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Mocellin A, Guidotti F, Rizzato S, Tacconi M, Bruzzi G, Messina J, Puggioni D, Patsoura A, Fantini R, Tabbì L, Castaniere I, Marchioni A, Clini E, Tonelli R. Monitoring and modulation of respiratory drive in patients with acute hypoxemic respiratory failure in spontaneous breathing. Intern Emerg Med 2024:10.1007/s11739-024-03715-3. [PMID: 39207721 DOI: 10.1007/s11739-024-03715-3] [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: 06/10/2024] [Accepted: 07/10/2024] [Indexed: 09/04/2024]
Abstract
Non-invasive respiratory support, namely, non-invasive ventilation, continuous positive airway pressure, and high-flow nasal cannula, has been increasingly used worldwide to treat acute hypoxemic respiratory failure, giving the benefits of keeping spontaneous breathing preserved. In this scenario, monitoring and controlling respiratory drive could be helpful to avoid patient self-inflicted lung injury and promptly identify those patients that require an upgrade to invasive mechanical ventilation. In this review, we first describe the physiological components affecting respiratory drive to outline the risks associated with its hyperactivation. Further, we analyze and compare the leading strategies implemented for respiratory drive monitoring and discuss the sedative drugs and the non-pharmacological approaches used to modulate respiratory drive during non-invasive respiratory support. Refining the available techniques and rethinking our therapeutic and monitoring targets can help critical care physicians develop a personalized and minimally invasive approach.
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Affiliation(s)
- Anna Mocellin
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Federico Guidotti
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Simone Rizzato
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Matteo Tacconi
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Giulia Bruzzi
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Jacopo Messina
- Internal Medicine Unit, University of Rome, Roma 1, Rome, Italy
| | - Daniele Puggioni
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Athina Patsoura
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Riccardo Fantini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Luca Tabbì
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Ivana Castaniere
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Alessandro Marchioni
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy.
| | - Enrico Clini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Roberto Tonelli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
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Abstract
Hypercapnia is commonly encountered by general and specialist respiratory clinicians. Patients at risk of developing hypercapnic respiratory failure include those with chronic obstructive pulmonary disease (COPD), obesity and neuromuscular disease. Such patients may present to clinicians acutely unwell on the acute medical take or during an inpatient deterioration, or be identified in the stable outpatient setting. In this review, we provide a practical guide to develop clinicians' knowledge, skills and confidence in promptly recognising and managing hypercapnic respiratory failure, and to promote national ventilation quality standards to encourage consistent delivery of high-quality care and optimise outcomes for patients.
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Affiliation(s)
- Laura Tregidgo
- Lane Fox Respiratory Unit, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Rebecca F D'Cruz
- Lane Fox Respiratory Unit, Guys and St Thomas' NHS Foundation Trust, London, UK; Centre for Human and Applied Physiological Sciences, King's College London, London, UK.
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Abdelbaky AM, Elmasry WG, Awad AH, Khan S, Jarrahi M. The Impact of High-Flow Nasal Cannula Therapy on Acute Respiratory Distress Syndrome Patients: A Systematic Review. Cureus 2023; 15:e41219. [PMID: 37397646 PMCID: PMC10313388 DOI: 10.7759/cureus.41219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2023] [Indexed: 07/04/2023] Open
Abstract
High-flow nasal cannula (HFNC) is a novel oxygenation approach in the management of acute respiratory distress syndrome (ARDS). This systematic review was focused on evaluating current evidence concerning the efficacy of HFNC in ARDS and its comparison with standard treatment approaches. For this review, a systematic search was undertaken in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Web of Science, Cochrane Library, and Google Scholar to identify relevant studies. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. All those studies that investigated the impact of HFNC on ARDS patients and were published in the English language were included. The literature search from all databases provided 6157 potentially relevant articles from PubMed (n = 1105), CINAHL (n = 808), Web of Science (n = 811), Embase (n = 2503), Cochrane database (n = 930), and Google Scholar (n = 46). After the exclusion of studies that did not fulfill the criteria, 18 studies were shortlisted for the scope of this systematic review. Among the included studies, five focused on HFNC's impact on COVID-19-related ARDS, whereas 13 studies focused on HFNC's impact on ARDS patients. Most studies demonstrated the efficacy of HFNC in managing ARDS, with some studies showing comparable efficacy and higher safety compared to noninvasive ventilation (NIV). This systematic review highlights the potential benefits of HFNC in ARDS management. The findings show that HFNC is effective in reducing the respiratory distress symptoms, the incidence of invasive ventilation, and the adverse events associated with ARDS. These findings can help clinical decision-making processes and contribute to the evidence base for optimal ARDS management strategies.
