Respiratory Failure

Hypoxaemic respiratory failure and awake prone ventilation (HYPER-AP) - Protocol for randomized, controlled clinical trial

BACKGROUND

Awake prone positioning is studied extensively during Covid-19 pandemic, but there is very limited evidence on its utility in acute hypoxic respiratory failure caused by bacterial infections or other causes. The aim of our research is to evaluate the impact of awake prone positioning on outcomes in non-intubated adult patients with acute non-Covid19 hypoxemic respiratory failure.

METHODS

This is a multi-center randomized controlled trial (RCT) with a parallel-group design and a 1:1 allocation ratio. Adult patients, admitted to ICU and diagnosed with hypoxemic respiratory failure will be randomly allocated into intervention (awake prone position (APP)) or control group. Our hypothesis is that addition of awake prone positioning to standard oxygen, high flow oxygen therapy and non-invasive ventilation may reduce the need for mechanical ventilation in adult patients diagnosed with acute hypoxemic respiratory failure. Primary outcome is rate of endotracheal intubation; secondary outcomes include intensive care and hospital mortality, duration of mechanical ventilation, length of intensive care and hospital stay and health related quality of life post hospital discharge. Primary and secondary outcomes will be assessed at hospital discharge, 30, 90 days and 1 year following randomisation.

CONCLUSION

The Hyper-AP study will assess the superiority of awake prone positioning versus standard treatment in spontaneously breathing ICU patients diagnosed with hypoxaemic respiratory failure.

Transcutaneous carbon-dioxide partial pressure trends during six-minute walk test in patients with very severe COPD

BACKGROUND

Transcutaneous carbon-dioxide partial-pressure (T_CPCO₂) can be reliably measured and may be of clinical relevance in COPD. Changes in T_CPCO₂ and exercise-induced hypercapnia (EIH) during six-minute walk test (6MWT) need further investigation. We aimed (1) to define patterns of T_CPCO₂ trends during 6MWT and (2) to study determinants of CO2-retention and EIH.

METHODS

Sixty-two COPD patients (age: 63±8years, FEV1: 33±10%pred.) were recruited and T_CPCO2 was recorded by SenTec digital-monitoring-system during 6MWT.

RESULTS

Half of patients (50%) exhibited CO₂-retention (T_CPCO₂[Δ]>4mmHg); 26% preserved and 24% reduced T_CPCO₂. Nineteen (31%) patients presented EIH (T_CPCO₂>45mmHg). EIH was associated to higher baseline-P_CCO₂, worse FEV1, lower inspiratory-pressures, underweight/normal BMI, and pre-walk dyspnea. Stronger determinants of CO₂-retention were FEV1 and pre-walk dyspnea, whereas baseline-P_CCO₂ and pre-walk dyspnea better predict EIH.

CONCLUSIONS

PCO₂ response to 6MWT is highly heterogeneous; however, very low FEV1 and elevated baseline-P_CCO₂ together with pre-walk dyspnea increase the risk for CO₂-retention and EIH. Overweight-BMI seems to carry a protective effect against EIH in very severe COPD.

A systematic review of validated methods for identifying acute respiratory failure using administrative and claims data

PURPOSE

The Food and Drug Administration's (FDA) Mini-Sentinel pilot program initially aims to conduct active surveillance to refine safety signals that emerge for marketed medical products. A key facet of this surveillance is to develop and understand the validity of algorithms for identifying health outcomes of interest (HOIs) from administrative and claims data. This paper summarizes the process and findings of the algorithm review of acute respiratory failure (ARF).

METHODS

PubMed and Iowa Drug Information Service searches were conducted to identify citations applicable to the anaphylaxis HOI. Level 1 abstract reviews and Level 2 full-text reviews were conducted to find articles using administrative and claims data to identify ARF, including validation estimates of the coding algorithms.

RESULTS

Our search revealed a deficiency of literature focusing on ARF algorithms and validation estimates. Only two studies provided codes for ARF, each using related yet different ICD-9 codes (i.e., ICD-9 codes 518.8, "other diseases of lung," and 518.81, "acute respiratory failure"). Neither study provided validation estimates.

CONCLUSIONS

Research needs to be conducted on designing validation studies to test ARF algorithms and estimating their predictive power, sensitivity, and specificity.

The pathophysiology of emphysema: considerations for critical care nursing practice

Emphysema is caused by exposure to cigarette smoking as well as alpha(1)-antitrypsin deficiency. It has been estimated to cost the National Health Service (NHS) in excess of 800 million pounds per year in related health care costs. The challenges for Critical Care nurses are those associated with dynamic hyperinflation, Auto-PEEP, malnutrition and the weaning from invasive and non-invasive mechanical ventilation. In this paper we consider the impact of the pathophysiology of emphysema, its effects on other body systems as well as the impact acute exacerbations have when patients are admitted to the Intensive Care Unit.