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Rossitto M, Vrenna G, Tuccio Guarna Assanti V, Essa N, De Santis ML, Granaglia A, Fini V, Costabile V, Onori M, Cristiani L, Boni A, Cutrera R, Perno CF, Bernaschi P. Identification of the blaOXA-23 Gene in the First Mucoid XDR Acinetobacter baumannii Isolated from a Patient with Cystic Fibrosis. J Clin Med 2023; 12:6582. [PMID: 37892720 PMCID: PMC10607117 DOI: 10.3390/jcm12206582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 10/10/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
Acinetobacter baumannii is one of the pathogens most involved in health care-associated infections in recent decades. Known for its ability to accumulate several antimicrobial resistance mechanisms, it possesses the oxacillinase blaoxa-23, a carbapenemase now endemic in Italy. Acinetobacter species are not frequently observed in patients with cystic fibrosis, and multidrug-resistant A. baumannii is a rare event in these patients. Non-mucoid A. baumannii carrying the blaoxa-23 gene has been sporadically detected. Here, we describe the methods used to detect blaoxa-23 in the first established case of pulmonary infection via a mucoid strain of A. baumannii producing carbapenemase in a 24-year-old cystic fibrosis patient admitted to Bambino Gesù Children's Hospital in Rome, Italy. This strain, which exhibited an extensively drug-resistant antibiotype, also showed a great ability to further increase its resistance in a short time.
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Affiliation(s)
- Martina Rossitto
- Multimodal Laboratory Medicine, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
- Major School in Microbiology and Virology, University Campus Bio-Medico, 00128 Rome, Italy
| | - Gianluca Vrenna
- Microbiology and Diagnostic Immunology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (V.T.G.A.); (N.E.); (M.L.D.S.); (A.G.); (V.F.); (V.C.); (M.O.); (C.F.P.); (P.B.)
- Department of Molecular Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Vanessa Tuccio Guarna Assanti
- Microbiology and Diagnostic Immunology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (V.T.G.A.); (N.E.); (M.L.D.S.); (A.G.); (V.F.); (V.C.); (M.O.); (C.F.P.); (P.B.)
| | - Nour Essa
- Microbiology and Diagnostic Immunology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (V.T.G.A.); (N.E.); (M.L.D.S.); (A.G.); (V.F.); (V.C.); (M.O.); (C.F.P.); (P.B.)
| | - Maria Luisa De Santis
- Microbiology and Diagnostic Immunology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (V.T.G.A.); (N.E.); (M.L.D.S.); (A.G.); (V.F.); (V.C.); (M.O.); (C.F.P.); (P.B.)
| | - Annarita Granaglia
- Microbiology and Diagnostic Immunology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (V.T.G.A.); (N.E.); (M.L.D.S.); (A.G.); (V.F.); (V.C.); (M.O.); (C.F.P.); (P.B.)
| | - Vanessa Fini
- Microbiology and Diagnostic Immunology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (V.T.G.A.); (N.E.); (M.L.D.S.); (A.G.); (V.F.); (V.C.); (M.O.); (C.F.P.); (P.B.)
| | - Valentino Costabile
- Microbiology and Diagnostic Immunology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (V.T.G.A.); (N.E.); (M.L.D.S.); (A.G.); (V.F.); (V.C.); (M.O.); (C.F.P.); (P.B.)
| | - Manuela Onori
- Microbiology and Diagnostic Immunology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (V.T.G.A.); (N.E.); (M.L.D.S.); (A.G.); (V.F.); (V.C.); (M.O.); (C.F.P.); (P.B.)
| | - Luca Cristiani
- Pneumology and Cystic Fibrosis Unit, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy; (L.C.); (A.B.); (R.C.)
| | - Alessandra Boni
- Pneumology and Cystic Fibrosis Unit, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy; (L.C.); (A.B.); (R.C.)
| | - Renato Cutrera
- Pneumology and Cystic Fibrosis Unit, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy; (L.C.); (A.B.); (R.C.)
| | - Carlo Federico Perno
- Microbiology and Diagnostic Immunology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (V.T.G.A.); (N.E.); (M.L.D.S.); (A.G.); (V.F.); (V.C.); (M.O.); (C.F.P.); (P.B.)
| | - Paola Bernaschi
- Microbiology and Diagnostic Immunology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (V.T.G.A.); (N.E.); (M.L.D.S.); (A.G.); (V.F.); (V.C.); (M.O.); (C.F.P.); (P.B.)
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2
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Milinic T, McElvaney OJ, Goss CH. Diagnosis and Management of Cystic Fibrosis Exacerbations. Semin Respir Crit Care Med 2023; 44:225-241. [PMID: 36746183 PMCID: PMC10131792 DOI: 10.1055/s-0042-1760250] [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: 02/08/2023]
Abstract
With the improving survival of cystic fibrosis (CF) patients and the advent of highly effective cystic fibrosis transmembrane conductance regulator (CFTR) therapy, the clinical spectrum of this complex multisystem disease continues to evolve. One of the most important clinical events for patients with CF in the course of this disease is acute pulmonary exacerbation (PEx). Clinical and microbial epidemiology studies of CF PEx continue to provide important insight into the disease course, prognosis, and complications. This work has now led to several large-scale clinical trials designed to clarify the treatment paradigm for CF PEx. The primary goal of this review is to provide a summary and update of the pathophysiology, clinical and microbial epidemiology, outcome and treatment of CF PEx, biomarkers for exacerbation, and the impact of highly effective modulator therapy on these events moving forward.
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Affiliation(s)
- Tijana Milinic
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Oliver J McElvaney
- Cysic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
| | - Christopher H Goss
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
- Cysic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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3
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McBennett KA, Davis PB, Konstan MW. Increasing life expectancy in cystic fibrosis: Advances and challenges. Pediatr Pulmonol 2022; 57 Suppl 1:S5-S12. [PMID: 34672432 PMCID: PMC9004282 DOI: 10.1002/ppul.25733] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/30/2021] [Accepted: 10/03/2021] [Indexed: 01/14/2023]
Abstract
Since the first description of cystic fibrosis in 1938, there have been significant advances in both quality of life and longevity for people living with this disease. In this article we describe the milestones of the last 80 years and what we perceive to be the remaining barriers to normalcy for this population.
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Affiliation(s)
- Kimberly A McBennett
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Pamela B Davis
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Michael W Konstan
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
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4
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Mingora CM, Flume PA. Pulmonary Complications in Cystic Fibrosis: Past, Present, and Future. Chest 2021; 160:1232-1240. [PMID: 34147501 DOI: 10.1016/j.chest.2021.06.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/14/2021] [Accepted: 06/14/2021] [Indexed: 12/22/2022] Open
Abstract
Cystic fibrosis (CF) is an autosomal recessive genetic condition with multisystemic disease manifestations, the most prominent of which occur in the respiratory system. Despite significant developments in disease understanding and therapeutics, each contributing to improved lung function and survival in patients with CF, several pulmonary complications, including pneumothorax, massive hemoptysis, and respiratory failure, continue to occur. In this review, we briefly describe each of these complications and their management and discuss how they impact the care and disease trajectory of individuals in whom they occur. Finally, we discuss the evolving role that palliative care and CF transmembrane conductance regular modulator therapies play in the natural disease course and care of patients with CF.
