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Kim G, Oh DK, Lee SY, Park MH, Lim CM. Impact of the timing of invasive mechanical ventilation in patients with sepsis: a multicenter cohort study. Crit Care 2024; 28:297. [PMID: 39252133 PMCID: PMC11385489 DOI: 10.1186/s13054-024-05064-1] [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: 02/04/2024] [Accepted: 08/10/2024] [Indexed: 09/11/2024] Open
Abstract
BACKGROUND The potential adverse effects associated with invasive mechanical ventilation (MV) can lead to delayed decisions on starting MV. We aimed to explore the association between the timing of MV and the clinical outcomes in patients with sepsis ventilated in intensive care unit (ICU). METHODS We analyzed data of adult patients with sepsis between September 2019 and December 2021. Data was collected through the Korean Sepsis Alliance from 20 hospitals in Korea. Patients who were admitted to ICU and received MV were included in the study. Patients were divided into 'early MV' and 'delayed MV' groups based on whether they were on MV on the first day of ICU admission or later. Propensity score matching was applied, and patients in the two groups were compared on a 1:1 ratio to overcome bias between the groups. Outcomes including ICU mortality, hospital mortality, length of hospital and ICU stay, and organ failure at ICU discharge were compared. RESULTS Out of 2440 patients on MV during ICU stay, 2119 'early MV' and 321 'delayed MV' cases were analyzed. The propensity score matching identified 295 patients in each group with similar baseline characteristics. ICU mortality was lower in 'early MV' group than 'delayed MV' group (36.3% vs. 46.4%; odds ratio, 0.66; 95% confidence interval, 0.47-0.93; p = 0.015). 'Early MV' group had lower in-hospital mortality, shorter ICU stay, and required tracheostomy less frequently than 'delayed MV' group. Multivariable logistic regression model identified 'early MV' as associated with lower ICU mortality (odds ratio, 0.38; 95% confidence interval, 0.29-0.50; p < 0.001). CONCLUSION In patients with sepsis ventilated in ICU, earlier start (first day of ICU admission) of MV may be associated with lower mortality.
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Affiliation(s)
- Gyungah Kim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Dong Kyu Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Su Yeon Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Mi Hyeon Park
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
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2
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Spinazzola G, Ferrone G, Michi T, Torrini F, Postorino S, Sbaraglia F, Gulmini L, Antonelli M, Conti G, Spadaro S. Focus on the Role of Non-Invasive Respiratory Support (NRS) during Palliative Care in Patients with Life-Limiting Respiratory Disease. J Clin Med 2024; 13:5165. [PMID: 39274381 PMCID: PMC11396473 DOI: 10.3390/jcm13175165] [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: 06/12/2024] [Revised: 08/24/2024] [Accepted: 08/27/2024] [Indexed: 09/16/2024] Open
Abstract
The management of patients with life-threatening respiratory disease in the ICU and at home has become increasingly of interest over the past decades. Growing knowledge supports the use of NRS, aimed at improving patient comfort and improving quality of life. However, its role during palliative care is not well defined, and evidence of support remains limited. The aim of this narrative review is to examine the recent evidence relating to the use of non-invasive respiratory support at the end of life, in order to clarify who benefits and when. The literature research was conducted on PubMed, using MeSH words. A review of the relevant literature showed that non-invasive respiratory support techniques for patients with life-limiting respiratory disease vary (from high-flow oxygen therapy to conventional oxygen therapy, from CPAP to NPPV) and each has precise indications. To date, from the hospital to the home setting, the monitoring and application of these respiratory support techniques have varied widely. In conclusion, the choice of respiratory support in this category of patients should be based on the technique that will optimize the comfort of the patient and improve the quality of their life. On the other hand, regarding monitoring, both telemedicine and ultrasound diagnostics help to satisfy the patient's wish to spend the last period of his life in the home environment, to avoid inappropriately aggressive diagnostic interventions, and to reduce the high costs of hospitalized procedures in this category of patients.
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Affiliation(s)
- Giorgia Spinazzola
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Giuliano Ferrone
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Teresa Michi
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Flavia Torrini
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Stefania Postorino
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Fabio Sbaraglia
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Loretta Gulmini
- Palliative Care/Hospice, University of Ferrara, 44100 Ferrara, Italy
| | - Massimo Antonelli
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Department of Translational Medicine, University of Ferrara, Azienda Ospedaliera-Universitaria di Ferrara, 44100 Ferrara, Italy
- Department of Anesthesia and Intensive Care, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Giorgio Conti
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Department of Translational Medicine, University of Ferrara, Azienda Ospedaliera-Universitaria di Ferrara, 44100 Ferrara, Italy
- Department of Anesthesia and Intensive Care, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Savino Spadaro
- Department of Translational Medicine, University of Ferrara, Azienda Ospedaliera-Universitaria di Ferrara, 44100 Ferrara, Italy
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3
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Steckert GV, Borba SA, Marchese GM, Medeiros FS, Garcia TS, Boniatti MM, Wawrzeniak IC. Respiratory mechanics characteristics at the time of barotrauma presentation in patients with critical COVID-19 infection. CRITICAL CARE SCIENCE 2024; 36:e20240248en. [PMID: 39230074 DOI: 10.62675/2965-2774.20240248-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 04/16/2024] [Indexed: 09/05/2024]
Abstract
OBJECTIVE To evaluate how ventilatory support, the duration of invasive ventilatory support use and lung mechanics are related to barotrauma development in patients who are severely infected with COVID-19 and who are admitted to the intensive care unit and develop pulmonary barotrauma. METHODS Retrospective cohort study of patients who were severely infected with COVID-19 and who developed pulmonary barotrauma secondary to mechanical ventilation. RESULTS This study included 60 patients with lung barotrauma who were divided into two groups: 37 with early barotrauma and 23 with late barotrauma. The early barotrauma group included more individuals who needed noninvasive ventilation (62.2% versus 26.1%, p = 0.01). The tidal volume/kg of predicted body weight on the day of barotrauma was measured, and 24 hours later, it was significantly greater in the late barotrauma group than in the early barotrauma group. During the day, barotrauma was accompanied by plateau pressure and driving pressure accompanied by tidal volume, which significantly increased in the late barotrauma group. According to the SAPS 3, patients in the early barotrauma group had more pulmonary thromboembolism and more severe illness. However, the intensive care unit mortality rates did not significantly differ between the two groups (66.7% for early barotrauma versus 76.9% for late barotrauma). CONCLUSION We investigated the effect of respiratory mechanics on barotrauma in patients with severe COVID-19 and found that 25% of patients were on nonprotective ventilation parameters when they developed barotrauma. However, 50% of patients were on protective ventilation parameters, suggesting that other nonventilatory factors may contribute to barotrauma.
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Affiliation(s)
- Gabriela Vieira Steckert
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul -Porto Alegre (RS), Brazil
| | - Sophia Andreola Borba
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul -Porto Alegre (RS), Brazil
| | | | | | - Tiago Severo Garcia
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul -Porto Alegre (RS), Brazil
| | - Marcio Manozzo Boniatti
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul -Porto Alegre (RS), Brazil
| | - Iuri Christmann Wawrzeniak
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul -Porto Alegre (RS), Brazil
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4
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Magdy DM. Outcome of Early Initiation of High-flow Nasal Oxygen Therapy among Pneumonia Patients Presenting with Acute Hypoxemic Respiratory Failure. Indian J Crit Care Med 2024; 28:753-759. [PMID: 39239186 PMCID: PMC11372677 DOI: 10.5005/jp-journals-10071-24769] [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: 05/08/2024] [Accepted: 06/30/2024] [Indexed: 09/07/2024] Open
Abstract
Background High-flow nasal oxygen (HFNO) therapy is an upcoming and beneficial modality for patients with acute hypoxemic respiratory failure (AHRF). Objectives To evaluate whether early use of HFNO in pneumonia patients with AHRF can reduce the need for invasive ventilation. Patients and methods In this prospective, randomized controlled trial, 160 patients who fulfilled the criteria were included. The patient's characteristics, sequential organ failure assessment score, and simplified acute physiology score were recorded. Respiratory rate (RR), and oxygenation parameters (PaO2/FiO2), and RR-oxygenation index at selected time intervals were collected and analyzed. The primary outcome was the number of patients who needed intubation. Secondary outcomes included length of intensive care unit (ICU) and hospital stay and mortality at day 28. Results The rate of intubation was not statistically significant between the two groups 15 vs 18.7%; difference 3.7% [(95% confidence interval (CI): 2.5-5.7%]. In 48-hour time periods, the mean PaO2/FiO2 ratio was significantly increased in the HFNO group compared with the non-invasive ventilation (NIV) group. The RRs and heart rate (HR) showed a significant decrease in the HFNO group.The length of ICU and hospital stays was not different between both groups. No significant differences were found in mortality rates between the HFNO and NIV groups 9 (11.2%) and 10 (12.5%), with 1.3% (95% CI: 0.7-3.8%) (p = 0.21). Multivariate analysis demonstrated that low baseline PaO2/FiO2, Respiratory rate-oxygenation index (ROX index) ≤ 5.4 measured at 12 hour and high severity scores were independent risk factors for intubation. Conclusion Treatment with HFNO did not reduce the need for intubation among patients with pneumonia-induced AHRF, despite the improved PaO2/FiO2 observed with HFNO compared with NIV. Clinical trial no NCT05809089. How to cite this article Magdy DM. Outcome of Early Initiation of High-flow Nasal Oxygen Therapy among Pneumonia Patients Presenting with Acute Hypoxemic Respiratory Failure. Indian J Crit Care Med 2024;28(8):753-759.
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Affiliation(s)
- Doaa M Magdy
- Department of Chest Diseases, Assiut University Hospital, Assiut, Egypt
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5
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Ferreyro BL, De Jong A, Grieco DL. How to use facemask noninvasive ventilation. Intensive Care Med 2024; 50:1346-1349. [PMID: 38801519 DOI: 10.1007/s00134-024-07471-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: 02/08/2024] [Accepted: 04/30/2024] [Indexed: 05/29/2024]
Affiliation(s)
- Bruno L Ferreyro
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Audrey De Jong
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhymedexpUniversité de Montpellier, InsermCNRSCHRU de Montpellier, Montpellier, France
| | - 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, L.Go F. Vito, 00168, Rome, Italy.
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6
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Marongiu I, Slobod D, Leali M, Spinelli E, Mauri T. Clinical and Experimental Evidence for Patient Self-Inflicted Lung Injury (P-SILI) and Bedside Monitoring. J Clin Med 2024; 13:4018. [PMID: 39064059 PMCID: PMC11278124 DOI: 10.3390/jcm13144018] [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: 06/17/2024] [Revised: 07/01/2024] [Accepted: 07/07/2024] [Indexed: 07/28/2024] Open
Abstract
Patient self-inflicted lung injury (P-SILI) is a major challenge for the ICU physician: although spontaneous breathing is associated with physiological benefits, in patients with acute respiratory distress syndrome (ARDS), the risk of uncontrolled inspiratory effort leading to additional injury needs to be assessed to avoid delayed intubation and increased mortality. In the present review, we analyze the available clinical and experimental evidence supporting the existence of lung injury caused by uncontrolled high inspiratory effort, we discuss the pathophysiological mechanisms by which increased effort causes P-SILI, and, finally, we consider the measurements and interpretation of bedside physiological measures of increased drive that should alert the clinician. The data presented in this review could help to recognize injurious respiratory patterns that may trigger P-SILI and to prevent it.
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Affiliation(s)
- Ines Marongiu
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (I.M.)
| | - Douglas Slobod
- Department of Critical Care Medicine, McGill University, Montreal, QC H4A 3J1, Canada
| | - Marco Leali
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (I.M.)
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (I.M.)
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
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7
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Kwizera A, Kabatoro D, Owachi D, Kansiime J, Kateregga G, Nanyunja D, Sendagire C, Nyakato D, Olaro C, Audureau E, Mekontso Dessap A. Respiratory support with standard low-flow oxygen therapy, high-flow oxygen therapy or continuous positive airway pressure in adults with acute hypoxaemic respiratory failure in a resource-limited setting: protocol for a randomised, open-label, clinical trial - the Acute Respiratory Intervention StudiEs in Africa (ARISE-AFRICA) study. BMJ Open 2024; 14:e082223. [PMID: 38951007 PMCID: PMC11218023 DOI: 10.1136/bmjopen-2023-082223] [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: 11/16/2023] [Accepted: 05/19/2024] [Indexed: 07/03/2024] Open
Abstract
RATIONALE Acute hypoxaemic respiratory failure (AHRF) is associated with high mortality in sub-Saharan Africa. This is at least in part due to critical care-related resource constraints including limited access to invasive mechanical ventilation and/or highly skilled acute care workers. Continuous positive airway pressure (CPAP) and high-flow oxygen by nasal cannula (HFNC) may prove useful to reduce intubation, and therefore, improve survival outcomes among critically ill patients, particularly in resource-limited settings, but data in such settings are lacking. The aim of this study is to determine whether CPAP or HFNC as compared with standard oxygen therapy, could reduce mortality among adults presenting with AHRF in a resource-limited setting. METHODS This is a prospective, multicentre, randomised, controlled, stepped wedge trial, in which patients presenting with AHRF in Uganda will be randomly assigned to standard oxygen therapy delivered through a face mask, HFNC oxygen or CPAP. The primary outcome is all-cause mortality at 28 days. Secondary outcomes include the number of patients with criteria for intubation at day 7, the number of patients intubated at day 28, ventilator-free days at day 28 and tolerance of each respiratory support. ETHICS AND DISSEMINATION The study has obtained ethical approval from the Research and Ethics Committee, School of Biomedical Sciences, College of Health Sciences, Makerere University as well as the Uganda National Council for Science and Technology. Patients will be included after informed consent. The results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04693403. PROTOCOL VERSION 8 September 2023; version 5.