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Affiliation(s)
- Ahmed M Abdelbaky
- Intensive Care Unit, Dubai Academic Health Corporation - Rashid Hospital, Dubai, ARE
| | - Wael G Elmasry
- Intensive Care Unit, Dubai Academic Health Corporation - Rashid Hospital, Dubai, ARE
| | - Ahmed H Awad
- Intensive Care Unit, Dubai Academic Health Corporation - Rashid Hospital, Dubai, ARE
| | - Sarrosh Khan
- Internal Medicine, Dubai Academic Health Corporation - Rashid Hospital, Dubai, ARE
| | - Maryam Jarrahi
- Internal Medicine, Dubai Academic Health Corporation - Rashid Hospital, Dubai, ARE
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Abrard S, Rineau E, Seegers V, Lebrec N, Sargentini C, Jeanneteau A, Longeau E, Caron S, Callahan JC, Chudeau N, Beloncle F, Lasocki S, Dupoiron D. Postoperative prophylactic intermittent noninvasive ventilation versus usual postoperative care for patients at high risk of pulmonary complications: a multicentre randomised trial. Br J Anaesth 2023; 130:e160-e168. [PMID: 34996593 DOI: 10.1016/j.bja.2021.11.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Pulmonary complications are an important cause of morbidity and mortality after surgery. We evaluated the clinical effectiveness of noninvasive ventilation (NIV) in preventing postoperative acute respiratory failure. METHODS This is an open, multicentre randomised trial that included patients at high risk of postoperative pulmonary complications after elective or semi-urgent surgery with an Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score ≥45. Patients were randomly assigned to intermittent prophylactic face-mask NIV for 6-8 h day-1 or usual postoperative care. The primary outcome was in-hospital acute respiratory failure within 7 days after surgery. Patients who underwent surgery and postoperative extubation were included in the modified intended-to-treat analysis. Results are presented as n (%) and odds ratios (ORs) with 95% confidence intervals. RESULTS Between November 2017 and October 2019, 266 patients were randomised and 253 included in the main analysis. Of these, 203 (80.2%) were male with a mean age of 68 (11) yr and an ARISCAT score of 53 (6); 237 subjects (93.7%) underwent cardiac or thoracic surgery. There were 125 patients allocated to prophylactic NIV and 128 to usual care. Unplanned treatment termination occurred in 58 subjects in the NIV group, which was linked to NIV discomfort for 36 subjects. There was no difference in the incidence of the primary outcome of postoperative acute respiratory failure between treatment groups (NIV: 30 of 125 subjects [24.0%] vs usual care: 35 of 128 subjects [27.3%]; OR 0.97 [0.90-1.04]; P=0.54). CONCLUSIONS Prophylactic NIV was difficult to implement after high-risk surgery because of low patient compliance. Prophylactic NIV did not prevent acute respiratory failure. CLINICAL TRIAL REGISTRATION NCT03629431 and EudraCT 2017-001011-36.
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Affiliation(s)
- Stanislas Abrard
- Department of Anesthesiology and Intensive Care, University Hospital of Angers, Angers, France; MITOVASC Institute, INSERM 1083, CNRS 6015, University of Angers, Angers, France; Department of Anesthesiology and Critical Care Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France.