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Affiliation(s)
- Christina M Mingora
- Department of Medicine, Medical University of South Carolina, Charleston, SC.
| | - Patrick A Flume
- Department of Medicine, Medical University of South Carolina, Charleston, SC
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5
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Kapnadak SG, Ramos KJ, Dellon EP. Enhancing care for individuals with advanced cystic fibrosis lung disease. Pediatr Pulmonol 2021; 56 Suppl 1:S69-S78. [PMID: 32609949 DOI: 10.1002/ppul.24937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/12/2020] [Accepted: 06/12/2020] [Indexed: 11/09/2022]
Abstract
While remarkable advances in cystic fibrosis (CF) care have led to improvements in survival and quality of life, many individuals with CF are living with advanced cystic fibrosis lung disease (ACFLD) and others will face continued disease progression and its associated complex treatments and choices. This review will provide a summary of recently published guidelines for ACFLD care and lung transplant referral and highlight ongoing work to enhance the care of those with ACFLD through improvements in medical and psychosocial care, palliative care, and care around lung transplantation.
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Affiliation(s)
- Siddhartha G Kapnadak
- Division of Pulmonary, Department of Medicine, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Kathleen J Ramos
- Division of Pulmonary, Department of Medicine, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Elisabeth P Dellon
- Division of Pulmonology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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6
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Abstract
OBJECTIVES Data on outcomes of children with cystic fibrosis admitted to PICUs are limited and outdated. Prior studies cite PICU mortality rates ranging from 37.5% to 100%. Given the advances made in cystic fibrosis care, we expect outcomes for these patients to have changed significantly since last studied. We provide an updated report on PICU mortality and the factors associated with death among critically ill children with cystic fibrosis. DESIGN Retrospective multicenter cohort analysis utilizing data from the Virtual Pediatric Systems database. SETTING Data were collected from 135 PICUs from January 1, 2009, to June 20, 2018. PATIENTS One-thousand six-hundred thirty-three children with cystic fibrosis accounting for 2,893 PICU admissions were studied. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was mortality during PICU admission. Predictors included demographics, anthropometrics, diagnoses, clinical characteristics, and critical care interventions. Odds ratios of mortality were calculated in univariate and multivariable analyses to assess differences in mortality associated with predictor variables. Generalized estimating equation models were used to account for multiple admissions per patient. The overall PICU mortality rate was 6.6%. Factors associated with increased odds of mortality included hemoptysis/pulmonary hemorrhage, pneumothorax, gastrointestinal bleeding, bacterial/fungal infections, lower body mass index/malnutrition, and need for noninvasive or invasive respiratory support. Intubation/mechanical ventilation occurred in 26.4% of the 2,893 admissions and was associated with a 19.1% mortality rate. Of the nonsurvivors, 20.7% died without receiving mechanical ventilation. CONCLUSIONS The mortality rate during PICU admissions for patients with cystic fibrosis is lower than has been reported in prior studies, both in the overall cohort and in the subset requiring invasive mechanical ventilation. These data provide updated insight into the prognosis for cystic fibrosis patients requiring critical care.
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7
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Mortality in Adults with Cystic Fibrosis Requiring Mechanical Ventilation. Cross-Sectional Analysis of Nationwide Events. Ann Am Thorac Soc 2020; 16:1017-1023. [PMID: 31026405 DOI: 10.1513/annalsats.201804-268oc] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Rationale: Survival in patients with cystic fibrosis (CF) is improving over time. Traditionally, there has been concern about high mortality in individuals with CF requiring invasive mechanical ventilation (IMV) for respiratory failure.Objectives: We hypothesized that mortality has decreased over time in this population because of improvements in disease-specific therapies.Methods: The U.S. Nationwide Healthcare Cost and Utilization Project database was used to identify adult patients with CF undergoing IMV between 2002 and 2014. Patients with nonurgent/nonemergent admissions, pregnancy, and encounters related to lung transplantation were excluded. Demographic, geographic, and comorbidities were analyzed. The Cochran-Armitage trend test was used to examine trends in mortality over time. Multivariate mixed effects logistic regression was used to account for possible differences in hospital mortality patterns.Results: We identified 58,799 CF admissions from 2002 to 2014, with 3,727 (6.3%) undergoing IMV. After exclusions, 1,711 admissions remained. In 762 (44.5%) of adult hospitalizations, the patient died. Annual mortality per hospitalization ranged from 29.9 to 55.3%. The Cochran-Armitage trend test suggested an increased probability of survival over time. Factors significantly associated with mortality in multivariate analysis included female sex (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.14-2.09), acute renal failure (OR, 1.99; 95% CI, 1.32-3.01), and malnutrition (OR, 1.44; 95% CI, 1.01-2.06). IMV greater than 96 hours was associated with increased mortality in univariate analysis (OR, 1.51; 95% CI, 1.14-1.98); however, after adjustment for potential confounders, the association was no longer statistically significant (OR, 1.05; 95% CI, 0.77-1.43).Conclusions: Mortality per hospitalization in adults with CF who are not bridging to lung transplant and require emergent IMV is 44.5%, suggesting IMV is not futile. Furthermore, mortality decreased over the study period. These finding may help providers, families, and patients with CF weigh the risks and benefits of IMV for respiratory failure.
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8
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Kapnadak SG, Dimango E, Hadjiliadis D, Hempstead SE, Tallarico E, Pilewski JM, Faro A, Albright J, Benden C, Blair S, Dellon EP, Gochenour D, Michelson P, Moshiree B, Neuringer I, Riedy C, Schindler T, Singer LG, Young D, Vignola L, Zukosky J, Simon RH. Cystic Fibrosis Foundation consensus guidelines for the care of individuals with advanced cystic fibrosis lung disease. J Cyst Fibros 2020; 19:344-354. [DOI: 10.1016/j.jcf.2020.02.015] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 02/14/2020] [Accepted: 02/19/2020] [Indexed: 12/25/2022]
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9
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Advanced Stage Lung Disease. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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10
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Atag E, Krivec U, Ersu R. Non-invasive Ventilation for Children With Chronic Lung Disease. Front Pediatr 2020; 8:561639. [PMID: 33262959 PMCID: PMC7687222 DOI: 10.3389/fped.2020.561639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 10/13/2020] [Indexed: 11/24/2022] Open
Abstract
Advances in medical care and supportive care options have contributed to the survival of children with complex disorders, including children with chronic lung disease. By delivering a positive pressure or a volume during the patient's inspiration, NIV is able to reverse nocturnal alveolar hypoventilation in patients who experience hypoventilation during sleep, such as patients with chronic lung disease. Bronchopulmonary dysplasia (BPD) is a common complication of prematurity, and despite significant advances in neonatal care over recent decades its incidence has not diminished. Most affected infants have mild disease and require a short period of oxygen supplementation or respiratory support. However, severely affected infants can become dependent on positive pressure support for a prolonged period. In case of established severe BPD, respiratory support with non-invasive or invasive positive pressure ventilation is required. Patients with cystic fibrosis (CF) and advanced lung disease develop hypoxaemia and hypercapnia during sleep and hypoventilation during sleep usually predates daytime hypercapnia. Hypoxaemia and hypercapnia indicates poor prognosis and prompts referral for lung transplantation. The prevention of respiratory failure during sleep in CF may prolong survival. Long-term oxygen therapy has not been shown to improve survival in people with CF. A Cochrane review on the use NIV in CF concluded that NIV in combination with oxygen therapy improves gas exchange during sleep to a greater extent than oxygen therapy alone in people with moderate to severe CF lung disease. Uncontrolled, non-randomized studies suggest survival benefit with NIV in addition to being an effective bridge to transplantation. Complications of NIV relate mainly to prolonged use of a face or nasal mask which can lead to skin trauma, and neurodevelopmental delay by acting as a physical barrier to social interaction. Another associated risk is pulmonary aspiration caused by vomiting whilst wearing a face mask. Adherence to NIV is one of the major barriers to treatment in children. This article will review the current evidence for indications, adverse effects and long term follow up including adherence to NIV in children with chronic lung disease.