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Affiliation(s)
- Arthur Kwizera
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Daphne Kabatoro
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Darius Owachi
- Department of Emergency Medicine, Kiruddu National Referral Hospital, Kampala, Uganda
| | - Jackson Kansiime
- Department of Internal Medicine, St Mary's Hospital, Gulu, Uganda
| | - George Kateregga
- Department of Anaesthesia and Intensive Care, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Doreen Nanyunja
- Department of Internal Medicine, China-Uganda Friendship Hospital Naguru, Kampala, Uganda
| | | | | | | | - Etienne Audureau
- CEPIA EA7376, Universite Paris-Est Creteil Val de Marne, Creteil, France
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8
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Giani M, Rezoagli E, Barbaro RP, Riera J, Bellani G, Brochard L, Combes A, Foti G, Brodie D. Noninvasive Ventilation Before Intubation and Mortality in Patients Receiving Extracorporeal Membrane Oxygenation for COVID-19: An Analysis of the Extracorporeal Life Support Organization Registry. ASAIO J 2024; 70:633-639. [PMID: 38237635 PMCID: PMC11210943 DOI: 10.1097/mat.0000000000002132] [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] [Indexed: 06/29/2024] Open
Abstract
Bilevel-positive airway pressure (BiPAP) is a noninvasive respiratory support modality which reduces effort in patients with respiratory failure. However, it may increase tidal ventilation and transpulmonary pressure, potentially aggravating lung injury. We aimed to assess if the use of BiPAP before intubation was associated with increased mortality in adult patients with coronavirus disease 2019 (COVID-19) who received venovenous extracorporeal membrane oxygenation (ECMO). We used the Extracorporeal Life Support Organization Registry to analyze adult patients with COVID-19 supported with venovenous ECMO from January 1, 2020, to December 31, 2021. Patients treated with BiPAP were compared with patients who received other modalities of respiratory support or no respiratory support. A total of 9,819 patients from 421 centers were included. A total of 3,882 of them (39.5%) were treated with BiPAP before endotracheal intubation. Patients supported with BiPAP were intubated later (4.3 vs . 3.3 days, p < 0.001) and showed higher unadjusted hospital mortality (51.7% vs. 44.9%, p < 0.001). The use of BiPAP before intubation and time from hospital admission to intubation resulted as independently associated with increased hospital mortality (odds ratio [OR], 1.32 [95% confidence interval {CI}, 1.08-1.61] and 1.03 [1-1.06] per day increase). In ECMO patients with severe acute respiratory failure due to COVID-19, the extended use of BiPAP before intubation should be regarded as a risk factor for mortality.
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Affiliation(s)
- Marco Giani
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Emanuele Rezoagli
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Ryan P. Barbaro
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Jordi Riera
- Division of Pediatric Critical Care Medicine and Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, Ann Arbor, Michigan
| | - Giacomo Bellani
- Critical Care Department, Hospital Universitario Vall d’Hebron, Barcelona, Spain
| | - Laurent Brochard
- SODIR, Vall d’Hebron Institut de Recerca, Barcelona, Spain
- CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Alain Combes
- Department of Medical Sciences, University of Trento, Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento, Italy
| | - Giuseppe Foti
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Daniel Brodie
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, Canada
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9
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Demoule A, Baptiste A, Thille AW, Similowski T, Ragot S, Prat G, Mercat A, Girault C, Carteaux G, Boulain T, Perbet S, Decavèle M, Belin L, Frat JP. Dyspnea is severe and associated with a higher intubation rate in de novo acute hypoxemic respiratory failure. Crit Care 2024; 28:174. [PMID: 38783367 PMCID: PMC11118550 DOI: 10.1186/s13054-024-04903-5] [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: 01/16/2024] [Accepted: 04/05/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Dyspnea is a key symptom of de novo acute hypoxemic respiratory failure. This study explores dyspnea and its association with intubation and mortality in this population. METHODS This was a secondary analysis of a multicenter, randomized, controlled trial. Dyspnea was quantified by a visual analog scale (dyspnea-VAS) from zero to 100 mm. Dyspnea was measured in 259 of the 310 patients included. Factors associated with intubation were assessed with a competing risks model taking into account ICU discharge. The Cox model was used to evaluate factors associated with 90-day mortality. RESULTS At baseline (randomization in the parent trial), median dyspnea-VAS was 46 (interquartile range, 16-65) mm and was ≥ 40 mm in 146 patients (56%). The intubation rate was 45%. Baseline variables independently associated with intubation were moderate (dyspnea-VAS 40-64 mm) and severe (dyspnea-VAS ≥ 65 mm) dyspnea at baseline (sHR 1.96 and 2.61, p = 0.023), systolic arterial pressure (sHR 2.56, p < 0.001), heart rate (sHR 1.94, p = 0.02) and PaO2/FiO2 (sHR 0.34, p = 0.028). 90-day mortality was 20%. The cumulative probability of survival was lower in patients with baseline dyspnea-VAS ≥ 40 mm (logrank test, p = 0.049). Variables independently associated with mortality were SAPS 2 ≥ 25 (p < 0.001), moderate-to-severe dyspnea at baseline (p = 0.073), PaO2/FiO2 (p = 0.118), and treatment arm (p = 0.046). CONCLUSIONS In patients admitted to the ICU for de novo acute hypoxemic respiratory failure, dyspnea is associated with a higher risk of intubation and with a higher mortality. TRIAL REGISTRATION clinicaltrials.gov Identifier # NCT01320384.
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Affiliation(s)
- Alexandre Demoule
- INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, 75005, Paris, France.
- Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation (Département R3S), Hôpital Universitaire Pitié-Salpêtrière, AP-HP, 47-83 Boulevard de L'Hôpital, 75651, Paris Cedex 13, France.
| | - Amandine Baptiste
- Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Unité de Recherche Clinique, AP-HP, Paris, France
| | - Arnaud W Thille
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
- Centre d'Investigation Clinique 1402 ALIVE, Université de Poitiers, Poitiers, France
| | - Thomas Similowski
- INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, 75005, Paris, France
- Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Département R3S, AP-HP, 75013, Paris, France
| | - Stephanie Ragot
- Centre d'Investigation Clinique 1402 ALIVE, Université de Poitiers, Poitiers, France
| | - Gwénael Prat
- Service de Médecine Intensive et Réanimation, CHU de Brest, Brest, France
| | - Alain Mercat
- Service de Réanimation médicale et Médecine Hyperbare, Centre Hospitalier Régional Universitaire, Angers, France
| | - Christophe Girault
- UNIROUEN, UR 3830, Medical Intensive Care Unit, Rouen University Hospital, Normandie University, Rouen, France
| | - Guillaume Carteaux
- Hôpitaux Universitaires Henri Mondor, Service de Médecine Intensive Réanimation, Université Paris Est Créteil, Groupe de Recherche Clinique CARMAS, AP-HP, Créteil, France
| | - Thierry Boulain
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire d'Orléans, Orléans, France
| | - Sébastien Perbet
- Réanimation Médico-Chirurgicale, CHU de Clermont-Ferrand, Clermont-Ferrand, France
- GReD, UMR/CNRS 6293, INSERM U1103, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Maxens Decavèle
- INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, 75005, Paris, France
- Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation (Département R3S), Hôpital Universitaire Pitié-Salpêtrière, AP-HP, 47-83 Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
| | - Lisa Belin
- Site Pitié-Salpêtrière, Département de Santé Publique, INSERM, Institut Pierre Louis d'Epidémiologie Et de Santé Publique, AP-HP, APHP-Sorbonne Université, Paris, France
| | - Jean-Pierre Frat
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
- Centre d'Investigation Clinique 1402 ALIVE, Université de Poitiers, Poitiers, France
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10
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Xu X, Ma M, Min Y, Hu W, Bai L, Duan J. PaCO 2 is nonlinearly associated with NIV failure in patients with hypoxemic respiratory failure. BMC Pulm Med 2024; 24:228. [PMID: 38730395 PMCID: PMC11088174 DOI: 10.1186/s12890-024-03023-8] [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: 03/05/2024] [Accepted: 04/18/2024] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVE To explore the association between PaCO2 and noninvasive ventilation (NIV) failure in patients with hypoxemic respiratory failure. METHODS A retrospective study was performed in a respiratory ICU of a teaching hospital. Patients admitted to ICU between 2011 and 2019 were screened. We enrolled the patients with hypoxemic respiratory failure. However, patients who used NIV due to acute-on-chronic respiratory failure or heart failure were excluded. Data before the use of NIV were collected. Requirement of intubation was defined as NIV failure. RESULTS A total of 1029 patients were enrolled in final analysis. The rate of NIV failure was 45% (461/1029). A nonlinear relationship between PaCO2 and NIV failure was found by restricted cubic splines (p = 0.03). The inflection point was 32 mmHg. The rate of NIV failure was 42% (224/535) in patients with PaCO2 >32 mmHg. However, it increased to 48% (237/494) in those with PaCO2 ≤ 32 mmHg. The crude and adjusted hazard ratio (HR) for NIV failure was 1.36 (95%CI:1.13-1.64) and 1.23(1.01-1.49), respectively, if the patients with PaCO2 >32 mmHg were set as reference. In patients with PaCO2 ≤ 32 mmHg, one unit increment of PaCO2 was associated with 5% reduction of NIV failure. However, it did not associate with NIV failure in patients with PaCO2 >32 mmHg. CONCLUSIONS PaCO2 and NIV failure was nonlinear relationship. The inflection point was 32 mmHg. Below the inflection point, lower PaCO2 was associated with higher NIV failure. However, it did not associate with NIV failure above this point.
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Affiliation(s)
- Xiaoping Xu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, P. R. China
| | - Mengyi Ma
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, P. R. China
| | - Yiwei Min
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, P. R. China
| | - Wenhui Hu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, P. R. China
| | - Linfu Bai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, P. R. China
| | - Jun Duan
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, P. R. China.
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11
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Luján M, Cinesi Gómez C, Peñuelas O, Ferrando C, Heili-Frades SB, Carratalá Perales JM, Mas A, Sayas Catalán J, Mediano O, Roca O, García Fernández J, González Varela A, Sempere Montes G, Rialp Cervera G, Hernández G, Millán T, Ferrer Monreal M, Egea Santaolalla C. Multidisciplinary Consensus on the Management of Non-Invasive Respiratory Support in the COVID-19 Patient. Arch Bronconeumol 2024; 60:285-295. [PMID: 38521646 DOI: 10.1016/j.arbres.2024.02.017] [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: 02/19/2024] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/25/2024]
Abstract
Acute respiratory failure due to COVID-19 pneumonia often requires a comprehensive approach that includes non-pharmacological strategies such as non-invasive support (including positive pressure modes, high flow therapy or awake proning) in addition to oxygen therapy, with the primary goal of avoiding endotracheal intubation. Clinical issues such as determining the optimal time to initiate non-invasive support, choosing the most appropriate modality (based not only on the acute clinical picture but also on comorbidities), establishing criteria for recognition of treatment failure and strategies to follow in this setting (including palliative care), or implementing de-escalation procedures when improvement occurs are of paramount importance in the ongoing management of severe COVID-19 cases. Organizational issues, such as the most appropriate setting for management and monitoring of the severe COVID-19 patient or protective measures to prevent virus spread to healthcare workers in the presence of aerosol-generating procedures, should also be considered. While many early clinical guidelines during the pandemic were based on previous experience with acute respiratory distress syndrome, the landscape has evolved since then. Today, we have a wealth of high-quality studies that support evidence-based recommendations to address these complex issues. This document, the result of a collaborative effort between four leading scientific societies (SEDAR, SEMES, SEMICYUC, SEPAR), draws on the experience of 25 experts in the field to synthesize knowledge to address pertinent clinical questions and refine the approach to patient care in the face of the challenges posed by severe COVID-19 infection.
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Affiliation(s)
- Manel Luján
- Servei de Pneumologia, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain; CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
| | - César Cinesi Gómez
- Servicio de Urgencias, Hospital General Universitario Reina Sofía, Murcia, Spain
| | - Oscar Peñuelas
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Servicio de Medicina Intensiva Hospital Universitario de Getafe, Madrid, Spain
| | - Carlos Ferrando
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Department of Anesthesia and Critical Care, Hospital Clínic, Institut D'investigació August Pi i Sunyer, Barcelona, Spain
| | - Sarah Béatrice Heili-Frades
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Hospital Universitario Fundación Jiménez Díaz Quirón Salud, Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD, UAM), CIBERES, REVA Network, Madrid, Spain
| | | | - Arantxa Mas
- Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain
| | | | - Olga Mediano
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Sleep Unit, Pneumology Department. Hospital Universitario de Guadalajara, Instituto de Investigación Sanitaria de Castilla la Mancha (IDISCAM), Universidad de Alcalá, Madrid, Spain
| | - Oriol Roca
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Servei de Medicina Intensiva, Parc Taulí Hospital Universitari, Institut de Recerca Parc Taulí-I3PT, Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Javier García Fernández
- Servicio de Anestesiología, UCI Quirúrgica y U. Dolor. H. U. Puerta de Hierro, Madrid, Spain
| | | | | | - Gemma Rialp Cervera
- Servicio de Medicina Intensiva, Hospital Universitari Son Llàtzer, Palma de Mallorca, Spain
| | - Gonzalo Hernández
- Servicio de Medicina Intensiva, Hospital Virgen de la Salud, Toledo, Spain
| | - Teresa Millán
- Servicio de Medicina Intensiva Hospital Universitario Son Espases, Facultad de Medicina de las Islas Baleares, Spain
| | - Miquel Ferrer Monreal
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; UVIIR, Servei de Pneumologia, Institut de Respiratori, Clínic Barcelona, IDIBAPS. Universitat de Barcelona, Barcelona, Spain
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12
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Mayaux J, Decavele M, Dres M, Lecronier M, Demoule A. [Non-invasive ventilation in acute respiratory failure of oncology-hematology patients: What are its current benefits and limitations?]. Rev Mal Respir 2024; 41:382-389. [PMID: 38609766 DOI: 10.1016/j.rmr.2024.03.005] [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: 04/12/2023] [Accepted: 08/04/2023] [Indexed: 04/14/2024]
Abstract
Acute respiratory failure (ARF) is a leading cause, along with sepsis, of admission to the intensive care unit (ICU) of patients with active cancer. Presenting variable clinical severity, ARF in onco-hematological patients has differing etiologies, primarily represented by possibly opportunistic acute infectious pneumonia (de novo hypoxemic ARF), and decompensation in chronic cardiac or respiratory diseases (e.g., acute pulmonary edema or exacerbated chronic obstructive pulmonary disease). In these patients, orotracheal intubation is associated with a doubled risk of in-hospital mortality. Consequently, over the last three decades, numerous researchers have attempted to demonstrate and pinpoint the precise role of non-invasive ventilation (NIV) in the specific context of ARF in onco-hematological patients. While the benefits of NIV in the management of acute pulmonary edema or alveolar hypoventilation (hypercapnic ARF) are well-demonstrated, its positioning in de novo hypoxemic ARF is debatable, and has recently been called into question. In the early 2000s, based on randomized controlled trials, NIV was recommended as first-line treatment, one reason being that it allowed significantly reduced use of orotracheal intubation. In the latest randomized studies, however, the benefits of NIV in terms of survival orotracheal intubation have not been observed; as a result, it is no longer recommended in the management of de novo hypoxemic ARF in onco-haematological patients.
