregnancy and the puerperium introduce similar challenges. Emergency providers must remain vigilant for subtle alterations in the expected baseline for these conditions to arrive at appropriate management decisions.