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Affiliation(s)
- Emine Atag
- Division of Pediatric Pulmonology, Medipol University, Istanbul, Turkey
| | - Uros Krivec
- Division of Pediatric Pulmonology, University Children's Hospital, University Medical Centre, Ljubljana, Slovenia
| | - Refika Ersu
- Division of Pediatric Respirology, Children's Hospital of Ontario, University of Ottawa, Ottawa, ON, Canada
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11
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Abstract
With the improving survival of cystic fibrosis (CF) patients and the advent of highly effective cystic fibrosis transmembrane conductance regulator therapy, the clinical spectrum of this complex multisystem disease continues to evolve. One of the most important clinical events for patients with CF in the course of this disease is an acute pulmonary exacerbation. Clinical and microbial epidemiology studies of CF pulmonary exacerbations continue to provide important insight into the disease course, prognosis, and complications. This work has now led to a number of large scale clinical trials with the goal of improving the treatment paradigm for CF pulmonary exacerbation. The primary goal of this review is to provide a summary of the pathophysiology, the clinical epidemiology, microbial epidemiology, outcome and the treatment of CF pulmonary exacerbation.
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Affiliation(s)
- Christopher H Goss
- CFF Therapeutics Development Network Coordinating Center, Department of Pediatrics, Seattle Children's Research Institute, Seattle, Washington.,Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine and Pediatrics, University of Washington School of Medicine, Seattle, Washington
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12
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Corcione N, Buonpensiero P, Esquinas AM. High flow oxygen therapy and the work of breathing assessed by thickening fraction of the diaphragm (TFdi): just a side of the moon in cystic fibrosis patients? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:58. [PMID: 30906762 DOI: 10.21037/atm.2018.12.54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Nadia Corcione
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Buonpensiero
- Department of Translational Medical Sciences, Cystic Fibrosis Center, University "Federico II" of Naples, Naples, Italy
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13
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Comellini V, Pacilli AMG, Nava S. Benefits of non-invasive ventilation in acute hypercapnic respiratory failure. Respirology 2019; 24:308-317. [PMID: 30636373 DOI: 10.1111/resp.13469] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/18/2018] [Accepted: 12/09/2018] [Indexed: 02/02/2023]
Abstract
Non-invasive ventilation (NIV) with bilevel positive airway pressure is a non-invasive technique, which refers to the provision of ventilatory support through the patient's upper airway using a mask or similar device. This technique is successful in correcting hypoventilation. It has become widely accepted as the standard treatment for patients with hypercapnic respiratory failure (HRF). Since the 1980s, NIV has been used in intensive care units and, after initial anecdotal reports and larger series, a number of randomized trials have been conducted. Data from these trials have shown that NIV is a valuable treatment for HRF. This review aims to explore the principal areas in which NIV can be useful, focusing particularly on patients with acute HRF (AHRF). We will update the evidence base with the goal of supporting clinical practice. We provide a practical description of the main indications for NIV in AHRF and identify the group of patients with hypercapnic failure who will benefit most from the application of NIV.
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Affiliation(s)
- Vittoria Comellini
- Respiratory and Critical Care Unit, University Hospital St Orsola-Malpighi, Bologna, Italy
| | - Angela Maria Grazia Pacilli
- Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Stefano Nava
- Respiratory and Critical Care Unit, University Hospital St Orsola-Malpighi, Bologna, Italy.,Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
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14
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King CS, Brown AW, Aryal S, Ahmad K, Donaldson S. Critical Care of the Adult Patient With Cystic Fibrosis. Chest 2019; 155:202-214. [DOI: 10.1016/j.chest.2018.07.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 07/19/2018] [Accepted: 07/20/2018] [Indexed: 01/24/2023] Open
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15
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Archangelidi O, Carr SB, Simmonds NJ, Bilton D, Banya W, Cullinan P. Non-invasive ventilation and clinical outcomes in cystic fibrosis: Findings from the UK CF registry. J Cyst Fibros 2018; 18:665-670. [PMID: 30503032 DOI: 10.1016/j.jcf.2018.11.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 11/03/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Non-invasive ventilation (NIV) for respiratory failure and airway clearance is an established intervention in cystic fibrosis (CF), but its therapeutic benefit on lung function and survival remains under-investigated. METHODS Using data from the UK CF Registry between 2007 and 2015, we explored the patterns of NIV use, and assessed changes in mean percent predicted FEV1 (ppFEV1) prior to and after NIV use, and the survival of patients on NIV. RESULTS Among 11,079 patients, 1107 had at least one record of NIV treatment. Incidence and prevalence of NIV was lower in children and followed non-linear temporal patterns. Adjusting for other risk factors, ppFEV1 rose by 0.70 (95%CI: -0.83, 2.24) after first NIV use in children. In adults with a low ppFEV1 (<40%) at initiation of treatment, NIV increased mean ppFEV1 by 2.60 (95% CI: 0.93, 4.27). Our analysis showed that NIV initiation is associated with an increased risk of death/transplant in both children (HR = 2.47; 95%CI: 1.20-5.08) and adults (HR = 1.96; 95% CI: 1.63-2.36) but effect was attenuated in children with low ppFEV1 (<40%). CONCLUSIONS NIV usage in CF improves spirometric values but does not benefit survival. Further studies are required to better understand survival outcomes and ultimately improve NIV outcomes in CF.
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Affiliation(s)
- Olga Archangelidi
- National Heart and Lung Institute, Imperial College London, United Kingdom.
| | | | - Nicholas J Simmonds
- National Heart and Lung Institute, Imperial College London, United Kingdom; Royal Brompton Hospital, London, United Kingdom
| | - Diana Bilton
- National Heart and Lung Institute, Imperial College London, United Kingdom; Royal Brompton Hospital, London, United Kingdom
| | - Winston Banya
- National Heart and Lung Institute, Imperial College London, United Kingdom; Royal Brompton Hospital, London, United Kingdom
| | - Paul Cullinan
- National Heart and Lung Institute, Imperial College London, United Kingdom
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16
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Oud L, Chan YM. Predictors and variation of routine home discharge in critically ill adults with cystic fibrosis. Heart Lung 2018; 47:511-515. [PMID: 29866586 DOI: 10.1016/j.hrtlng.2018.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/21/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The short-term outcomes of patients with cystic fibrosis (CF) surviving critical illness were not examined systematically. OBJECTIVES To determine the factors associated with and variation in rates of routine home discharge among ICU-managed adult CF patients. METHODS Predictors of routine home discharge and its hospital-level variation were examined in ICU-managed adults with cystic fibrosis in Texas during 2004-2013. RESULTS Older age, rural residence, and severity of illness decreased odds of routine home discharge, while hospitalization in facilities accredited as part of the Cystic Fibrosis Foundation Care Center Network nearly doubled the odds of routine home discharge. The median (interquartile) adjusted rate of routine home discharge was 62.0% (31.5-82.5). CONCLUSIONS The identified determinants of routine home discharge can inform clinical decision-making, while the demonstrated wide variation in adjusted across-hospital rates of routine home discharge of ICU-managed adults with CF can provide benchmark data for future quality improvement efforts.
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Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, 701 W. 5th St., Odessa, Texas, 79763, USA.
| | - Yiu Ming Chan
- Mathematics and Computer Science Department, University of Texas at the Permian Basin, 4901 East University, Odessa, Texas, 79762, USA
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17
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Inhalation Techniques Used in Patients with Respiratory Failure Treated with Noninvasive Mechanical Ventilation. Can Respir J 2018; 2018:8959370. [PMID: 29973963 PMCID: PMC6008820 DOI: 10.1155/2018/8959370] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 05/02/2018] [Indexed: 11/18/2022] Open
Abstract
The administration of aerosolized medication is a basic therapy for patients with numerous respiratory tract diseases, including obstructive airway diseases (OADs), cystic fibrosis (CF), and infectious airway diseases. The management and care for patients requiring mechanical ventilation remains one of the greatest challenges for medical practitioners, both in intensive care units (ICUs) and pulmonology wards. Aerosol therapy is often necessary for patients receiving noninvasive ventilation (NIV), which may be stopped for the time of drug delivery and administered through a metered-dose inhaler or nebulizer in the traditional way. However, in most severe cases, this may result in rapid deterioration of the patient's clinical condition. Unfortunately, only limited number of original well-planned studies addressed this problem. Due to inconsistent information coming from small studies, there is a need for more precise data coming from large prospective real life studies on inhalation techniques in patients receiving NIV.