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Affiliation(s)
- J Mayaux
- Service de médecine intensive et réanimation, département R3S - DMU APPROCHES, hôpital universitaire Pitié-Salpêtrière - Sorbonne université médecine, Paris, France.
| | - M Decavele
- Service de médecine intensive et réanimation, département R3S - DMU APPROCHES, hôpital universitaire Pitié-Salpêtrière - Sorbonne université médecine, Paris, France
| | - M Dres
- Service de médecine intensive et réanimation, département R3S - DMU APPROCHES, hôpital universitaire Pitié-Salpêtrière - Sorbonne université médecine, Paris, France
| | - M Lecronier
- Service de médecine intensive et réanimation, département R3S - DMU APPROCHES, hôpital universitaire Pitié-Salpêtrière - Sorbonne université médecine, Paris, France
| | - A Demoule
- Service de médecine intensive et réanimation, département R3S - DMU APPROCHES, hôpital universitaire Pitié-Salpêtrière - Sorbonne université médecine, Paris, France
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13
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Grotberg JC, Kraft BD, Sullivan M, Pawale AA, Kotkar KD, Masood MF. Advanced Respiratory Support Days as a Novel Marker of Mortality in COVID-19 Acute Respiratory Distress Syndrome Requiring Extracorporeal Membrane Oxygenation. ASAIO J 2024; 70:427-435. [PMID: 38295398 PMCID: PMC11062834 DOI: 10.1097/mat.0000000000002119] [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] [Indexed: 02/02/2024] Open
Abstract
Emerging evidence suggests prolonged use of noninvasive respiratory support may increase mortality of patients with coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome who require extracorporeal membrane oxygenation (ECMO). Using a database of adults receiving ECMO for COVID-19, we calculated survival curves and multivariable Cox regression to determine the risk of death associated with pre-ECMO use of high-flow nasal oxygen (HFNO), noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) days. We investigated the performance of a novel variable, advanced respiratory support days (composite of HFNO, NIV, and IMV days), on Respiratory ECMO Survival Prediction (RESP) score. Subjects (N = 146) with increasing advanced respiratory support days (<5, 5-9, and ≥10) had a stepwise increase in 90 day mortality (32.2%, 57.7%, and 75.4%, respectively; p = 0.002). Ninety-day mortality was significantly higher in subjects (N = 121) receiving NIV >4 days (81.8% vs. 52.4%, p < 0.001). Each additional pre-ECMO advanced respiratory support day increased the odds of right ventricular failure (odds ratio [OR]: 1.066, 95% confidence interval [CI]: 1.002-1.135) and in-hospital mortality (1.17, 95% CI: 1.08-1.27). Substituting advanced respiratory support days for IMV days improved RESP score mortality prediction (area under the curve (AUC) or: 0.64 vs. 0.71). Pre-ECMO advanced respiratory support days were associated with increased 90 day mortality compared with IMV days alone. Adjusting the RESP score for advanced respiratory support days improved mortality prediction.
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Affiliation(s)
- John C. Grotberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Bryan D. Kraft
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Mary Sullivan
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Amit A. Pawale
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Kunal D. Kotkar
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Muhammad F. Masood
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
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14
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Gatti S, Rezoagli E, Madotto F, Foti G, Bellani G. A non-invasive continuous and real-time volumetric monitoring in spontaneous breathing subjects based on bioimpedance-ExSpiron®Xi: a validation study in healthy volunteers. J Clin Monit Comput 2024; 38:539-551. [PMID: 38238635 PMCID: PMC10994998 DOI: 10.1007/s10877-023-01107-0] [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: 03/13/2023] [Accepted: 11/10/2023] [Indexed: 04/06/2024]
Abstract
Tidal volume (TV) monitoring breath-by-breath is not available at bedside in non-intubated patients. However, TV monitoring may be useful to evaluate the work of breathing. A non-invasive device based on bioimpedance provides continuous and real-time volumetric tidal estimation during spontaneous breathing. We performed a prospective study in healthy volunteers aimed at evaluating the accuracy, the precision and the trending ability of measurements of ExSpiron®Xi as compared with the gold standard (i.e. spirometry). Further, we explored whether the differences between the 2 devices would be improved by the calibration of ExSpiron®Xi with a pre-determined tidal volume. Analysis accounted for the repeated nature of measurements within each subject. We enrolled 13 healthy volunteers, including 5 men and 8 women. Tidal volume, TV/ideal body weight (IBW) and respiratory rate (RR) measured with spirometer (TVSpirometer) and with ExSpiron®Xi (TVExSpiron) showed a robust correlation, while minute ventilation (MV) showed a weak correlation, in both non/calibrated and calibrated steps. The analysis of the agreement showed that non-calibrated TVExSpiron underestimated TVspirometer, while in the calibrated steps, TVExSpiron overestimated TVspirometer. The calibration procedure did not reduce the average absolute difference (error) between TVSpirometer and TVExSpiron. This happened similarly for TV/IBW and MV, while RR showed high accuracy and precision. The trending ability was excellent for TV, TV/IBW and RR. The concordance rate (CR) was >95% in both calibrated and non-calibrated measurements. The trending ability of minute ventilation was limited. Absolute error for both calibrated and not calibrated values of TV, TV/IBW and MV accounting for repeated measurements was variably associated with BMI, height and smoking status. Conclusions: Non-invasive TV, TV/IBW and RR estimation by ExSpiron®Xi was strongly correlated with tidal ventilation according to the gold standard spirometer technique. This data was not confirmed for MV. The calibration of the device did not improve its performance. Although the accuracy of ExSpiron®Xi was mild and the precision was limited for TV, TV/IBW and MV, the trending ability of the device was strong specifically for TV, TV/IBW and RR. This makes ExSpiron®Xi a non-invasive monitoring system that may detect real-time tidal volume ventilation changes and then suggest the need to better optimize the patient ventilatory support.
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Affiliation(s)
- Stefano Gatti
- Department of Emergency and Intensive Care, Terapia Intensiva e Semintensiva adulti e Pediatrica, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Emanuele Rezoagli
- Department of Emergency and Intensive Care, Terapia Intensiva e Semintensiva adulti e Pediatrica, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Fabiana Madotto
- Department of Area Emergenza Urgenza, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Foti
- Department of Emergency and Intensive Care, Terapia Intensiva e Semintensiva adulti e Pediatrica, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Giacomo Bellani
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy.
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento Largo Medaglie d'Oro, Trento, Italy.
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15
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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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Mosier JM, Tidswell M, Wang HE. Noninvasive respiratory support in the emergency department: Controversies and state-of-the-art recommendations. J Am Coll Emerg Physicians Open 2024; 5:e13118. [PMID: 38464331 PMCID: PMC10920951 DOI: 10.1002/emp2.13118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/21/2024] [Accepted: 01/26/2024] [Indexed: 03/12/2024] Open
Abstract
Acute respiratory failure is a common reason for emergency department visits and hospital admissions. Diverse underlying physiologic abnormalities lead to unique aspects about the most common causes of acute respiratory failure: acute decompensated heart failure, acute exacerbation of chronic obstructive pulmonary disease, and acute de novo hypoxemic respiratory failure. Noninvasive respiratory support strategies are increasingly used methods to support work of breathing and improve gas exchange abnormalities to improve outcomes relative to conventional oxygen therapy or invasive mechanical ventilation. Noninvasive respiratory support includes noninvasive positive pressure ventilation and nasal high flow, each with unique physiologic mechanisms. This paper will review the physiology of respiratory failure and noninvasive respiratory support modalities and offer data and guideline-driven recommendations in the context of key clinical controversies.
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Affiliation(s)
- Jarrod M. Mosier
- Department of Emergency MedicineThe University of Arizona College of MedicineTucsonArizonaUSA
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Department of MedicineThe University of Arizona College of MedicineTucsonArizonaUSA
| | - Mark Tidswell
- Division of Pulmonary and Critical Care, Department of MedicineUniversity of Massachusetts Chan Medical School – Baystate Medical CenterSpringfieldMassachusettsUSA
| | - Henry E. Wang
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
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Fu W, Liu X, Guan L, Lin Z, He Z, Niu J, Huang Q, Liu Q, Chen R. Prognostic analysis of high-flow nasal cannula therapy and non-invasive ventilation in mild to moderate hypoxemia patients and construction of a machine learning model for 48-h intubation prediction-a retrospective analysis of the MIMIC database. Front Med (Lausanne) 2024; 11:1213169. [PMID: 38495114 PMCID: PMC10941954 DOI: 10.3389/fmed.2024.1213169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 02/13/2024] [Indexed: 03/19/2024] Open
Abstract
Background This study aims to investigate the clinical outcome between high-flow nasal cannula (HFNC) and non-invasive ventilation (NIV) therapy in mild to moderate hypoxemic patients on the first ICU day and to develop a predictive model of 48-h intubation. Methods The study included adult patients from the MIMIC III and IV databases who first initiated HFNC or NIV therapy due to mild to moderate hypoxemia (100 < PaO2/FiO2 ≤ 300). The 48-h and 30-day intubation rates were compared using cross-sectional and survival analysis. Nine machine learning and six ensemble algorithms were deployed to construct the 48-h intubation predictive models, of which the optimal model was determined by its prediction accuracy. The top 10 risk and protective factors were identified using the Shapley interpretation algorithm. Result A total of 123,042 patients were screened, of which, 673 were from the MIMIC IV database for ventilation therapy comparison (HFNC n = 363, NIV n = 310) and 48-h intubation predictive model construction (training dataset n = 471, internal validation set n = 202) and 408 were from the MIMIC III database for external validation. The NIV group had a lower intubation rate (23.1% vs. 16.1%, p = 0.001), ICU 28-day mortality (18.5% vs. 11.6%, p = 0.014), and in-hospital mortality (19.6% vs. 11.9%, p = 0.007) compared to the HFNC group. Survival analysis showed that the total and 48-h intubation rates were not significantly different. The ensemble AdaBoost decision tree model (internal and external validation set AUROC 0.878, 0.726) had the best predictive accuracy performance. The model Shapley algorithm showed Sequential Organ Failure Assessment (SOFA), acute physiology scores (APSIII), the minimum and maximum lactate value as risk factors for early failure and age, the maximum PaCO2 and PH value, Glasgow Coma Scale (GCS), the minimum PaO2/FiO2 ratio, and PaO2 value as protective factors. Conclusion NIV was associated with lower intubation rate and ICU 28-day and in-hospital mortality. Further survival analysis reinforced that the effect of NIV on the intubation rate might partly be attributed to the other impact factors. The ensemble AdaBoost decision tree model may assist clinicians in making clinical decisions, and early organ function support to improve patients' SOFA, APSIII, GCS, PaCO2, PaO2, PH, PaO2/FiO2 ratio, and lactate values can reduce the early failure rate and improve patient prognosis.
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Affiliation(s)
- Wei Fu
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Xiaoqing Liu
- Department of Critical Care Medicine, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Lili Guan
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Zhimin Lin
- Department of Critical Care Medicine, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Zhenfeng He
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jianyi Niu
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Qiaoyun Huang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Qi Liu
- Emergency Intensive Care Department, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Hena, China
| | - Rongchang Chen
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
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18
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Lepage-Farrell A, Tabone L, Plante V, Kawaguchi A, Feder J, Al Omar S, Emeriaud G. Noninvasive Neurally Adjusted Ventilatory Assist in Infants With Bronchiolitis: Respiratory Outcomes in a Single-Center, Retrospective Cohort, 2016-2018. Pediatr Crit Care Med 2024; 25:201-211. [PMID: 38019615 DOI: 10.1097/pcc.0000000000003407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
OBJECTIVES To describe our experience of using noninvasive neurally adjusted ventilatory assist (NIV-NAVA) in infants with bronchiolitis, its association with the evolution of respiratory effort, and PICU outcomes. DESIGN Retrospective analysis of a prospectively curated, high-frequency electronic database. SETTING A PICU in a university-affiliated maternal-child health center in Canada. PATIENTS Patients younger than 2 years old who were admitted with a diagnosis of acute bronchiolitis and treated with NIV-NAVA from October 2016 to June 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patient characteristics, as well as respiratory and physiologic parameters, including electrical diaphragmatic activity (Edi), were extracted from the electronic database. Respiratory effort was estimated using the modified Wood Clinical Asthma Score (mWCAS) and the inspiratory Edi. A comparison in the respiratory effort data was made between the 2 hours before and 2 hours after starting NIV-NAVA. In the two seasons, 64 of 205 bronchiolitis patients were supported with NIV-NAVA. These 64 patients had a median (interquartile range [IQR]) age of 52 days (32-92 d), and there were 36 of 64 males. Treatment with NIV-NAVA was used after failure of first-tier noninvasive respiratory support; 25 of 64 patients (39%) had at least one medical comorbidity. NIV-NAVA initiation was associated with a moderate decrease in mWCAS from 3.0 (IQR, 2.5-3.5) to 2.5 (IQR, 2.0-3.0; p < 0.001). NIV-NAVA initiation was also associated with a statistically significant decrease in Edi ( p < 0.01). However, this decrease was only clinically relevant in infants with a 2-hour baseline Edi greater than 20 μV; here, the before and after Edi was 44 μV (IQR, 33-54 μV) compared with 27 μV (IQR, 21-36 μV), respectively ( p < 0.001). Overall, six of 64 patients (9%) required endotracheal intubation. CONCLUSIONS In this single-center retrospective cohort, in infants with bronchiolitis who were considered to have failed first-tier noninvasive respiratory support, the use of NIV-NAVA was associated with a rapid decrease in respiratory effort and a 9% intubation rate.
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Affiliation(s)
- Alex Lepage-Farrell
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
- Department of Pediatrics, London Children's Hospital, Western University, London, ON, Canada
| | - Laurence Tabone
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
- Pediatric Intensive Care and Pediatric Emergency Department, CHU Clocheville, Tours, France
| | - Virginie Plante
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Atsushi Kawaguchi
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
- Department of Pediatrics, Pediatric Critical Care, St Marianna University, Kawasaki, Japan
| | - Joshua Feder
- Department of Pediatrics, Pediatric Intensive Care Unit, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - Sally Al Omar
- CHU Sainte Justine Research Center, Université de Montréal, Montreal, QC, Canada
| | - Guillaume Emeriaud
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
- CHU Sainte Justine Research Center, Université de Montréal, Montreal, QC, Canada
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19
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Nagata K, Yokoyama T, Tsugitomi R, Nakashima H, Kuraishi H, Ohshimo S, Mori Y, Sakuraya M, Kagami R, Tanigawa M, Tobino K, Kamo T, Kadowaki T, Koga Y, Ogata Y, Nishimura N, Kondoh Y, Taniuchi S, Shintani A, Tomii K. Continuous positive airway pressure versus high-flow nasal cannula oxygen therapy for acute hypoxemic respiratory failure: A randomized controlled trial. Respirology 2024; 29:36-45. [PMID: 37648252 DOI: 10.1111/resp.14588] [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: 02/01/2023] [Accepted: 08/16/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND AND OBJECTIVE The relative effectiveness of initial non-invasive respiratory strategies for acute respiratory failure using continuous positive airway pressure (CPAP) or high-flow nasal cannula (HFNC) is unclear. METHODS We conducted a multicenter, open-label, parallel-group randomized controlled trial to compare the efficacy of CPAP and HFNC on reducing the risk of meeting the prespecified criteria for intubation and improving clinical outcomes of acute hypoxemic respiratory failure. The primary endpoint was the time taken to meet the prespecified criteria for intubation within 28 days. RESULTS Eighty-five patients were randomly assigned to the CPAP or HFNC group. Eleven (28.9%) in the CPAP group and twenty (42.6%) in the HFNC group met the criteria for intubation within 28 days. Compared with HFNC, CPAP reduced the risk of meeting the intubation criteria (hazard ratio [HR], 0.327; 95% CI, 0.148-0.724; p = 0.006). There were no significant between-group differences in the intubation rates, in-hospital and 28-day mortality rates, ventilator-free days, duration of the need for respiratory support, or duration of hospitalization for respiratory illness. Pulmonary oxygenation was significantly better in the CPAP group, with significantly lower pH and higher partial pressure of carbon dioxide, but there were no differences in the respiratory rate between groups. CPAP and HFNC were associated with few possibly causal adverse events. CONCLUSION CPAP is more effective than HFNC at reducing the risk of meeting the intubation criteria in patients with acute hypoxemic respiratory failure.
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Affiliation(s)
- Kazuma Nagata
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Toshiki Yokoyama
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Ryosuke Tsugitomi
- Department of Pulmonary Medicine, Thoracic Center, St. Luke's International Hospital, Chuo City, Tokyo, Japan
| | - Harunori Nakashima
- Department of Respiratory Medicine, Ogaki Municipal Hospital, Ogaki, Gifu, Japan
| | - Hiroshi Kuraishi
- Department of Pulmonary Medicine, Nagano Red Cross Hospital, Nagano, Nagano, Japan
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Hiroshima, Japan
| | - Yoshihiro Mori
- Department of Respiratory Medicine, KKR Takamatsu Hospital, Takamatsu, Kagawa, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hiroshima, Hiroshima, Japan
| | - Ryogo Kagami
- Department of Pulmonary Medicine, National Hospital Organization Himeji Medical Center, Himeji, Hyogo, Japan
| | - Motoaki Tanigawa
- Department of Respiratory Medicine, Japanese Red Cross Ise Hospital, Ise, Mie, Japan
| | - Kazunori Tobino
- Department of Respiratory Medicine, Iizuka Hospital, Iizuka, Fukuoka, Japan
| | - Tetsuro Kamo
- Department of Respiratory Medicine, Saiseikai Utsunomiya Hospital, Utsunomiya, Tochigi, Japan
| | - Toru Kadowaki
- Department of Pulmonary Medicine, National Hospital Organization Matsue Medical Center, Matsue, Shimane, Japan
| | - Yasutaka Koga
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, Yamaguchi, Japan
| | - Yoshitaka Ogata
- Department of Critical Care Medicine, Yao Tokushukai General Hospital, Yao, Osaka, Japan
| | - Naoki Nishimura
- Department of Pulmonary Medicine, Thoracic Center, St. Luke's International Hospital, Chuo City, Tokyo, Japan
| | - Yasuhiro Kondoh
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Satsuki Taniuchi
- Department of Medical Statistics, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Osaka, Japan
| | - Ayumi Shintani
- Department of Medical Statistics, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Osaka, Japan
| | - Keisuke Tomii
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
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20
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Chiappero C, Mattei A, Guidelli L, Millotti S, Ceccherini E, Oczkowski S, Scala R. Prone positioning during CPAP therapy in SARS-CoV-2 pneumonia: a concise clinical review. Ther Adv Respir Dis 2024; 18:17534666231219630. [PMID: 38159215 PMCID: PMC10757797 DOI: 10.1177/17534666231219630] [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: 07/03/2023] [Accepted: 11/23/2023] [Indexed: 01/03/2024] Open
Abstract
During the COVID-19 pandemic, the number of patients with hypoxemic acute respiratory failure (ARF) due to SARS-CoV-2 pneumonia threatened to overwhelm intensive care units. To reduce the need for invasive mechanical ventilation (IMV), clinicians tried noninvasive strategies to manage ARF, including the use of awake prone positioning (PP) with continuous positive airway pressure (CPAP). In this article, we review the patho-physiologic rationale, clinical effectiveness and practical issues of the use of PP during CPAP in non-intubated, spontaneously breathing patients affected by SARS-CoV-2 pneumonia with ARF. Use of PP during CPAP appears to be safe and feasible and may have a lower rate of adverse events compared to IMV. A better response to PP is observed among patients in early phases of acute respiratory distress syndrome. While PP during CPAP may improve oxygenation, the impact on the need for intubation and mortality remains unclear. It is possible to speculate on the role of PP during CPAP in terms of improvement of ventilation mechanics and reduction of strain stress.
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Affiliation(s)
- Chiara Chiappero
- Cardiovascular and Thoracic Department, Pneumology, AOU Città della Salute e della Scienza di Torino – Molinette hospital, c.so Bramante 88, Turin 10126, Italy
| | - Alessio Mattei
- Cardiovascular and Thoracic Department, Pneumology, AOU Città della Salute e della Scienza di Torino – Molinette hospital, Turin, Italy
| | - Luca Guidelli
- CardioThoraco-Neuro-Vascular Department, Pulmonology and RICU, S Donato Hospital USL Toscana Sudest, Arezzo, Italy
| | - Serena Millotti
- UOP RF Arezzo, Department of Healthcare technical professions, Rehabilitation and Prevention, USL Toscana Sudest, Arezzo, Italy
| | - Emiliano Ceccherini
- UOP RF Arezzo, Department of Healthcare technical professions, Rehabilitation and Prevention, USL Toscana Sudest, Arezzo, Italy
| | - Simon Oczkowski
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Raffaele Scala
- CardioThoraco-Neuro-Vascular Department, Pulmonology and RICU, S Donato Hospital USL Toscana Sudest, Arezzo, Italy
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21
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Watson A, Yadollahi S, Fahmy A, Mahar S, Fritche D, Beecham R, Saeed K, Dushianthan A. Non-Invasive Ventilation for Community-Acquired Pneumonia: Outcomes and Predictors of Failure from an ICU Cohort. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:81. [PMID: 38256342 PMCID: PMC10821344 DOI: 10.3390/medicina60010081] [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: 12/02/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: The use of non-invasive ventilation (NIV) for community-acquired pneumonia (CAP) remains controversial. NIV failure in the setting of acute hypoxemic respiratory failure is associated with increased mortality, highlighting the need for careful patient selection. Methods and Methods: This is a retrospective observational cohort study. We included 140 patients with severe CAP, treated with either NIV or invasive mechanical ventilation (IMV) as their primary oxygenation strategy. Results: The median PaO2/FiO2 ratio and SOFA score upon ICU admission were 151 mmHg and 6, respectively. We managed 76% of patients with NIV initially and report an NIV success rate of 59%. Overall, the 28-day mortality was 25%, whilst for patients with NIV success, the mortality was significantly lower at 13%. In the univariate analysis, NIV failure was associated with the SOFA score (OR 1.33), the HACOR score (OR 1.14) and the presence of septic shock (OR 3.99). The SOFA score has an AUC of 0.75 for NIV failure upon ICU admission, whilst HACOR has an AUC of 0.76 after 2 h of NIV. Conclusions: Our results suggest that a SOFA ≤ 4 and an HACOR ≤ 5 are reasonable thresholds to identify patients with severe CAP likely to benefit from NIV.
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Affiliation(s)
- Adam Watson
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (A.W.); (S.M.); (R.B.)
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK; (D.F.); (K.S.)
| | - Sina Yadollahi
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (A.W.); (S.M.); (R.B.)
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK; (D.F.); (K.S.)
| | - Alexander Fahmy
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (A.W.); (S.M.); (R.B.)
| | - Sania Mahar
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (A.W.); (S.M.); (R.B.)
| | - Dominic Fritche
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK; (D.F.); (K.S.)
| | - Ryan Beecham
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (A.W.); (S.M.); (R.B.)
| | - Kordo Saeed
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK; (D.F.); (K.S.)
- Department of Microbiology, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Ahilanandan Dushianthan
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (A.W.); (S.M.); (R.B.)
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK; (D.F.); (K.S.)
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
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22
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Chiappero C, Misseri G, Mattei A, Ippolito M, Albera C, Pivetta E, Cortegiani A, Gregoretti C. Effectiveness and safety of a new helmet CPAP configuration allowing tidal volume monitoring in patients with COVID-19. Pulmonology 2023; 29 Suppl 4:S9-S17. [PMID: 34326019 PMCID: PMC8266523 DOI: 10.1016/j.pulmoe.2021.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/28/2021] [Accepted: 06/30/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND High generated tidal volumes (Vt) have been correlated with higher risk of self-induced lung injury and worse clinical outcome. This study aimed to evaluate the effectiveness and safety of a new helmet continuous positive airway pressure delivered (h-CPAP) configuration allowing Vt monitoring in patients affected by COVID-19. METHODS This prospective observational study was performed in the respiratory intermediate care unit of University Hospital in Turin, Italy, between March 24th, and June 15th, 2020. Included patients were treated with CPAP via a single-limb intentional leak configuration by a turbine-driven ventilator, provided with a dedicated patch. Effectiveness and safety of the configuration and healthcare workers safety were the outcomes of the study. MAIN FINDINGS Thirty-five patients were included in this study. Median age was 67 years (IQR 57-76 years), and 30 patients (85.7%) were men. Median value of overall leaks (intentional plus unintentional) was 68 L/min (IQR 63-75). Reliability of Vt measurements was 100%. An out of scale of Vt (above 50% compared to the previous values) was never recorded. Six patients (17.1%) needed more than two helmet replacements, due to leak test >10 l/min. Arm oedema and skin breakdowns were reported in sixteen (45.7%) and seven (20%) patients respectively. Among the 63 healthcare workers involved in the care of COVID-19 patients during the study only one was positive at RT-PCR nasopharyngeal swab testing. CONCLUSIONS The use of h-CPAP for treating COVID-19 in this configuration allowed for reliable Vt monitoring. Further studies evaluating this configuration in larger patients' cohorts are needed.
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Affiliation(s)
- C Chiappero
- Pneumology, Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino - Molinette hospital, Turin, Italy
| | | | - A Mattei
- Pneumology, Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino - Molinette hospital, Turin, Italy
| | - M Ippolito
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.). University of Palermo, Italy
| | - C Albera
- Pneumology, Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino - Molinette hospital, Turin, Italy; University of Turin, School of Medicine, Department of Medical Sciences, Italy
| | - E Pivetta
- Division of Emergency Medicine and High Dependency Unit, Department of General and Specialized Medicine, AOU Città della Salute e della Scienza di Torino - Molinette hospital, Turin, Italy
| | - A Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.). University of Palermo, Italy; Department of Anaesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy.
| | - C Gregoretti
- Fondazione "Giglio", Cefalù, Italy; Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.). University of Palermo, Italy
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23
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Coppadoro A, Bellani G, Foti G. A technique to measure tidal volume during noninvasive respiratory support by continuous-flow helmet CPAP. J Clin Monit Comput 2023; 37:1473-1479. [PMID: 37329389 PMCID: PMC10651536 DOI: 10.1007/s10877-023-01034-0] [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: 11/29/2022] [Accepted: 05/12/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE The coronavirus disease 2019 (COVID-19) pandemic has promoted the use of helmet continuous positive airway pressure (CPAP) for noninvasive respiratory support in hypoxic respiratory failure patients, despite the lack of tidal volume monitoring. We evaluated a novel technique designed to measure tidal volume during noninvasive continuous-flow helmet CPAP. METHODS A bench model of spontaneously breathing patients undergoing helmet CPAP therapy (three positive end-expiratory pressure [PEEP] levels) at different levels of respiratory distress was used to compare measured and reference tidal volumes. Tidal volume measurement by the novel technique was based on helmet outflow-trace analysis. Helmet inflow was increased from 60 to 75 and 90 L/min to match the patient's peak inspiratory flow; an additional subset of tests was conducted under the condition of purposely insufficient inflow (i.e., high respiratory distress and 60 L/min inflow). RESULTS The tidal volumes examined herein ranged from 250 to 910 mL. The Bland‒Altman analysis showed a bias of -3.2 ± 29.3 mL for measured tidal volumes compared to the reference, corresponding to an average relative error of -1 ± 4.4%. Tidal volume underestimation correlated with respiratory rate (rho = .411, p = .004) but not with peak inspiratory flow, distress, or PEEP. When the helmet inflow was maintained purposely low, tidal volume underestimation occurred (bias - 93.3 ± 83.9 mL), corresponding to an error of -14.8 ± 6.3%. CONCLUSION Tidal volume measurement is feasible and accurate during bench continuous-flow helmet CPAP therapy by the analysis of the outflow signal, provided that helmet inflow is adequate to match the patient's inspiratory efforts. Insufficient inflow resulted in tidal volume underestimation. In vivo data are needed to confirm these findings.