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Dellon E, Goldfarb SB, Hayes D, Sawicki GS, Wolfe J, Boyer D. Pediatric lung transplantation and end of life care in cystic fibrosis: Barriers and successful strategies. Pediatr Pulmonol 2017; 52:S61-S68. [PMID: 28786560 DOI: 10.1002/ppul.23748] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 05/17/2017] [Indexed: 11/06/2022]
Abstract
Pediatric lung transplantation has advanced over the years, providing a potential life-prolonging therapy to patients with cystic fibrosis. Despite this, many challenges in lung transplantation remain and result in worse outcomes than other solid organ transplants. As CF lung disease progresses, children and their caregivers are often simultaneously preparing for lung transplantation and end of life. In this article, we will discuss the current barriers to success in pediatric CF lung transplantation as well as approaches to end of life care in this population.
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Affiliation(s)
- Elisabeth Dellon
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Samuel B Goldfarb
- Division of Pulmonary Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Don Hayes
- Section of Pulmonary Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Gregory S Sawicki
- Division of Respiratory Diseases, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Debra Boyer
- Division of Respiratory Diseases, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Oud L. Critical illness among adults with cystic fibrosis in Texas, 2004-2013: Patterns of ICU utilization, characteristics, and outcomes. PLoS One 2017; 12:e0186770. [PMID: 29065161 PMCID: PMC5655478 DOI: 10.1371/journal.pone.0186770] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/07/2017] [Indexed: 02/07/2023] Open
Abstract
Objective Available reports on critically ill adults with cystic fibrosis (CF) suggest improving short-term outcomes. However, there is marked heterogeneity in reported findings, with studies mostly based on single-centered data, limiting generalizability. We sought to examine population-level patterns of demand for critical care resources, and the characteristics, resource utilization, and outcomes of ICU-managed adults with CF. Methods We used the Texas Inpatient Public Use Data File to identify ICU admissions with CF aged ≥18 years in Texas between 2004–2013. We examined ICU utilization at population level (using CF Foundation annual reports) and, among ICU admissions, socio-demographic characteristics, burden of comorbidities, organ failure, life-support utilization and hospital disposition. Linear regression and multilevel logistic regression were used to examine temporal trends and predictors of short-term mortality (hospital death and discharge to hospice), respectively. Results Of 9,579 hospitalizations of adults with CF, 1,249 (13%) were admitted to ICU. The incidence of ICU admission among adults with CF in Texas increased between 2004–2005 and 2012–2013 from 16.7 to 19.2 per 100 person-years (p = 0.0181), with ICU admissions aged ≥30 years accounting for 80.3% of the change. Among ICU admissions the following changes were noted between 2004–2005 and 2012–2013: any organ failure 30.2% vs. 56.3% (p = 0.0004), mechanical ventilation 11.5% vs. 19.2% (p = 0.0216), and hemodialysis 1.0% vs. 8.1% (p = 0.0007). Short-term mortality for the whole cohort and for those with mechanical ventilation was 11.4% and 41.8%, respectively, with corresponding home discharge among survivors 84% and 62.1%, respectively. Key predictors (adjusted odds ratios [aOR (95% CI)]) of short-term mortality included age ≥45 years (2.051 [1.231–3.415]), female gender (1.907 [1.237–2.941]), and mechanical ventilation (7.982 [5.001–12.739]). Conclusions Adults with CF had high and rising population-level burden of critical illness. Although ICU admissions were increasingly older and sicker, the majority survived hospitalization, with most discharged home, supporting short-term benefits of critical care in the present cohort.
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Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, Odessa, Texas, United States
- * E-mail:
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Somayaji R, Ramos KJ, Kapnadak SG, Aitken ML, Goss CH. Common clinical features of CF (respiratory disease and exocrine pancreatic insufficiency). Presse Med 2017; 46:e109-e124. [PMID: 28554722 DOI: 10.1016/j.lpm.2017.03.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/06/2017] [Accepted: 03/29/2017] [Indexed: 12/17/2022] Open
Abstract
First described as a disease of the pancreas, cystic fibrosis is a genetically inherited progressive disease affecting multiple organ systems. Pulmonary and pancreatic involvement is common in individuals with cystic fibrosis, and the former is attributable to most of the mortality that occurs with the condition. This chapter provides an overview of a clinical approach to the pulmonary and pancreatic manifestations of cystic fibrosis.
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Affiliation(s)
- Ranjani Somayaji
- University of Calgary, Department of Medicine, Calgary, AB, Canada
| | - Kathleen J Ramos
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA
| | - Siddhartha G Kapnadak
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA
| | - Moira L Aitken
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA
| | - Christopher H Goss
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA; University of Washington, Department of Pediatrics, Division of Pediatric Pulmonology, Seattle, WA, USA; Seattle Children's Research Institute, Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle, WA, USA.
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21
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Long-term non-invasive ventilation in children. THE LANCET RESPIRATORY MEDICINE 2016; 4:999-1008. [DOI: 10.1016/s2213-2600(16)30151-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 05/27/2016] [Accepted: 05/27/2016] [Indexed: 11/23/2022]
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Chaparro C, Keshavjee S. Lung transplantation for cystic fibrosis: an update. Expert Rev Respir Med 2016; 10:1269-1280. [DOI: 10.1080/17476348.2016.1261016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Lynch JP, Sayah DM, Belperio JA, Weigt SS. Lung transplantation for cystic fibrosis: results, indications, complications, and controversies. Semin Respir Crit Care Med 2015; 36:299-320. [PMID: 25826595 DOI: 10.1055/s-0035-1547347] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Survival in patients with cystic fibrosis (CF) has improved dramatically over the past 30 to 40 years, with mean survival now approximately 40 years. Nonetheless, progressive respiratory insufficiency remains the major cause of mortality in CF patients, and lung transplantation (LT) is eventually required. Timing of listing for LT is critical, because up to 25 to 41% of CF patients have died while awaiting LT. Globally, approximately 16.4% of lung transplants are performed in adults with CF. Survival rates for LT recipients with CF are superior to other indications, yet LT is associated with substantial morbidity and mortality (∼50% at 5-year survival rates). Myriad complications of LT include allograft failure (acute or chronic), opportunistic infections, and complications of chronic immunosuppressive medications (including malignancy). Determining which patients are candidates for LT is difficult, and survival benefit remains uncertain. In this review, we discuss when LT should be considered, criteria for identifying candidates, contraindications to LT, results post-LT, and specific complications that may be associated with LT. Infectious complications that may complicate CF (particularly Burkholderia cepacia spp., opportunistic fungi, and nontuberculous mycobacteria) are discussed.
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Affiliation(s)
- Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - David M Sayah
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John A Belperio
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - S Sam Weigt
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
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Kioumis IP, Zarogoulidis K, Huang H, Li Q, Dryllis G, Pitsiou G, Machairiotis N, Katsikogiannis N, Papaiwannou A, Lampaki S, Porpodis K, Zaric B, Branislav P, Mpoukovinas I, Lazaridis G, Zarogoulidis P. Pneumothorax in cystic fibrosis. J Thorac Dis 2014; 6:S480-7. [PMID: 25337406 DOI: 10.3978/j.issn.2072-1439.2014.09.27] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 09/01/2014] [Indexed: 12/15/2022]
Abstract
Pneumothorax is recognized as a common and life-threatening complication in cystic fibrosis (CF) patients, especially in those who are infected with P. aeruginosa, B. cepacia or Aspergillus, need enteral feeding, are diagnosed as suffering from allergic bronchopulmonary aspergillosis (ABPA), developed massive hemoptysis, and their respiratory function is seriously compromised. Structural impairment and altered airflow dynamics in the lungs of CF patients are considered as the main predisposing factors, but also inhaled medications and non-invasive positive pressure ventilation (NIPPV) could increase the risk of pneumothorax. Clinical presentation could range from dramatic to very mild. Management of spontaneous pneumothorax occurring to patients with CF is essentially similar to that for non-CF patients. Therapeutic options include intercostal tube drainage, video-assisted thoracoscopic surgery (VATS), and medical or surgical pleurodesis. Pneumothorax increases both short- and long-term morbidity and mortality in CF patients and causes significant deterioration of their quality of life.
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Affiliation(s)
- Ioannis P Kioumis
- 1 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200438, China ; 3 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 4 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 5 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 6 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 7 Oncology Department, "Biomedicine" Private Hospital, Thessaloniki, Greece ; 8 Oncology Department, "Papageorgiou" General Hospital, Thessaloniki, Greece
| | - Konstantinos Zarogoulidis
- 1 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200438, China ; 3 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 4 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 5 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 6 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 7 Oncology Department, "Biomedicine" Private Hospital, Thessaloniki, Greece ; 8 Oncology Department, "Papageorgiou" General Hospital, Thessaloniki, Greece
| | - Haidong Huang
- 1 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200438, China ; 3 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 4 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 5 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 6 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 7 Oncology Department, "Biomedicine" Private Hospital, Thessaloniki, Greece ; 8 Oncology Department, "Papageorgiou" General Hospital, Thessaloniki, Greece
| | - Qiang Li
- 1 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200438, China ; 3 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 4 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 5 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 6 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 7 Oncology Department, "Biomedicine" Private Hospital, Thessaloniki, Greece ; 8 Oncology Department, "Papageorgiou" General Hospital, Thessaloniki, Greece
| | - Georgios Dryllis
- 1 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200438, China ; 3 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 4 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 5 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 6 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 7 Oncology Department, "Biomedicine" Private Hospital, Thessaloniki, Greece ; 8 Oncology Department, "Papageorgiou" General Hospital, Thessaloniki, Greece
| | - Georgia Pitsiou
- 1 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200438, China ; 3 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 4 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 5 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 6 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 7 Oncology Department, "Biomedicine" Private Hospital, Thessaloniki, Greece ; 8 Oncology Department, "Papageorgiou" General Hospital, Thessaloniki, Greece
| | - Nikolaos Machairiotis
- 1 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200438, China ; 3 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 4 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 5 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 6 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 7 Oncology Department, "Biomedicine" Private Hospital, Thessaloniki, Greece ; 8 Oncology Department, "Papageorgiou" General Hospital, Thessaloniki, Greece
| | - Nikolaos Katsikogiannis
- 1 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200438, China ; 3 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 4 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 5 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 6 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 7 Oncology Department, "Biomedicine" Private Hospital, Thessaloniki, Greece ; 8 Oncology Department, "Papageorgiou" General Hospital, Thessaloniki, Greece
| | - Antonis Papaiwannou
- 1 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200438, China ; 3 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 4 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 5 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 6 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 7 Oncology Department, "Biomedicine" Private Hospital, Thessaloniki, Greece ; 8 Oncology Department, "Papageorgiou" General Hospital, Thessaloniki, Greece
| | - Sofia Lampaki
- 1 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200438, China ; 3 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 4 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 5 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 6 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 7 Oncology Department, "Biomedicine" Private Hospital, Thessaloniki, Greece ; 8 Oncology Department, "Papageorgiou" General Hospital, Thessaloniki, Greece
| | - Konstantinos Porpodis
- 1 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200438, China ; 3 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 4 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 5 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 6 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 7 Oncology Department, "Biomedicine" Private Hospital, Thessaloniki, Greece ; 8 Oncology Department, "Papageorgiou" General Hospital, Thessaloniki, Greece
| | - Bojan Zaric
- 1 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200438, China ; 3 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 4 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 5 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 6 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 7 Oncology Department, "Biomedicine" Private Hospital, Thessaloniki, Greece ; 8 Oncology Department, "Papageorgiou" General Hospital, Thessaloniki, Greece
| | - Perin Branislav
- 1 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200438, China ; 3 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 4 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 5 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 6 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 7 Oncology Department, "Biomedicine" Private Hospital, Thessaloniki, Greece ; 8 Oncology Department, "Papageorgiou" General Hospital, Thessaloniki, Greece
| | - Ioannis Mpoukovinas
- 1 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200438, China ; 3 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 4 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 5 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 6 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 7 Oncology Department, "Biomedicine" Private Hospital, Thessaloniki, Greece ; 8 Oncology Department, "Papageorgiou" General Hospital, Thessaloniki, Greece
| | - George Lazaridis
- 1 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200438, China ; 3 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 4 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 5 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 6 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 7 Oncology Department, "Biomedicine" Private Hospital, Thessaloniki, Greece ; 8 Oncology Department, "Papageorgiou" General Hospital, Thessaloniki, Greece
| | - Paul Zarogoulidis
- 1 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai 200438, China ; 3 Hematology Department, "Laiko" University General Hospital, Athens, Greece ; 4 Obstetric-Gynecology Department, "Thriassio" General Hospital of Athens, Athens, Greece ; 5 Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 6 Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Serbia; 7 Oncology Department, "Biomedicine" Private Hospital, Thessaloniki, Greece ; 8 Oncology Department, "Papageorgiou" General Hospital, Thessaloniki, Greece
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Experience of extracorporeal membrane oxygenation as a bridge to lung transplantation in France. J Heart Lung Transplant 2014; 32:905-13. [PMID: 23953818 DOI: 10.1016/j.healun.2013.06.009] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 05/16/2013] [Accepted: 06/12/2013] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is increasingly used as a bridge to lung transplantation (LTx). However, data concerning this approach remain limited. METHODS We retrospectively reviewed the medical records of all patients in France who received ECMO as a bridge to LTx from 2007 to 2011. Post-transplant survival and associated factors were assessed by the Kaplan-Meier method and the Cox model. RESULTS Included were 36 patients from 11 centers. Indications for LTx were cystic fibrosis (CF) in 20 (56%), pulmonary fibrosis (PF) in 11 (30%), and other diagnoses in 5 (14%). ECMO was venovenous for 27 patients (75%) and venoarterial for 9 (25%). Mean follow-up was 17 months. Bridging to LTx was achieved in 30 patients (83%); however, only 27 patients (75%) survived the LTx procedure, and 20 (56%) were discharged from hospital. From ECMO initiation, 2-year survival rates were 50.4% overall, 71.0% for CF patients, 27.3% for PF patients, and 20.0% for other patients (p < 0.001). From LTx, 2-year survival rates were 60.5% overall, 71.0% for CF patients, 42.9% for PF patients, and 33.0% for other patients (p = 0.04). CONCLUSIONS Our study confirms that the use of ECMO as a bridge to LTx in France could provide a medium-term survival benefit for LTx recipients with critical conditions. Survival differed by underlying respiratory disease. Larger studies are needed to further define the optimal use of ECMO.