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Affiliation(s)
- Andrea Coppadoro
- Department of Anesthesia and Intensive care, San Gerardo Hospital, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - 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
| | - Giuseppe Foti
- Department of Anesthesia and Intensive care, San Gerardo Hospital, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
- Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB, Italy.
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24
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Artaud-Macari E, Le Bouar G, Maris J, Dantoing E, Vatignez T, Girault C. [Ventilatory management of SARS-CoV-2 acute respiratory failure]. Rev Mal Respir 2023; 40:751-767. [PMID: 37865564 DOI: 10.1016/j.rmr.2023.09.005] [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] [Accepted: 09/19/2023] [Indexed: 10/23/2023]
Abstract
COVID-19 pneumonia presents several particularities in its clinical presentation (cytokine storm, silent hypoxemia, thrombo-embolic risk) and may lead to a number of acute respiratory distress syndrome (ARDS) phenotypes. While the optimal oxygenation strategy in cases of hypoxemic acute respiratory failure (ARF) is still under debate, ventilatory management of COVID-19-related ARF has confirmed the efficacy of high-flow oxygen therapy and restored interest in other ventilatory approaches such as continuous positive airway pressure (CPAP) and noninvasive ventilation involving a helmet, which due to patient overflow are sometimes implemented outside of critical care units. However, further studies are still needed to determine which patients should be given which oxygenation technique, and under which conditions they require invasive mechanical ventilation, given that delayed initiation potentially burdens prognosis. During invasive mechanical ventilation, ventral decubitus and extracorporeal membrane oxygenation have become increasingly prevalent. While innovative therapies such as awake prone position or lung transplantation have likewise been developed, their indications, modalities and efficacy remain to be determined.
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Affiliation(s)
- E Artaud-Macari
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France; UNIROUEN, UR-3830, Normandie université, CHU de Rouen, 76000 Rouen, France.
| | - G Le Bouar
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France
| | - J Maris
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France
| | - E Dantoing
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France
| | - T Vatignez
- Service de médecine intensive et réanimation, CHU de Rouen, 76000 Rouen, France
| | - C Girault
- UNIROUEN, UR-3830, Normandie université, CHU de Rouen, 76000 Rouen, France; Service de médecine intensive et réanimation, CHU de Rouen, 76000 Rouen, France
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25
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Tonelli R, Castaniere I, Cortegiani A, Tabbì L, Fantini R, Andrisani D, Gozzi F, Moretti A, Bruzzi G, Manicardi L, Cerbone C, Nani C, Biagioni E, Cerri S, Samarelli V, Busani S, Girardis M, Marchioni A, Clini E. Inspiratory Effort and Respiratory Mechanics in Patients with Acute Exacerbation of Idiopathic Pulmonary fibrosis: A Preliminary Matched Control Study. Pulmonology 2023; 29:469-477. [PMID: 36180352 DOI: 10.1016/j.pulmoe.2022.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 08/03/2022] [Accepted: 08/04/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Patients with acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) may experience severe acute respiratory failure, even requiring ventilatory assistance. Physiological data on lung mechanics during these events are lacking. METHODS Patients with AE-IPF admitted to Respiratory Intensive Care Unit to receive non-invasive ventilation (NIV) were retrospectively analyzed. Esophageal pressure swing (ΔPes) and respiratory mechanics before and after 2 hours of NIV were collected as primary outcome. The correlation between positive end-expiratory pressure (PEEP) levels and changes of in dynamic compliance (dynCRS) and PaO2/FiO2 ratio was assessed. Further, an exploratory comparison with a historical cohort of ARDS patients matched 1:1 by age, sequential organ failure assessment score, body mass index and PaO2/FiO2 level was performed. RESULTS At baseline, AE-IPF patients presented a high respiratory drive activation with ΔPes = 27 (21-34) cmH2O, respiratory rate (RR) = 34 (30-39) bpm and minute ventilation (VE) = 21 (20-26) L/min. Two hours after NIV application, ΔPes, RR and VE values showed a significant reduction (16 [14-24] cmH2O, p<0.0001, 27 [25-30] bpm, p=0.001, and 18 [17-20] L/min, p=0.003, respectively) while no significant change was found in dynamic transpulmonary pressure, expiratory tidal volume (Vte), dynCRS and dynamic mechanical power. PEEP levels negatively correlated with PaO2/FiO2 ratio and dynCRS (r=-0.67, p=0.03 and r=-0.27, p=0.4, respectively). When compared to AE-IPF, ARDS patients presented lower baseline ΔPes, RR, VE and dynamic mechanical power. Differently from AE-IPF, in ARDS both Vte and dynCRS increased significantly following NIV (p=0.01 and p=0.004 respectively) with PEEP levels directly associated with PaO2/FiO2 ratio and dynCRS (r=0.24, p=0.5 and r=0.65, p=0.04, respectively). CONCLUSIONS In this study, patients with AE-IPF showed a high inspiratory effort, whose intensity was reduced by NIV application without a significant improvement in respiratory mechanics. In an exploratory analysis, AE-IPF patients showed a different mechanical behavior under spontaneous unassisted and assisted breathing compared with ARDS patients of similar severity.
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Affiliation(s)
- R Tonelli
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena Reggio Emilia, Modena, Italy; Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children & Adults University Hospital of Modena and Reggio Emilia, Italy
| | - I Castaniere
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena Reggio Emilia, Modena, Italy; Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children & Adults University Hospital of Modena and Reggio Emilia, Italy
| | - A Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy; Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
| | - L Tabbì
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - R Fantini
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - D Andrisani
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena Reggio Emilia, Modena, Italy; Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children & Adults University Hospital of Modena and Reggio Emilia, Italy
| | - F Gozzi
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena Reggio Emilia, Modena, Italy; Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children & Adults University Hospital of Modena and Reggio Emilia, Italy
| | - A Moretti
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy; Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children & Adults University Hospital of Modena and Reggio Emilia, Italy
| | - G Bruzzi
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy; Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children & Adults University Hospital of Modena and Reggio Emilia, Italy
| | - L Manicardi
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy; Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children & Adults University Hospital of Modena and Reggio Emilia, Italy
| | - C Cerbone
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - C Nani
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - E Biagioni
- Intensive Care Unit, University Hospital of Modena, Italy
| | - S Cerri
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy; Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children & Adults University Hospital of Modena and Reggio Emilia, Italy
| | - V Samarelli
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy; Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children & Adults University Hospital of Modena and Reggio Emilia, Italy
| | - S Busani
- Intensive Care Unit, University Hospital of Modena, Italy
| | - M Girardis
- Intensive Care Unit, University Hospital of Modena, Italy
| | - A Marchioni
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy; Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children & Adults University Hospital of Modena and Reggio Emilia, Italy.
| | - E Clini
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy; Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children & Adults University Hospital of Modena and Reggio Emilia, Italy
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Saunders H, Khadka S, Shrestha R, Balavenkataraman A, Hochwald A, Ball C, Helgeson SA. The Association between Non-Invasive Ventilation and the Rate of Ventilator-Associated Pneumonia. Diseases 2023; 11:151. [PMID: 37987262 PMCID: PMC10660719 DOI: 10.3390/diseases11040151] [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: 08/31/2023] [Revised: 10/17/2023] [Accepted: 10/25/2023] [Indexed: 11/22/2023] Open
Abstract
Ventilator-associated pneumonia (VAP) has significant effects on patient outcomes, including prolonging the duration of both mechanical ventilation and stay in the intensive care unit (ICU). The aim of this study was to assess the association between non-invasive ventilation/oxygenation (NIVO) prior to intubation and the rate of subsequent VAP. This was a multicenter retrospective cohort study of adult patients who were admitted to the medical ICU from three tertiary care academic centers in three distinct regions. NIVO was defined as continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), or high-flow nasal cannula (HFNC) for any duration during the hospitalization prior to intubation. The primary outcome variable was VAP association with NIVO. A total of 17,302 patients were included. VAP developed in 2.6% of the patients (444/17,302), 2.3% (285/12,518) of patients among those who did not have NIVO, 1.6% (30/1879) of patients who had CPAP, 2.5% (17/690) of patients who had HFNC, 8.1% (16/197) of patients who had BiPAP, and 4.8% (96/2018) of patients who had a combination of NIVO types. Compared to those who did not have NIVO, VAP was more likely to develop among those who had BiPAP (adj OR 3.11, 95% CI 1.80-5.37, p < 0.001) or a combination of NIVO types (adj OR 1.91, 95% CI 1.49-2.44, p < 0.001) after adjusting for patient demographics and comorbidities. The use of BiPAP or a combination of NIVO types significantly increases the odds of developing VAP once receiving IMV.
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Affiliation(s)
- Hollie Saunders
- Department of Pulmonary and Critical Care, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA; (S.K.); (R.S.); (A.B.)
| | - Subekshya Khadka
- Department of Pulmonary and Critical Care, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA; (S.K.); (R.S.); (A.B.)
| | - Rabi Shrestha
- Department of Pulmonary and Critical Care, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA; (S.K.); (R.S.); (A.B.)
| | - Arvind Balavenkataraman
- Department of Pulmonary and Critical Care, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA; (S.K.); (R.S.); (A.B.)
| | - Alexander Hochwald
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Colleen Ball
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Scott A. Helgeson
- Department of Pulmonary and Critical Care, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA; (S.K.); (R.S.); (A.B.)
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Kramer D, Hilton R, Roman J. Pulmonary fibrosis and COVID-19. Am J Med Sci 2023; 366:245-253. [PMID: 37481205 DOI: 10.1016/j.amjms.2023.07.006] [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: 04/08/2023] [Revised: 07/10/2023] [Accepted: 07/17/2023] [Indexed: 07/24/2023]
Abstract
The COVID-19 pandemic has caused the death of millions and many more have been infected worldwide. The causative virus, SARS-CoV-2, affects the lung where it elicits an aggressive inflammatory response leading to respiratory failure in severe cases. This infection has been linked to pulmonary fibrosis, a process characterized by fibroproliferation and the exaggerated deposition of collagen and other extracellular matrices. These events damage the lung architecture, especially its gas-exchanging units, leading to hypoxemic respiratory failure. The mechanisms by which the virus affects the lung remain incompletely understood, but it is postulated that after entering the airways, the virus binds to Angiotensin Converting Enzyme (ACE) receptors on the surface of epithelial cells, not only stimulating oxidative stress and inflammation, but also promoting the expression of soluble pro-fibrotic factors responsible for the accumulation of fibroblasts, their activation into myofibroblasts, and their unregulated expression of extracellular matrices. These events may trigger the rapid progression or exacerbation of underlying interstitial lung disorders or promote fibrosis in a previously healthy lung. Although the natural progression of such conditions cannot always be predicted, fibrosis may progress even after the virus has been eliminated or, in cases where it does not progress, may become irreversible, leading to long-standing symptoms like shortness of breath and exercise intolerance resulting from loss of lung function. Although COVID-19 related pulmonary fibrosis is not common, preventive measures like vaccination are encouraged, as they are expected to reduce infection or its severity, thereby decreasing the possibility of life-changing respiratory conditions such as pulmonary fibrosis.
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Affiliation(s)
- Daniel Kramer
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine; Jane & Leonard Korman Respiratory Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert Hilton
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine; Jane & Leonard Korman Respiratory Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jesse Roman
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine; Jane & Leonard Korman Respiratory Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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28
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Sakuraya M. Lung-Protective Concept and Noninvasive Respiratory Support. Chest 2023; 164:814-815. [PMID: 37805237 DOI: 10.1016/j.chest.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/11/2023] [Indexed: 10/09/2023] Open
Affiliation(s)
- Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hatsukaichi, Hiroshima, Japan.
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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: 5] [Impact Index Per Article: 5.0] [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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30
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Feng X, Wang D, Pan Q, Yan M, Liu X, Shen Y, Fang L, Cai G, Ning G. Reinforcement Learning Model for Managing Noninvasive Ventilation Switching Policy. IEEE J Biomed Health Inform 2023; 27:4120-4130. [PMID: 37159312 DOI: 10.1109/jbhi.2023.3274568] [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: 05/11/2023]
Abstract
Noninvasive ventilation (NIV) has been recognized as a first-line treatment for respiratory failure in patients with chronic obstructive pulmonary disease (COPD) and hypercapnia respiratory failure, which can reduce mortality and burden of intubation. However, during the long-term NIV process, failure to respond to NIV may cause overtreatment or delayed intubation, which is associated with increased mortality or costs. Optimal strategies for switching regime in the course of NIV treatment remain to be explored.For the goal of reducing 28-day mortality of the patients undergoing NIV, Double Dueling Deep Q Network (D3QN) of offline-reinforcement learning algorithm was adopted to develop an optimal regime model for making treatment decisions of discontinuing ventilation, continuing NIV, or intubation. The model was trained and tested using the data from Multi-Parameter Intelligent Monitoring in Intensive Care III (MIMIC-III) and evaluated by the practical strategies. Furthermore, the applicability of the model in majority disease subgroups (Catalogued by International Classification of Diseases, ICD) was investigated. Compared with physician's strategies, the proposed model achieved a higher expected return score (4.25 vs. 2.68) and its recommended treatments reduced the expected mortality from 27.82% to 25.44% in all NIV cases. In particular, for these patients finally received intubation in practice, if the model also supported the regime, it would warn of switching to intubation 13.36 hours earlier than clinicians (8.64 vs. 22 hours after the NIV treatment), granting a 21.7% reduction in estimated mortality. In addition, the model was applicable across various disease groups with distinguished achievement in dealing with respiratory disorders. The proposed model is promising to dynamically provide personalized optimal NIV switching regime for patients undergoing NIV with the potential of improving treatment outcomes.