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Jones A, Bilton D, Evans TW, Finney SJ. Predictors of outcome in patients with cystic fibrosis requiring endotracheal intubation. Respirology 2013; 18:630-6. [DOI: 10.1111/resp.12051] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2012] [Revised: 07/25/2012] [Accepted: 10/23/2012] [Indexed: 11/29/2022]
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Abstract
Haemoptysis is a common complication in cystic fibrosis (CF), occurring in approximately 9% of the population. Massive haemoptysis is associated with older patients, more severe disease and carries a high mortality rate. Despite this there are few robust published studies of effective treatments and knowledge of the precise pathogenesis is limited. Current guidelines for treatment from the Cystic Fibrosis Foundation (CFF) are based on consensus opinion of experts. Patients with massive haemoptysis who do not respond to initial medical treatments should undergo bronchial artery embolization. This will control the bleeding in the majority of cases but recurrence rates are high and there are little data to support long-term improved outcomes. Surgery is a last resort in patients with CF.
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Affiliation(s)
- K Hurt
- Department of Respiratory Medicine, Kings College Hospital, Denmark Hill, London, SE5 9RS.
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Management issues for adolescents with cystic fibrosis. Pulm Med 2012; 2012:134132. [PMID: 22991662 PMCID: PMC3444048 DOI: 10.1155/2012/134132] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 08/15/2012] [Indexed: 11/17/2022] Open
Abstract
The healthy adolescent will encounter major changes in biological and psychosocial domains. The adolescent period can be greatly affected by a chronic illness. Cystic fibrosis is a terminal illness that can significantly affect an adolescent's biological, mental and psychosocial health. This paper discusses general issues to consider when managing an adolescent with a chronic medical condition, and specifically how cystic fibrosis may impact upon puberty, body image, risk-taking behaviours, mental health, independence, nonadherence, reproductive health, transition, lung transplantation, and end of life care.
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Abstract
Cystic fibrosis (CF) is an inherited chronic disease that remains a common cause of morbidity and mortality in affected patients, mostly in the young. A wealth of knowledge has been gained into the genetics, pathophysiology, and clinical manifestation of the disease. In parallel with these new insights into the disease, novel treatments have been developed or are under development that have had a major impact on quality of life and survival. Improvement in the delivery of care to patients in CF centers, using a team-based approach, and constant review of process, and by quality improvement projects, have also had an impact on outcomes in CF.
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Affiliation(s)
- Jason Lobo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina, Chapel Hill, 27599-7020, USA
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Dhand R. Aerosol therapy in patients receiving noninvasive positive pressure ventilation. J Aerosol Med Pulm Drug Deliv 2011; 25:63-78. [PMID: 22191396 DOI: 10.1089/jamp.2011.0929] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In selected patients, noninvasive positive pressure ventilation (NIPPV) with a facemask is now commonly employed as the first choice for providing mechanical ventilation in the intensive care unit (ICU). Aerosol therapy for treatment of acute or acute-on-chronic respiratory failure in this setting may be delivered by pressurized metered-dose inhaler (pMDI) with a chamber spacer and facemask or nebulizer and facemask. This article reviews the host of factors influencing aerosol delivery with these devices during NIPPV. These factors include (1) the type of ventilator, (2) mode of ventilation, (3) circuit conditions, (4) type of interface, (5) type of aerosol generator, (6) drug-related factors, (7) breathing parameters, and (8) patient-related factors. Despite the impediments to efficient aerosol delivery because of continuous gas flow, high inspiratory flow rates, air leaks, circuit humidity, and patient-ventilator asynchrony, significant therapeutic effects are achieved after inhaled bronchodilator administration to patients with asthma and chronic obstructive pulmonary disease. Similarly to invasive mechanical ventilation, careful attention to the technique of drug administration is required to optimize therapeutic effects of inhaled therapies during NIPPV. Assessment of the patient's ability to tolerate a facemask, the level of respiratory distress, hemodynamic status, and synchronization of aerosol generation with inspiratory airflow are important factors contributing to the success of aerosol delivery during NIPPV. Further research into novel delivery methods, such as the use of NIPPV with nasal cannulae, could enhance the efficiency, ease of use, and reproducibility of inhalation therapy during noninvasive ventilation.
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Affiliation(s)
- Rajiv Dhand
- Division of Pulmonary, Critical Care, and Environmental Medicine, Department of Internal Medicine, University of Missouri, Columbia, Missouri 65212, USA.
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Dellon EP, Sawicki GS, Shores MD, Wolfe J, Hanson LC. Physician practices for communicating with patients with cystic fibrosis about the use of noninvasive and invasive mechanical ventilation. Chest 2011; 141:1010-1017. [PMID: 21998257 DOI: 10.1378/chest.11-1323] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Many patients with advanced cystic fibrosis (CF) lung disease receive intensive treatments such as noninvasive and invasive mechanical ventilation for respiratory failure after little or no communication with physicians. METHODS Using surveys and follow-up interviews, physicians at two major CF care centers reported their practices for discussing intensive treatment preferences with patients with CF and about barriers and facilitators to communication. RESULTS Surveys were completed by 30 (88%) and 26 (76%) of 34 eligible CF physicians who provide care for children (60%), adults (23%), or both (17%). Respondents described variable timing and content of discussions. They identified patient/family factors such as denial of disease severity, optimistic expectations of treatment outcomes, inability of ill patients to participate in discussions, and family disagreements about treatments as primary barriers to discussions. They also acknowledged physician factors, including concern for taking away hope and uncertainty about when to address treatment preferences. Patient/family factors were also the most common facilitators identified, particularly disease severity and inquiry about intensive treatments. They recommended: (1) developing standards for communication, (2) offering training in communication for physicians, (3) creating decision support tools for patients and families, and (4) using the multidisciplinary CF care team to facilitate communication. CONCLUSIONS CF physicians describe numerous patient/family factors barriers to communicating about intensive treatments for respiratory failure. They recommend changing physician and organizational factors to improve practice and promote effective communication. Innovation in clinical training, team roles, and decision support may prompt changes in practice standards.
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Affiliation(s)
- Elisabeth P Dellon
- Department of Pediatrics, Division of Pulmonology, University of North Carolina, Chapel Hill, NC.
| | - Gregory S Sawicki
- Department of Medicine, Division of Respiratory Diseases, Children's Hospital Boston, Boston, MA
| | - Mitchell D Shores
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
| | - Laura C Hanson
- Department of Medicine, Division of Geriatric Medicine, Palliative Care Program, Chapel Hill, NC
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Sheikh HS, Tiangco ND, Harrell C, Vender RL. Severe hypercapnia in critically ill adult cystic fibrosis patients. J Clin Med Res 2011; 3:209-12. [PMID: 22383907 PMCID: PMC3279481 DOI: 10.4021/jocmr612w] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2011] [Indexed: 01/27/2023] Open
Abstract
Background Cystic fibrosis (CF) is a monogenetic autosomal recessive multi-organ disease affecting approximately 50,000 patients worldwide. Overall median survival is continually increasing but pulmonary disease remains the most common cause of death. Guidelines have been published in relation to the outpatient maintenance of lung health for CF patients and treatment of acute lung exacerbations but little information exists about the management of the critically ill CF patient. Invasive mechanical ventilation in CF patients with acute respiratory failure is associated with poor outcome and high mortality. Methods Retrospective analysis of adult patients with CF who required endotracheal intubation and invasive mechanical ventilation in the Medical Intensive Care Unit (MICU). Results Between the years 2003 - 2009, 14 adult patients with CF required endotracheal intubation and invasive mechanical ventilation in the Medical Intensive Care Unit (MICU) of the Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA. Eleven patients died in the MICU because of progressive respiratory failure and inability to liberate from mechanical ventilation. Seven individuals consistently manifested arterial partial pressures of carbon dioxide (PaCO2) greater than 20.00 kPa despite high levels of conventional modes of mechanical ventilation. Conclusion Intubated CF patients with respiratory failure have a high mortality rate. Based on our experience, multiple factors contribute to severe hypercapnia and the effectiveness of conventional modes of mechanical ventilation in many of these patients is limited. Keywords Cystic fibrosis; Mechanical ventilation; Critical care; Hypercapnia; Respiratory failure
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Affiliation(s)
- Hassan S Sheikh
- Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033, USA
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Hayes D, Mansour HM. Improved Outcomes of Patients with End-stage Cystic Fibrosis Requiring Invasive Mechanical Ventilation for Acute Respiratory Failure. Lung 2011; 189:409-15. [DOI: 10.1007/s00408-011-9311-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Accepted: 06/28/2011] [Indexed: 11/30/2022]
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Sands D, Repetto T, Dupont LJ, Korzeniewska-Eksterowicz A, Catastini P, Madge S. End of life care for patients with cystic fibrosis. J Cyst Fibros 2011; 10 Suppl 2:S37-44. [DOI: 10.1016/s1569-1993(11)60007-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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36
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Urgent lung transplantation in cystic fibrosis patients: experience of a French center. Eur J Cardiothorac Surg 2011; 40:e101-6. [DOI: 10.1016/j.ejcts.2011.04.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Revised: 04/11/2011] [Accepted: 04/18/2011] [Indexed: 11/23/2022] Open
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Chapron J, Zuber B, Kanaan R, Hubert D, Desmazes-Dufeu N, Mira JP, Dusser D, Burgel PR. Prise en charge des complications aiguës sévères chez l’adulte mucoviscidosique. Rev Mal Respir 2011; 28:503-16. [DOI: 10.1016/j.rmr.2010.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Accepted: 11/08/2010] [Indexed: 12/01/2022]
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Dellon EP, Shores MD, Nelson KI, Wolfe J, Noah TL, Hanson LC. Caregiver perspectives on discussions about the use of intensive treatments in cystic fibrosis. J Pain Symptom Manage 2010; 40:821-8. [PMID: 20828981 PMCID: PMC3762977 DOI: 10.1016/j.jpainsymman.2010.03.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2009] [Revised: 03/05/2010] [Accepted: 03/09/2010] [Indexed: 10/19/2022]
Abstract
CONTEXT Intensive treatments intended to sustain life are often used for patients with advanced cystic fibrosis (CF). There are no guidelines for selecting patients whose survival and quality of life may be enhanced by such treatments or for communication with patients and caregivers about possible treatment outcomes. OBJECTIVES We aimed to describe caregivers' perspectives on decision making for the use of intensive treatments for patients with advanced CF lung disease. METHODS We conducted semi-structured interviews with 36 caregivers of 36 patients who died of CF about treatment preference discussions and solicited recommendations for improving discussions. RESULTS Twenty (56%) patients received intensive treatments during the last week of life. Twenty-two (61%) caregivers reported ever having discussed intensive treatment preferences with a physician, and 17 (77%) of these discussions were initiated during an acute illness. Only 14 (39%) of all patients participated. Caregivers expressed less certainty about consistency of treatments with patient preferences when patients did not participate. Twenty-nine (81%) caregivers endorsed first discussing treatment preferences during a period of medical stability. CONCLUSIONS Discussions about preferences for the use of intensive treatments for patients with CF often take place during episodes of acute illness and may be delayed until patients themselves are too ill to participate. Bereaved caregivers suggest first addressing intensive treatment preferences during a stable period so that patient preferences are understood and unwanted treatments are minimized.
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Affiliation(s)
- Elisabeth P Dellon
- Division of Pulmonology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina 27599-7217, USA.
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Rosenthal M. Patients with cystic fibrosis should not be intubated and ventilated. J R Soc Med 2010; 103 Suppl 1:S25-6. [PMID: 20573665 DOI: 10.1258/jrsm.2010.s11006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Affiliation(s)
- Mark Rosenthal
- Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.
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Ketchell I. Patients with cystic fibrosis should be intubated and ventilated. J R Soc Med 2010; 103 Suppl 1:S20-4. [PMID: 20573664 DOI: 10.1258/jrsm.2010.s11005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Ian Ketchell
- All Wales Adult Cystic Fibrosis Centre, University Hospital Llandough, Penlan Road, Penarth CF64 2XX, UK.
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41
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Efrati O, Bylin I, Segal E, Vilozni D, Modan-Moses D, Vardi A, Szeinberg A, Paret G. Outcome of patients with cystic fibrosis admitted to the intensive care unit: is invasive mechanical ventilation a risk factor for death in patients waiting lung transplantation? Heart Lung 2009; 39:153-9. [PMID: 20207276 DOI: 10.1016/j.hrtlng.2009.06.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Revised: 06/12/2009] [Accepted: 06/17/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The admission of patients with cystic fibrosis (CF) to the intensive care unit (ICU) is controversial. Our aim was to study the long-term outcome of patients with CF who were admitted to the ICU and the effect of ventilation modality. METHODS The medical records of 104 admissions (1996-2006) of 48 patients with CF (age 18+/-9 years) were reviewed. Seventeen patients were admitted with reversible conditions (group 1). Thirty-one patients were admitted for acute on chronic respiratory failure (group 2). RESULTS In group 1, 16 of 17 patients survived up to 10 years from ICU admission. Conversely, in group 2, 23 of 31 patients (74%) died of respiratory failure. In group 2, 17 of 18 patients who were mechanically ventilated died within 90 days from admission, and 7 of 10 patients treated for prolonged periods with bi-level positive airway pressure are still alive up to 10 years after admission and transplantation. CONCLUSION Patients requiring mechanical ventilation may have a poor prognosis. The outcome of treatment with bi-level positive airway pressure is good, even in patients who had many episodes of acute respiratory failure.
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Affiliation(s)
- Ori Efrati
- Pediatric Pulmonology Unit, The Edmond and Lili Safra Children's Hospital, Sheba Medical Center Ramat-Gan, Tel Hashomer 52621, Israel.
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Frías Pérez MA, Ibarra de la Rosa I, García Menor E, Santos Luna F, Ulloa Santamaría E, Velasco Jabalquinto MJ, Jaraba Caballero S. [Invasive mechanical ventilation in cystic fibrosis: Influence in lung transplant]. An Pediatr (Barc) 2009; 71:128-34. [PMID: 19604738 DOI: 10.1016/j.anpedi.2009.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2009] [Revised: 04/15/2009] [Accepted: 04/18/2009] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Invasive mechanical ventilation (IMV) in patients with advanced cystic fibrosis (CF) is a relative contraindication for lung transplant (LT) in adults, although there is currently no data on children. PATIENTS AND METHODS An 8-year retrospective study on 21 children with CF who underwent LT was performed, analysing their results as they were receiving (n = 8) or not (n = 13) IMV pretransplant. Demographic and surgical data, postoperative course, lung function and survival (immediate and 1-year) were compared between both groups. The role of the IMV pretransplant as a postoperative risk factor was estimated (odds ratio) and Kaplan Meier survival study was performed in both groups. RESULTS No differences in patient age, sex and nutritional parameters were observed between both groups. Those on IMV who received LT required more frequent and longer bypass, more need for tracheotomy, a higher number of rejection episodes per patient and multiorgan failure, longer PICU stay and longer time on IMV than those who were not on IMV when LT was received. Nevertheless, no differences could be found regarding graft function and immediate and 1-year survivals (62.5% vs. 92.3% with and without IMV respectively). On the other hand, long-term survival was significantly lower than in patients on IMV. CONCLUSIONS In our experience, children with CF on IMV who receive LT have more complicated surgery and immediate postoperative course. Though immediate and 1-year results and survivals may be encouraging, medium and long-term ones are significantly lower.