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Motes A, Singh T, Vinan Vega N, Nugent K. A Focused Review of the Initial Management of Patients with Acute Respiratory Distress Syndrome. J Clin Med 2023; 12:4650. [PMID: 37510765 PMCID: PMC10380732 DOI: 10.3390/jcm12144650] [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: 05/05/2023] [Revised: 06/24/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
At present, the management of patients with acute respiratory distress syndrome (ARDS) largely focuses on ventilator settings to limit intrathoracic pressures by using low tidal volumes and on FiO2/PEEP relationships to maintain optimal gas exchange. Acute respiratory distress syndrome is a complex medical disorder that can develop in several primary acute disorders, has a rapid time course, and has several classifications that can reflect either the degree of hypoxemia, the extent of radiographic involvement, or the underlying pathogenesis. The identification of subtypes of patients with ARDS would potentially make precision medicine possible in these patients. This is a very difficult challenge given the heterogeneity in the clinical presentation, pathogenesis, and treatment responses in these patients. The analysis of large databases of patients with acute respiratory failure using statistical methods such as cluster analysis could identify phenotypes that have different outcomes or treatment strategies. However, clinical information available on presentation is unlikely to separate patients into groups that allow for secure treatment decisions or outcome predictions. In some patients, non-invasive positive pressure ventilation provides adequate support through episodes of acute respiratory failure, and the development of specialized units to manage patients with this support might lead to the better use of hospital resources. Patients with ARDS have capillary leak, which results in interstitial and alveolar edema. Early attention to fluid balance in these patients might improve gas exchange and alter the pathophysiology underlying the development of severe ARDS. Finally, more attention to the interaction of patients with ventilators through complex monitoring systems has the potential to identify ventilator dyssynchrony, leading to ventilator adjustments and potentially better outcomes. Recent studies with COVID-19 patients provide tentative answers to some of these questions. In addition, expert clinical investigators have analyzed the promise and difficulties associated with the development of precision medicine in patients with ARDS.
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Affiliation(s)
- Arunee Motes
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Tushi Singh
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Noella Vinan Vega
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Kenneth Nugent
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
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32
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Brochard LJ. Mechanical Ventilation: Negative to Positive and Back Again. Crit Care Clin 2023; 39:437-449. [PMID: 37230549 DOI: 10.1016/j.ccc.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Critical care and mechanical ventilation have a relatively brief history in medicine. Premises existed through the seventeenth to nineteenth centuries but modern mechanical ventilation started in the twentieth century. Noninvasive ventilation techniques had started both in the intensive care unit and for home ventilation at the end of the 1980s and the 1990s. The need for mechanical ventilation is increasingly influenced worldwide by the spread of respiratory viruses, and the last coronavirus disease 2019 pandemic has seen a massive successful use of noninvasive ventilation.
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Affiliation(s)
- Laurent J Brochard
- Keenan Research Centre, St Michael's Hospital, Unity Health Toronto, 209 Victoria Street, Room 4-08, Toronto, Ontario M5B 1T8, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
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33
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McNicholas BA, Ibarra-Estrada M, Perez Y, Li J, Pavlov I, Kharat A, Vines DL, Roca O, Cosgrave D, Guerin C, Ehrmann S, Laffey JG. Awake prone positioning in acute hypoxaemic respiratory failure. Eur Respir Rev 2023; 32:32/168/220245. [PMID: 37137508 PMCID: PMC10155045 DOI: 10.1183/16000617.0245-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/22/2023] [Indexed: 05/05/2023] Open
Abstract
Awake prone positioning (APP) of patients with acute hypoxaemic respiratory failure gained considerable attention during the early phases of the coronavirus disease 2019 (COVID-19) pandemic. Prior to the pandemic, reports of APP were limited to case series in patients with influenza and in immunocompromised patients, with encouraging results in terms of tolerance and oxygenation improvement. Prone positioning of awake patients with acute hypoxaemic respiratory failure appears to result in many of the same physiological changes improving oxygenation seen in invasively ventilated patients with moderate-severe acute respiratory distress syndrome. A number of randomised controlled studies published on patients with varying severity of COVID-19 have reported apparently contrasting outcomes. However, there is consistent evidence that more hypoxaemic patients requiring advanced respiratory support, who are managed in higher care environments and who can be prone for several hours, benefit most from APP use. We review the physiological basis by which prone positioning results in changes in lung mechanics and gas exchange and summarise the latest evidence base for APP primarily in COVID-19. We examine the key factors that influence the success of APP, the optimal target populations for APP and the key unknowns that will shape future research.
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Affiliation(s)
- Bairbre A McNicholas
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland
| | - Miguel Ibarra-Estrada
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - Yonatan Perez
- Clinical Investigation Center, INSERM 1415, CHRU Tours, Tours, France
- Médecine Intensive Réanimation, CHRU Tours, Tours, France
- Médecine Intensive Réanimation, Hôpital de Hautepierre, Hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
| | - Ivan Pavlov
- Department of Emergency Medicine, Hôpital de Verdun, Montréal, QC, Canada
| | - Aileen Kharat
- Department of Respiratory Medicine, Geneva University Hospital, Geneva, Switzerland
| | - David L Vines
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
| | - Oriol Roca
- Servei de Medicina Intensiva, Parc Taulí Hospital Universitari, Sabadell, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - David Cosgrave
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland
| | - Claude Guerin
- University of Lyon, Lyon and INSERM 955, Créteil, France
| | - Stephan Ehrmann
- Clinical Investigation Center, INSERM 1415, CHRU Tours, Tours, France
- Médecine Intensive Réanimation, CHRU Tours, Tours, France
| | - John G Laffey
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland
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Zhou X, Pan J, Wang H, Xu Z, Zhao L, Chen B. Prophylactic noninvasive respiratory support in the immediate postoperative period after cardiac surgery - a systematic review and network meta-analysis. BMC Pulm Med 2023; 23:233. [PMID: 37380968 DOI: 10.1186/s12890-023-02525-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 06/17/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Noninvasive respiratory support has been increasingly applied in the immediate postoperative period to prevent postoperative pulmonary complications (PPCs). However, the optimal approach remains uncertain. We sought to evaluate the comparative effectiveness of various noninvasive respiratory strategies used in the immediate postoperative period after cardiac surgery. METHODS We conducted a frequentist random-effect network meta-analysis (NMA) of randomized controlled trials (RCTs) comparing the prophylactic use of noninvasive ventilation (NIV), continuous positive airway pressure (CPAP), high flow nasal cannula (HFNC), or postoperative usual care (PUC) in the immediate postoperative period after cardiac surgery. Databases were systematically searched through September 28, 2022. Study selection, data extraction, and quality assessment were performed in duplicate. The primary outcome was the incidence of PPCs. RESULTS Sixteen RCTs enrolling 3011 patients were included. Compared with PUC, NIV significantly reduced the incidence of PPCs [relative risk (RR) 0.67, 95% confidence interval (CI): 0.49 to 0.93; absolute risk reduction (ARR) 7.6%, 95% CI: 1.6-11.8%; low certainty] and the incidence of atelectasis (RR 0.65, 95% CI: 0.45 to 0.93; ARR 19.3%, 95% CI: 3.9-30.4%; moderate certainty); however, prophylactic NIV was not associated with a decreased reintubation rate (RR 0.82, 95% CI: 0.29 to 2.34; low certainty) or reduced short-term mortality (RR 0.64, 95% CI: 0.16 to 2.52; very low certainty). As compared to PUC, the preventive use of CPAP (RR 0.85, 95% CI: 0.60 to 1.20; very low certainty) or HFNC (RR 0.74, 95% CI: 0.46 to 1.20; low certainty) had no significant beneficial effect on the incidence of PPCs, despite exhibiting a downward trend. Based on the surface under the cumulative ranking curve, the highest-ranked treatment for reducing the incidence of PPCs was NIV (83.0%), followed by HFNC (62.5%), CPAP (44.3%), and PUC (10.2%). CONCLUSIONS Current evidence suggest that the prophylactic use of NIV in the immediate postoperative period is probably the most effective noninvasive respiratory approach to prevent PPCs in patients undergoing cardiac surgery. Given the overall low certainty of the evidence, further high-quality research is warranted to better understand the relative benefits of each noninvasive ventilatory support. CLINICAL TRIAL REGISTRATION PROSPERO, https://www.crd.york.ac.uk/prospero/ , registry number: CRD42022303904.
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Affiliation(s)
- Xiaoyang Zhou
- Department of Intensive Care Medicine, Ningbo No.2 Hospital, Ningbo, 315000, Zhejiang, China
| | - Jianneng Pan
- Department of Intensive Care Medicine, Ningbo No.2 Hospital, Ningbo, 315000, Zhejiang, China
| | - Hua Wang
- Department of Intensive Care Medicine, Ningbo No.2 Hospital, Ningbo, 315000, Zhejiang, China
| | - Zhaojun Xu
- Department of Intensive Care Medicine, Ningbo No.2 Hospital, Ningbo, 315000, Zhejiang, China
| | - Long Zhao
- Department of Cardiovascular Surgery, Ningbo No.2 Hospital, Ningbo, Ningbo, 315000, Zhejiang, China
| | - Bixin Chen
- Department of Intensive Care Medicine, Ningbo No.2 Hospital, Ningbo, 315000, Zhejiang, China.
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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 PMCID: PMC10342961 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 (T.M.); (M.C.); (T.R.); (G.P.); (L.S.M.); (E.R.); (V.G.); (G.B.); (M.A.)
- 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 (T.M.); (M.C.); (T.R.); (G.P.); (L.S.M.); (E.R.); (V.G.); (G.B.); (M.A.)
- 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 (T.M.); (M.C.); (T.R.); (G.P.); (L.S.M.); (E.R.); (V.G.); (G.B.); (M.A.)
- 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 (T.M.); (M.C.); (T.R.); (G.P.); (L.S.M.); (E.R.); (V.G.); (G.B.); (M.A.)
- 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 (T.M.); (M.C.); (T.R.); (G.P.); (L.S.M.); (E.R.); (V.G.); (G.B.); (M.A.)
- 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 (T.M.); (M.C.); (T.R.); (G.P.); (L.S.M.); (E.R.); (V.G.); (G.B.); (M.A.)
- 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 (T.M.); (M.C.); (T.R.); (G.P.); (L.S.M.); (E.R.); (V.G.); (G.B.); (M.A.)
- 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 (T.M.); (M.C.); (T.R.); (G.P.); (L.S.M.); (E.R.); (V.G.); (G.B.); (M.A.)
- 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 (T.M.); (M.C.); (T.R.); (G.P.); (L.S.M.); (E.R.); (V.G.); (G.B.); (M.A.)
- 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 (T.M.); (M.C.); (T.R.); (G.P.); (L.S.M.); (E.R.); (V.G.); (G.B.); (M.A.)
- 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 (T.M.); (M.C.); (T.R.); (G.P.); (L.S.M.); (E.R.); (V.G.); (G.B.); (M.A.)
- 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 (T.M.); (M.C.); (T.R.); (G.P.); (L.S.M.); (E.R.); (V.G.); (G.B.); (M.A.)
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Musso G, Taliano C, De Iuliis M, Paschetta E, Fonti C, Ferraris A, Druetta M, Vianou IS, Ranghino F, Riedo F, Deangelis D, Tirabassi G. Mechanical power normalized to aerated lung predicts noninvasive ventilation failure and death and contributes to the benefits of proning in COVID-19 hypoxemic respiratory failure. EPMA J 2023:1-39. [PMID: 37359998 PMCID: PMC10256581 DOI: 10.1007/s13167-023-00325-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 05/15/2023] [Indexed: 06/28/2023]
Abstract
Background Concern exists that noninvasive ventilation (NIV) may promote ventilation-induced lung injury(VILI) and worsen outcome in acute hypoxemic respiratory failure (AHRF). Different individual ventilatory variables have been proposed to predict clinical outcomes, with inconsistent results.Mechanical power (MP), a measure of the energy transfer rate from the ventilator to the respiratory system during mechanical ventilation, might provide solutions for this issue in the framework of predictive, preventive and personalized medicine (PPPM). We explored (1) the impact of ventilator-delivered MP normalized to well-aerated lung (MPWAL) on physio-anatomical and clinical responses to NIV in COVID-19-related AHRF and (2) the effect of prone position(PP) on MPWAL. Methods We analyzed 216 noninvasively ventilated COVID-19 patients (108 patients receiving PP + NIV and 108 propensity score-matched patients receiving supine NIV) with moderate-to-severe(paO2/FiO2 ratio < 200) AHRF enrolled in the PRO-NIV controlled non-randomized study (ISRCTN23016116).Quantification of differentially aerated lung volumes by lung ultrasonography (LUS) was validated against CT scans. Respiratory parameters were hourly recorded, ABG were performed 1 h after each postural change. Time-weighed average values of ventilatory variables, including MPWAL, and gas exchange parameters (paO2/FiO2 ratio, dead space indices) were calculated for each ventilatory session. LUS and circulating biomarkers were assessed daily. Results Compared with supine position, PP was associated with a 34% MPWAL reduction, attributable largely to an absolute MP reduction and secondly to an enhanced lung reaeration.Patients receiving a high MPWAL during the 1st 24 h of NIV [MPWAL(day 1)] had higher 28-d NIV failure (HR = 4.33,95%CI:3.09 - 5.98) and death (HR = 5.17,95%CI: 3.01 - 7.35) risks than those receiving a low MPWAL(day 1).In Cox multivariate analyses, MPWAL(day 1) remained independently associated with 28-d NIV failure (HR = 1.68,95%CI:1.15-2.41) and death (HR = 1.69,95%CI:1.22-2.32).MPWAL(day 1) outperformed other power measures and ventilatory variables as predictor of 28-d NIV failure (AUROC = 0.89;95%CI:0.85-0.93) and death (AUROC = 0.89;95%CI:0.85-0.94).MPWAL(day 1) predicted also gas exchange, ultrasonographic and inflammatory biomarker responses, as markers of VILI, on linear multivariate analysis. Conclusions In the framework of PPPM, early bedside MPWAL calculation may provide added value to predict response to NIV and guide subsequent therapeutic choices i.e. prone position adoption during NIV or upgrading to invasive ventilation, to reduce hazardous MPWAL delivery, prevent VILI progression and improve clinical outcomes in COVID-19-related AHRF. Supplementary Information The online version contains supplementary material available at 10.1007/s13167-023-00325-5.
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Affiliation(s)
- Giovanni Musso
- Emergency Medicine Department, San Luigi Gonzaga Hospital, Regione Gonzole 10, Orbassano, 10043 Turin, TO Italy
| | - Claudio Taliano
- Emergency Medicine Department, HUMANITAS Gradenigo, Turin, Italy
| | | | - Elena Paschetta
- Emergency Medicine Department, HUMANITAS Gradenigo, Turin, Italy
| | - Caterina Fonti
- Emergency Medicine Department, San Luigi Gonzaga Hospital, Regione Gonzole 10, Orbassano, 10043 Turin, TO Italy
| | | | - Marta Druetta
- Emergency Medicine Department, HUMANITAS Gradenigo, Turin, Italy
| | | | | | - Federica Riedo
- Emergency Medicine Department, HUMANITAS Gradenigo, Turin, Italy
| | - Davide Deangelis
- Emergency Medicine Department, HUMANITAS Gradenigo, Turin, Italy
| | - Gloria Tirabassi
- Department of Biomedical Sciences, HUMANITAS University, Via Rita Levi Montalcini 4, 20072 Milan, Pieve Emanuele Italy
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Aswanetmanee P, Limsuwat C, Maneechotesuwan K, Wongsurakiat P. Noninvasive ventilation in patients with acute hypoxemic respiratory failure: a systematic review and meta-analysis of randomized controlled trials. Sci Rep 2023; 13:8283. [PMID: 37217643 DOI: 10.1038/s41598-023-35323-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 05/16/2023] [Indexed: 05/24/2023] Open
Abstract
The clinical benefits of noninvasive ventilation (NIV) for patients with acute hypoxemic respiratory failure (AHRF) is still inconclusive. We aimed to evaluate the effect of NIV compared with conventional oxygen therapy (COT)/high-flow nasal cannula (HFNC) in this patient population. We searched for relevant studies from PubMed, Embase, Cochrane Library, ClinicalTrials.gov, CINHAL, Web of Science up to August 2019 for randomized controlled trials (RCTs) that compared NIV with COT/HFNC in AHRF. The primary outcome was the tracheal intubation rate. Secondary outcomes were intensive care unit (ICU) mortality, and hospital mortality. We applied the GRADE approach to grade the strength of the evidence. Seventeen RCTs that recruited 1738 patients were included in our meta-analysis. When comparing NIV versus COT/HFNC, the pooled risk ratio (RR) for the tracheal intubation rate was 0.68, 95% confidence interval (CI) 0.52-0.89, p = 0.005, I2 = 72.4%, low certainty of evidence. There were no significant differences in ICU mortality (pooled RR = 0.87, 95% CI 0.60-1.26), p = 0.45, I2 = 64.6%) and hospital mortality (pooled RR = 0.71, 95% CI 0.51-1.00, p = 0.05, I2 = 27.4%). Subgroup analysis revealed that NIV application with helmet was significantly associated with a lower intubation rate than NIV with face mask. NIV did not show a significant reduction in intubation rate compared to HFNC. In conclusion, NIV application in patients with medical illness and AHRF was associated with a lower risk of tracheal intubation compared to COT. NIV with helmet and HFNC are promising strategies to avoid tracheal intubation in this patient population and warrant further studies. NIV application had no effect on mortality.The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42018087342).
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Affiliation(s)
- Pantaree Aswanetmanee
- Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Chok Limsuwat
- Pulmonary and Critical Care Department, Bumrungrad International Hospital, Khet Watthana, Bangkok, 10110, Thailand
| | - Kittipong Maneechotesuwan
- Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Phunsup Wongsurakiat
- Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.
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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: 28] [Impact Index Per Article: 28.0] [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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Nurok M, Friedman O, Driver M, Sun N, Kumaresan A, Chen P, Cheng S, Talmor DS, Ebinger J. Mechanically Ventilated Patients With Coronavirus Disease 2019 Had a Higher Chance of In-Hospital Death If Treated With High-Flow Nasal Cannula Oxygen Before Intubation. Anesth Analg 2023; 136:692-698. [PMID: 36730796 PMCID: PMC9990488 DOI: 10.1213/ane.0000000000006211] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The impact of high-flow nasal cannula (HFNC) on outcomes of patients with respiratory failure from coronavirus disease 2019 (COVID-19) is unknown. We sought to assess whether exposure to HFNC before intubation was associated with successful extubation and in-hospital mortality compared to patients receiving intubation only. METHODS This single-center retrospective study examined patients with COVID-19-related respiratory failure from March 2020 to March 2021 who required HFNC, intubation, or both. Data were abstracted from the electronic health record. Use and duration of HFNC and intubation were examined' as well as demographics and clinical characteristics. We assessed the association between HFNC before intubation (versus without) and chance of successful extubation and in-hospital death using Cox proportional hazards models adjusting for age, sex, race/ethnicity, obesity, hypertension, diabetes, prior chronic obstructive pulmonary disease or asthma, HCO 3 , CO 2 , oxygen-saturation-to-inspired-oxygen (S:F) ratio, pulse, respiratory rate, temperature, and length of stay before intervention. RESULTS A total of n = 440 patients were identified, of whom 311 (70.7%) received HFNC before intubation, and 129 (29.3%) were intubated without prior use of HFNC. Patients who received HFNC before intubation had a higher chance of in-hospital death (hazard ratio [HR], 2.08; 95% confidence interval [CI], 1.06-4.05). No difference was found in the chance of successful extubation between the 2 groups (0.70, 0.41-1.20). CONCLUSIONS Among patients with respiratory failure from COVID-19 requiring mechanical ventilation, patients receiving HFNC before intubation had a higher chance of in-hospital death. Decisions on initial respiratory support modality should weigh the risks of intubation with potential increased mortality associated with HFNC.
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Affiliation(s)
- Michael Nurok
- From the Departments of Anesthesiology and Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Oren Friedman
- Department of Medicine, Intensive Care Unit, Marina del Rey Hospital, Division of Pulmonary & Critical Care Medicine, Cedars-Sinai Health System and Medical Center, Los Angeles, California
| | - Matthew Driver
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nancy Sun
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Abirami Kumaresan
- From the Departments of Anesthesiology and Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Peter Chen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Women's Guild Lung Institute, Cedars-Sinai Medical Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Susan Cheng
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel S Talmor
- Department of Anesthesia, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Joseph Ebinger
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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Mechanical Power Ratio and Respiratory Treatment Escalation in COVID-19 Pneumonia: A Secondary Analysis of a Prospectively Enrolled Cohort. Anesthesiology 2023; 138:289-298. [PMID: 36571571 PMCID: PMC9904389 DOI: 10.1097/aln.0000000000004465] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Under the hypothesis that mechanical power ratio could identify the spontaneously breathing patients with a higher risk of respiratory failure, this study assessed lung mechanics in nonintubated patients with COVID-19 pneumonia, aiming to (1) describe their characteristics; (2) compare lung mechanics between patients who received respiratory treatment escalation and those who did not; and (3) identify variables associated with the need for respiratory treatment escalation. METHODS Secondary analysis of prospectively enrolled cohort involving 111 consecutive spontaneously breathing adults receiving continuous positive airway pressure, enrolled from September 2020 to December 2021. Lung mechanics and other previously reported predictive indices were calculated, as well as a novel variable: the mechanical power ratio (the ratio between the actual and the expected baseline mechanical power). Patients were grouped according to the outcome: (1) no-treatment escalation (patient supported in continuous positive airway pressure until improvement) and (2) treatment escalation (escalation of the respiratory support to noninvasive or invasive mechanical ventilation), and the association between lung mechanics/predictive scores and outcome was assessed. RESULTS At day 1, patients undergoing treatment escalation had spontaneous tidal volume similar to those of patients who did not (7.1 ± 1.9 vs. 7.1 ± 1.4 ml/kgIBW; P = 0.990). In contrast, they showed higher respiratory rate (20 ± 5 vs. 18 ± 5 breaths/min; P = 0.028), minute ventilation (9.2 ± 3.0 vs. 7.9 ± 2.4 l/min; P = 0.011), tidal pleural pressure (8.1 ± 3.7 vs. 6.0 ± 3.1 cm H2O; P = 0.003), mechanical power ratio (2.4 ± 1.4 vs. 1.7 ± 1.5; P = 0.042), and lower partial pressure of alveolar oxygen/fractional inspired oxygen tension (174 ± 64 vs. 220 ± 95; P = 0.007). The mechanical power (area under the curve, 0.738; 95% CI, 0.636 to 0.839] P < 0.001), the mechanical power ratio (area under the curve, 0.734; 95% CI, 0.625 to 0.844; P < 0.001), and the pressure-rate index (area under the curve, 0.733; 95% CI, 0.631 to 0.835; P < 0.001) showed the highest areas under the curve. CONCLUSIONS In this COVID-19 cohort, tidal volume was similar in patients undergoing treatment escalation and in patients who did not; mechanical power, its ratio, and pressure-rate index were the variables presenting the highest association with the clinical outcome. EDITOR’S PERSPECTIVE
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Viegas P, Ageno E, Corsi G, Tagariello F, Razakamanantsoa L, Vilde R, Ribeiro C, Heunks L, Patout M, Fisser C. Highlights from the Respiratory Failure and Mechanical Ventilation 2022 Conference. ERJ Open Res 2023; 9:00467-2022. [PMID: 36949961 PMCID: PMC10026011 DOI: 10.1183/23120541.00467-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/10/2022] [Indexed: 11/25/2022] Open
Abstract
The Respiratory Intensive Care Assembly of the European Respiratory Society gathered in Berlin to organise the second Respiratory Failure and Mechanical Ventilation Conference in June 2022. The conference covered several key points of acute and chronic respiratory failure in adults. During the 3-day conference, ventilatory strategies, patient selection, diagnostic approaches, treatment and health-related quality of life topics were addressed by a panel of international experts. Lectures delivered during the event have been summarised by Early Career Members of the Assembly and take-home messages highlighted.
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Affiliation(s)
- Pedro Viegas
- Pulmonology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Elisa Ageno
- Respiratory and Critical Care Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, University Hospital Sant'Orsola-Malpighi, Bologna, Italy
- Department of Clinical, Integrated and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Gabriele Corsi
- Respiratory and Critical Care Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, University Hospital Sant'Orsola-Malpighi, Bologna, Italy
- Department of Clinical, Integrated and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Federico Tagariello
- Respiratory and Critical Care Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, University Hospital Sant'Orsola-Malpighi, Bologna, Italy
- Department of Clinical, Integrated and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Léa Razakamanantsoa
- Unité Ambulatoire d'Appareillage Respiratoire de Domicile (UAARD), Service de Pneumologie (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Paris, France
| | - Rudolfs Vilde
- Centre of Pulmonology and Thoracic Surgery, Pauls Stradiņš Clinical University Hospital, Riga, Latvia
- Riga Stradiņš University, Riga, Latvia
| | - Carla Ribeiro
- Pulmonology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Leo Heunks
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Maxime Patout
- Service des Pathologies du Sommeil (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Christoph Fisser
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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Roshdy A. Respiratory Monitoring During Mechanical Ventilation: The Present and the Future. J Intensive Care Med 2023; 38:407-417. [PMID: 36734248 DOI: 10.1177/08850666231153371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The increased application of mechanical ventilation, the recognition of its harms and the interest in individualization raised the need for an effective monitoring. An increasing number of monitoring tools and modalities were introduced over the past 2 decades with growing insight into asynchrony, lung and chest wall mechanics, respiratory effort and drive. They should be used in a complementary rather than a standalone way. A sound strategy can guide a reduction in adverse effects like ventilator-induced lung injury, ventilator-induced diaphragm dysfunction, patient-ventilator asynchrony and helps early weaning from the ventilator. However, the diversity, complexity, lack of expertise, and associated cost make formulating the appropriate monitoring strategy a challenge for clinicians. Most often, a big amount of data is fed to the clinicians making interpretation difficult. Therefore, it is fundamental for intensivists to be aware of the principle, advantages, and limits of each tool. This analytic review includes a simplified narrative of the commonly used basic and advanced respiratory monitors along with their limits and future prospective.
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Affiliation(s)
- Ashraf Roshdy
- Critical Care Medicine Department, Faculty of Medicine, 54562Alexandria University, Alexandria, Egypt.,Critical Care Unit, North Middlesex University Hospital, London, UK
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Buell KG, Patel BK. Helmet noninvasive ventilation in acute hypoxic respiratory failure. Curr Opin Crit Care 2023; 29:8-13. [PMID: 36580369 PMCID: PMC9830589 DOI: 10.1097/mcc.0000000000001008] [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] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW Invasive mechanical ventilation is a lifesaving intervention for patients with severe acute hypoxic respiratory failure (AHRF), but it is associated with neuromuscular, cognitive, and infectious complications. Noninvasive ventilation (NIV) may provide sufficient respiratory support without these complications. The helmet interface for NIV could address concerns raised for the use of NIV as first-line therapy in AHRF. This review will summarize and appraise the current evidence for helmet NIV in AHRF. RECENT FINDINGS There are only six randomized controlled trials comparing helmet NIV to standard nasal cannula, facemask NIV, or high-flow nasal oxygen in patients with AHRF. Lower rates of endotracheal intubations and fewer days of mechanical ventilation were reported, with inconsistent findings on patient survival. Facemask NIV may worsen preexisting lung injury, delay intubations, and be inferior at delivering lung protective ventilation strategies compared with mechanical ventilation. The helmet interface could circumvent some of these concerns through the delivery of higher positive end expiratory pressure and more uniform distribution of negative pleural pressure. SUMMARY There is limited evidence to support or refute the use of helmet NIV in AHRF. Further studies investigating the interface of helmet in NIV as a separate clinical entity are needed.