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Affiliation(s)
- M A Frías Pérez
- Unidad de Cuidados Intensivos Pediátricos, Servicio de Pediatría, Hospital Universitario Reina Sofía, Córdoba, España
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HSU HH, CHEN JS, HUANG SC, KO WJ, KUO SW, LEE YC. Lung transplantation from a deceased donor into an Asian cystic fibrosis patient. Respirology 2009; 14:462-3. [DOI: 10.1111/j.1440-1843.2009.01485.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kremer TM, Zwerdling RG, Michelson PH, O'Sullivan P. Intensive care management of the patient with cystic fibrosis. J Intensive Care Med 2008; 23:159-77. [PMID: 18443012 DOI: 10.1177/0885066608315679] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cystic fibrosis was previously thought to be a disease of childhood. With a better understanding of this condition along with improvements in therapy, patients with cystic fibrosis are now living well into adulthood. The aim of this article is to familiarize the intensive care unit physician with cystic fibrosis care, to discuss complications associated with cystic fibrosis specifically related to the intensive care unit, and to detail the current recommendations for the clinical management of the patient with cystic fibrosis. With advancing disease, the most severely affected organs are the lungs. Obstruction, infection, and inflammation contribute to the decline of pulmonary function, ultimately leading to death. Some patients may be eligible for lung transplantation, but choosing wisely will affect posttransplant survival. Because other organs are affected by the genetic defect and associated treatments, serious complications related to the liver, pancreas, intestines, and kidneys must be considered by the intensivist faced with a patient with cystic fibrosis. As practitioners, the fact that not all patients will survive and help our patients and families gracefully through the end-of-life process should be accepted.
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Affiliation(s)
- Ted M Kremer
- Department of Pediatrics, University of Massachusetts Medical Center, Worcester, Massachusetts 01655, USA.
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Fauroux B, Le Roux E, Ravilly S, Bellis G, Clément A. Long-Term Noninvasive Ventilation in Patients with Cystic Fibrosis. Respiration 2008; 76:168-74. [DOI: 10.1159/000110893] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2007] [Accepted: 07/19/2007] [Indexed: 11/19/2022] Open
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47
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Ford D, Flume PA. Impact of lung transplantation on site of death in cystic fibrosis. J Cyst Fibros 2007; 6:391-5. [PMID: 17448734 DOI: 10.1016/j.jcf.2007.03.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2006] [Revised: 02/13/2007] [Accepted: 03/05/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Cystic fibrosis (CF) remains a lethal condition where a palliative approach is often taken at the end of life. We wanted to evaluate how lung transplantation impacts end of life care in adult CF patients. METHODS Data were abstracted using a standardized data collection instrument from all outpatient and inpatient records of adult CF patients with an FEV1< or =30% or prior lung transplantation followed at our Center. Comparisons were made between those who were listed/received lung transplant and those who were not listed. RESULTS A total of 41 patients met the entry criteria. Of these, 63% (n=26) were referred for lung transplant evaluation and 39% (n=16) had undergone lung transplantation. Of these 41, 59% (n=24) are deceased. The majority of deceased patients expired in an acute care hospital (63%, n=15). There was no difference in site of death between the two groups (hospital versus home). However, listed/transplanted patients were more likely to die in an intensive care unit setting compared to patients not listed/transplanted (p=.013). CONCLUSIONS Most of our CF patients' deaths occurred in an acute care hospital. Lung transplant significantly alters site of death and shifts it from medical floors to the intensive care unit.
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Affiliation(s)
- Dee Ford
- Department of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA.
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Abstract
With the improving survival of patients with cystic fibrosis (CF), the clinical spectrum of this complex multisystem disease continues to evolve. One of the most important clinical events for patients with CF in the course of this disease is an acute pulmonary exacerbation. Clinical and microbial epidemiology studies of CF pulmonary exacerbations continue to provide important insight into the course, prognosis and complications of the disease. This review provides a summary of the pathophysiology, clinical epidemiology and microbial epidemiology of a CF pulmonary exacerbation.
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Affiliation(s)
- Christopher H Goss
- Department of Medicine, University of Washington Medical Center, Campus Box 356522, 1959 NE Pacific, Seattle, Washington 98195, USA.
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Dellon EP, Leigh MW, Yankaskas JR, Noah TL. Effects of lung transplantation on inpatient end of life care in cystic fibrosis. J Cyst Fibros 2007; 6:396-402. [PMID: 17481967 PMCID: PMC4394360 DOI: 10.1016/j.jcf.2007.03.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2006] [Revised: 01/31/2007] [Accepted: 03/13/2007] [Indexed: 12/20/2022]
Abstract
BACKGROUND The impact of lung transplantation on end of life care in cystic fibrosis (CF) has not been widely investigated. METHODS Information about end of life care was collected from records of all patients who died in our hospital from complications of CF between 1995 and 2005. Transplant and non-transplant patients were compared. RESULTS Of 38 patients who died, 20 (53%) had received or were awaiting lung transplantation ("transplant" group), and 18 (47%) were not referred, declined transplant, or were removed from the waiting list ("non-transplant"). Transplant patients were more likely than non-transplant patients to die in the intensive care unit (17 (85%) versus 9 (50%); P=0.04). 16 (80%) transplant patients remained intubated at or shortly before death, versus 7 (39%) non-transplant patients (P=0.02). Do-not-resuscitate orders were written later for transplant patients; 12 (60%) on the day of death versus 5 (28%) in non-transplant patients (P=0.02). Transplant patients were less likely to participate in this decision. Alternatives to hospital death were rarely discussed. CONCLUSIONS Receiving or awaiting lung transplantation affords more aggressive inpatient end of life care. Despite the chronic nature of CF and knowledge of a shortened life span, discussions about terminal care are often delayed until patients themselves are unable to participate.
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Affiliation(s)
- Elisabeth P Dellon
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC 27599-7220, USA.
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Efrati O, Kremer MR, Barak A, Augarten A, Reichart N, Vardi A, Modan-Moses D. Improved Survival Following Lung Transplantation with Long-Term Use Of Bilevel Positive Pressure Ventilation in Cystic Fibrosis. Lung 2007; 185:73-9. [PMID: 17393239 DOI: 10.1007/s00408-006-0036-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2006] [Indexed: 10/23/2022]
Abstract
Bilevel positive airway pressure ventilation (BIPAP) has been used in cystic fibrosis (CF) patients as a bridge to transplantation. Our aim was to evaluate the effect of BIPAP use before transplantation on post-transplantation morbidity and mortality. We performed a retrospective study at a tertiary care center. Twelve CF patients (9 males; mean age = 26 years) were assessed. Group 1 consisted of eight patients that did not use BIPAP before lung transplantation. Group 2 comprised four patients who used BIPAP for 3-15 months while awaiting transplantation. Patients were evaluated before and two to ten years after transplantation. All eight patients who did not use BIPAP died two months to ten years after transplantation. All four BIPAP users are alive with no evidence of bronchiolitis obliterans two to eight years after lung transplantation. We demonstrated a significant improvement in acid-base balance (p < 0.01) and body mass index (p < 0.05) and a tendency toward improvement in the work of breathing and number of hospitalizations. We conclude that improvement in nutritional status and respiratory muscle strength before lung transplantation in BIPAP users may prevent post lung transplantation infection and acute rejection rate, which in turn may reduce chronic rejection (bronchiolitis obliterans) and improve long-term survival after lung transplantation.
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Affiliation(s)
- Ori Efrati
- Pediatric Pulmonology Unit, Safra Children's Hospital, The Chaim Sheba Medical Center, 25621, Tel-Hashomer, Israel.
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