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Affiliation(s)
- Kevin G. Buell
- University of Chicago, Department of Medicine, Section of Pulmonary and Critical Care, Chicago, Illinois
| | - Bhakti K. Patel
- University of Chicago, Department of Medicine, Section of Pulmonary and Critical Care, Chicago, Illinois
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44
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Noninvasive Ventilation Alone Cannot Solve COVID-19 Respiratory Failure. Ann Emerg Med 2023; 81:159-161. [PMID: 36328856 PMCID: PMC9797249 DOI: 10.1016/j.annemergmed.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 08/19/2022] [Accepted: 09/09/2022] [Indexed: 12/31/2022]
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45
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Frat JP, Marchasson L, Arrivé F, Coudroy R. High-flow nasal cannula oxygen therapy in acute hypoxemic respiratory failure and COVID-19-related respiratory failure. JOURNAL OF INTENSIVE MEDICINE 2023; 3:20-26. [PMID: 36756183 PMCID: PMC9534601 DOI: 10.1016/j.jointm.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/19/2022] [Accepted: 07/13/2022] [Indexed: 11/17/2022]
Abstract
Although standard oxygen face masks are first-line therapy for patients with acute hypoxemic respiratory failure, high-flow nasal cannula oxygen therapy has gained major popularity in intensive care units. The physiological effects of high-flow oxygen counterbalance the physiological consequences of acute hypoxemic respiratory failure by lessening the deleterious effects of intense and prolonged inspiratory efforts generated by patients. Its simplicity of application for physicians and nurses and its comfort for patients are other arguments for its use in this setting. Although clinical studies have reported a decreased risk of intubation with high-flow oxygen compared with standard oxygen, its survival benefit is uncertain. A more precise definition of acute hypoxemic respiratory failure, including a classification of severity based on oxygenation levels, is needed to better compare the efficiencies of different non-invasive oxygenation support methods (standard oxygen, high-flow oxygen, and non-invasive ventilation). Additionally, the respective role of each non-invasive oxygenation support method needs to be established through further clinical trials in acute hypoxemic respiratory failure, especially in severe forms.
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Affiliation(s)
- Jean-Pierre Frat
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers 86021, France
- Centre d'Investigation Clinique 1402 ALIVE, INSERM, Université de Poitiers, Poitiers 86021, France
| | - Laura Marchasson
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers 86021, France
| | - François Arrivé
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers 86021, France
| | - Rémi Coudroy
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers 86021, France
- Centre d'Investigation Clinique 1402 ALIVE, INSERM, Université de Poitiers, Poitiers 86021, France
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46
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Keshavjee S, Jivraj NK, Tejpal A, Sklar MC. Non-invasive support for the hypoxaemic patient. Br J Hosp Med (Lond) 2023; 84:1-10. [PMID: 36708347 DOI: 10.12968/hmed.2022.0420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Optimisation of oxygenation strategies in patients with hypoxaemic respiratory failure is a top priority for acute care physicians, as hypoxaemic respiratory failure is one of the leading causes of admission. Various oxygenation methods range from non-invasive face masks to high flow nasal cannulae, which have advantages and disadvantages for this heterogeneous patient group. Focus has turned toward examining the benefits of non-invasive ventilation, as this was heavily researched in resource-limited settings during the COVID-19 pandemic. The oxygenation strategy should be determined on an individualised basis for patients, and with new evidence from the COVID-19 pandemic, providers may now consider placing further emphasis on non-invasive approaches. As non-invasive ventilation continues to be used in increasing frequency, new methods of monitoring patient response, including when to escalate ventilation strategy, will need to be validated.
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Affiliation(s)
- Sara Keshavjee
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Naheed K Jivraj
- Interdepartmental Division of Critical Care Medicine and Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Ambika Tejpal
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Michael C Sklar
- Interdepartmental Division of Critical Care Medicine and Department of Anesthesia, University of Toronto, Toronto, ON, Canada
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Bongiovanni F, Michi T, Natalini D, Grieco DL, Antonelli M. Advantages and drawbacks of helmet noninvasive support in acute respiratory failure. Expert Rev Respir Med 2023; 17:27-39. [PMID: 36710082 DOI: 10.1080/17476348.2023.2174974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Non-invasive ventilation (NIV) represents an effective strategy for managing acute respiratory failure. Facemask NIV is strongly recommended in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with hypercapnia and acute cardiogenic pulmonary edema (ACPE). Its role in managing acute hypoxemic respiratory failure (AHRF) remains a debated issue. NIV and continuous positive airway pressure (CPAP) delivered through the helmet are recently receiving growing interest for AHRF management. AREAS COVERED In this narrative review, we discuss the clinical applications of helmet support compared to the other available noninvasive strategies in the different phenotypes of acute respiratory failure. EXPERT OPINION Helmets enable the use of high positive end-expiratory pressure, which may protect from self-inflicted lung injury: in AHRF, the possible superiority of helmet support over other noninvasive strategies in terms of clinical outcome has been hypothesized in a network metanalysis and a randomized trial, but has not been confirmed by other investigations and warrants confirmation. In AECOPD patients, helmet efficacy may be inferior to that of face masks, and its use prompts caution due to the risk of CO2 rebreathing. Helmet support can be safely applied in hypoxemic patients with ACPE, with no advantages over facemasks.
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Affiliation(s)
- Filippo Bongiovanni
- 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
| | - 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, Rome, Italy
| | - Daniele Natalini
- 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
| | - 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
| | - 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, Rome, Italy
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Zbiral M, Weber M, König S, Kraft F, Ullrich R, Krenn K. Usefulness and limitations of the acute respiratory distress syndrome definitions in non-intubated patients. A narrative review. Front Med (Lausanne) 2023; 10:1088709. [PMID: 36910485 PMCID: PMC9995400 DOI: 10.3389/fmed.2023.1088709] [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: 11/03/2022] [Accepted: 02/07/2023] [Indexed: 02/25/2023] Open
Abstract
According to the Berlin Definition of acute respiratory distress syndrome (ARDS), a positive end-expiratory pressure (PEEP) of at least 5 cmH2O is required to diagnose and grade ARDS. While the Berlin consensus statement specifically acknowledges the role of non-invasive ventilation (NIV) in mild ARDS, this stratification has traditionally presumed a mechanically ventilated patient in the context of moderate to severe ARDS. This may not accurately reflect today's reality of clinical respiratory care. NIV and high-flow nasal cannula oxygen therapy (HFNO) have been used for managing of severe forms of acute hypoxemic respiratory failure with growing frequency, including in patients showing pathophysiological signs of ARDS. This became especially relevant during the COVID-19 pandemic. The levels of PEEP achieved with HFNO have been particularly controversial, and the exact FiO2 it achieves is subject to variability. Pinpointing the presence of ARDS in patients receiving HNFO and the severity in those receiving NIV therefore remains methodically problematic. This narrative review highlights the evolution of the ARDS definition in the context of non-invasive ventilatory support and provides an overview of the parallel development of definitions and ventilatory management of ARDS. It summarizes the methodology applied in clinical trials to classify ARDS in non-intubated patients and the respective consequences on treatment. As ARDS severity has significant therapeutic and prognostic consequences, and earlier treatment in non-intubated patients may be beneficial, closing this knowledge gap may ultimately be a relevant step to improve comparability in clinical trial design and outcomes.
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Affiliation(s)
- Martin Zbiral
- Department of Anesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Maximilian Weber
- Department of Anesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Sebastian König
- Department of Anesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Felix Kraft
- Department of Anesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Roman Ullrich
- Department of Anesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria.,Department of Anesthesiology and Intensive Care Medicine, AUVA Trauma Center Vienna, Vienna, Austria
| | - Katharina Krenn
- Department of Anesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
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Chen LL, Weng H, Li HY, Wang XH. Noninvasive Mechanical Ventilation in Patients with Viral Pneumonia-Associated Acute Respiratory Distress Syndrome: An Observational Retrospective Study. Int J Clin Pract 2023; 2023:1819087. [PMID: 36793926 PMCID: PMC9908335 DOI: 10.1155/2023/1819087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 12/02/2022] [Accepted: 12/08/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES Appropriate mechanical ventilation may change the prognosis of patients with viral pneumonia-associated acute respiratory distress syndrome (ARDS). This study aimed to identify the factors associated with the success of noninvasive ventilation in the management of patients with ARDS secondary to respiratory viral infection. METHODS In this retrospective cohort study, all patients with viral pneumonia-associated ARDS were divided into the noninvasive mechanical ventilation (NIV) success group and the NIV failure group. The demographic and clinical data of all patients were collected. The factors associated with the success of noninvasive ventilation were identified by the logistic regression analysis. RESULTS Among this cohort, 24 patients with an average age of 57.9 ± 17.0 years received successful NIVs, and NIV failure occurred in 21 patients with an average age of 54.1 ± 14.0 years. The independent influencing factors for the success of the NIV were the acute physiology and chronic health evaluation (APACHE) II score (odds ratio (OR): 1.83, 95% confidence interval (CI): 1.10-3.03) and lactate dehydrogenase (LDH) (OR: 1.011, 95% CI: 1.00-1.02). When the oxygenation index (OI) is <95 mmHg, APACHE II > 19, and LDH > 498 U/L, the sensitivity and specificity of predicting a failed NIV were (66.6% (95% CI: 43.0%-85.4%) and 87.5% (95% CI: 67.6%-97.3%)); (85.7% (95% CI: 63.7%-97.0%) and 79.1% (95% CI: 57.8%-92.9%)); (90.4% (95% CI: 69.6%-98.8%) and 62.5% (95% CI: 40.6%-81.2%)), respectively. The areas under the receiver operating characteristic curve (AUC) of the OI, APACHE II scores, and LDH were 0.85, which was lower than the AUC of the OI combined with LDH and the APACHE II score (OLA) of 0.97 (P=0.0247). CONCLUSIONS Overall, patients with viral pneumonia-associated ARDS receiving successful NIV have lower mortality rates than those for whom NIV failed. In patients with influenza A-associated ARDS, the OI may not be the only indicator of whether NIV can be used; a new indicator of NIV success may be the OLA.
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Affiliation(s)
- Lu-lu Chen
- Department of Respiratory Diseases, People' Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou 350009, China
| | - Heng Weng
- Department of Respiratory Diseases, People' Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou 350009, China
| | - Hong-yan Li
- Department of Critical Care Medicine, People' Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou 350009, China
| | - Xin-hang Wang
- Department of Respiratory Diseases, Fuzhou Pulmonary Hospital of Fujian, Fuzhou 350008, China
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50
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Chelly J, Coupry LM, van Phach Vong L, Kamel T, Marzouk M, Terzi N, Bruel C, Autret A, Garnero A, Arnal JM. Comparison of high-flow nasal therapy, noninvasive ventilation, and continuous positive airway pressure on outcomes in critically ill patients admitted for COVID-19 with acute respiratory failure. Minerva Anestesiol 2023; 89:66-73. [PMID: 36448989 DOI: 10.23736/s0375-9393.22.16918-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND The optimal first-line noninvasive respiratory support (NIRS) to improve outcome in patients affected by COVID-19 pneumonia admitted to ICU is still debated. METHODS We conducted a retrospective study in seven French ICUs, including all adults admitted between July and December 2020 with documented SARS-CoV-2 acute respiratory failure (PaO2/FiO2<300 mmHg), and treated with either high-flow nasal therapy (HFNT) alone, noninvasive ventilation alone or in combination with HFNT (NIV), or continuous positive airway pressure alone or in combination with HFNT (CPAP). The primary outcome was NIRS failure at day 28, defined as the need for endotracheal intubation (ETI) or death without ETI. RESULTS Among the 355 patients included, 160 (45%) were treated with HFNT alone, 115 (32%) with NIV and 80 (23%) with CPAP. The primary outcome occurred in 65 (41%), 69 (60%), and 25 (31%) patients among those treated with HFNT alone, NIV, and CPAP, respectively (P<0.001). After univariate analysis, patients treated with CPAP had a trend for a lower incidence of the primary outcome, whereas patients treated with NIV had a significant higher incidence of the primary outcome, both compared to those treated with HFNT alone (unadjusted Hazard ratio 0.67; 95% CI [0.42-1.06], and 1.58; 95% CI [1.12-2.22]; P=0.09 and 0.008, respectively). CONCLUSIONS Among ICU patients admitted for severe COVID-19 pneumonia and managed with NIRS, the outcome seems to differ according to the initial chosen strategy. Prospective randomized controlled studies are warranted to identify the optimal strategy.
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Affiliation(s)
- Jonathan Chelly
- Intensive Care Unit, Centre Hospitalier Intercommunal Toulon La Seyne sur Mer, Sainte Musse Hospital, Toulon, France -
| | - Louis-Marie Coupry
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, Melun, France
| | - Ly van Phach Vong
- Intensive Care Unit, Grand Hôpital de l'Est Francilien (GHEF), Jossigny, France
| | - Toufik Kamel
- Intensive Care Unit, Centre Hospitalier Régional (CHR) d'Orléans, Orléans, France
| | - Mehdi Marzouk
- Intensive Care Unit, Hospital of Béthune, Béthune, France
| | - Nicolas Terzi
- Intensive Care Unit, Centre Hospitalier Universitaire (CHU) de Grenoble, Grenoble, France
| | - Cedric Bruel
- Intensive Care Unit, Saint Joseph Hospital, Paris, France
| | - Aurélie Autret
- Clinical Research Department, Centre Hospitalier Intercommunal de Toulon La Seyne sur Mer - Sainte Musse Hospital, Toulon, France
| | - Aude Garnero
- Intensive Care Unit, Centre Hospitalier Intercommunal Toulon La Seyne sur Mer, Sainte Musse Hospital, Toulon, France
| | - Jean-Michel Arnal
- Intensive Care Unit, Centre Hospitalier Intercommunal Toulon La Seyne sur Mer, Sainte Musse Hospital, Toulon, France
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