| | - Emmanuel Rineau
- Department of Anesthesiology and Intensive Care, University Hospital of Angers, Angers, France; MITOVASC Institute, INSERM 1083, CNRS 6015, University of Angers, Angers, France
| | - Valerie Seegers
- Department of Clinical Research, Integrated Center for Oncology Paul Papin, Angers, France
| | - Nathalie Lebrec
- Anesthesiology and Pain Medicine Department, Integrated Center for Oncology Paul Papin, Angers, France
| | - Cyril Sargentini
- Department of Anesthesiology and Intensive Care, University Hospital of Angers, Angers, France
| | - Audrey Jeanneteau
- Department of Anesthesiology and Intensive Care, University Hospital of Angers, Angers, France
| | - Emmanuelle Longeau
- Department of Anesthesiology and Intensive Care, University Hospital of Angers, Angers, France
| | - Sigrid Caron
- Department of Anesthesiology, Le Mans Hospital, Le Mans, France
| | | | - Nicolas Chudeau
- Department of Intensive Care, Le Mans Hospital, Le Mans, France
| | - François Beloncle
- Medical Intensive Care Department, University Hospital of Angers, Angers, France
| | - Sigismond Lasocki
- Department of Anesthesiology and Intensive Care, University Hospital of Angers, Angers, France
| | - Denis Dupoiron
- Anesthesiology and Pain Medicine Department, Integrated Center for Oncology Paul Papin, Angers, France
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Ferrone G, Spinazzola G, Costa R, Piastra M, Maresca G, Antonelli M, Conti G. Influence of total face masks design and circuit on synchrony and performance during pressure support ventilation: A bench study. Respir Med Res 2022; 82:100963. [DOI: 10.1016/j.resmer.2022.100963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
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Pierucci P, Portacci A, Carpagnano GE, Banfi P, Crimi C, Misseri G, Gregoretti C. The right interface for the right patient in noninvasive ventilation: a systematic review. Expert Rev Respir Med 2022; 16:931-944. [PMID: 36093799 DOI: 10.1080/17476348.2022.2121706] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Research in the field of noninvasive ventilation (NIV) has contributed to the development of new NIV interfaces. However, interface tolerance plays a crucial role in determining the beneficial effects of NIV therapy. AREAS COVERED This systematic review explores the most significant scientific research on NIV interfaces, with a focus on the potential impact that their design might have on treatment adherence and clinical outcomes. The rationale on the choice of the right interface among the wide variety of devices that are currently available is discussed here. EXPERT OPINION The paradigm "The right mask for the right patient" seems to be difficult to achieve in real life. Ranging from acute to chronic settings, the gold standard should include the tailoring of NIV interfaces to patients' needs and preferences. However, such customization may be hampered by issues of economic nature. High production costs and the increasing demand represent consistent burdens and have to be considered when dealing with patient-tailored NIV interfaces. New research focusing on developing advanced and tailored NIV masks should be prioritized; indeed, interfaces should be designed according to the specific patient and clinical setting where they need to be used.
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Affiliation(s)
- Paola Pierucci
- A. Cardiothoracic Department, Respiratory and Critical care Unit Bari Policlinic University Hospital, B. Section of Respiratory Diseases, Dept. of Basic Medical Science Neuroscience and Sense Organs, University of Bari 'Aldo Moro'
| | - Andrea Portacci
- A. Cardiothoracic Department, Respiratory and Critical care Unit Bari Policlinic University Hospital, B. Section of Respiratory Diseases, Dept. of Basic Medical Science Neuroscience and Sense Organs, University of Bari 'Aldo Moro'
| | - Giovanna Elisiana Carpagnano
- A. Cardiothoracic Department, Respiratory and Critical care Unit Bari Policlinic University Hospital, B. Section of Respiratory Diseases, Dept. of Basic Medical Science Neuroscience and Sense Organs, University of Bari 'Aldo Moro'
| | - Paolo Banfi
- IRCCS Fondazione Don Carlo Gnocchi, Milano,Italy
| | - Claudia Crimi
- Respiratory Medicine Unit, "Policlinico-Vittorio Emanuele San Marco" University Hospital, Catania, Italy
| | | | - Cesare Gregoretti
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy and Fondazione Istituto "G.Giglio" Cefalù', Palermo, Italy
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7
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Karim HMR, Šarc I, Calandra C, Spadaro S, Mina B, Ciobanu LD, Gonçalves G, Caldeira V, Cabrita B, Perren A, Fiorentino G, Utku T, Piervincenzi E, El-Khatib M, Alpay N, Ferrari R, Abdelrahim MEA, Saeed H, Madney YM, Harb HS, Vargas N, Demirkiran H, Bhakta P, Papadakos P, Gómez-Ríos MÁ, Abad A, Alqahtani JS, Hadda V, Singha SK, Esquinas AM. Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations. Indian J Crit Care Med 2022; 26:938-948. [PMID: 36042773 PMCID: PMC9363803 DOI: 10.5005/jp-journals-10071-23950] [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] [Indexed: 11/28/2022] Open
Abstract
Aim This systematic review aimed to investigate the drugs used and their potential effect on noninvasive ventilation (NIV). Background NIV is used increasingly in acute respiratory failure (ARF). Sedation and analgesia are potentially beneficial in NIV, but they can have a deleterious impact. Proper guidelines to specifically address this issue and the recommendations for or against it are scarce in the literature. In the most recent guidelines published in 2017 by the European Respiratory Society/American Thoracic Society (ERS/ATS) relating to NIV use in patients having ARF, the well-defined recommendation on the selective use of sedation and analgesia is missing. Nevertheless, some national guidelines suggested using sedation for agitation. Methods Electronic databases (PubMed/Medline, Google Scholar, and Cochrane library) from January 1999 to December 2019 were searched systematically for research articles related to sedation and analgosedation in NIV. A brief review of the existing literature related to sedation and analgesia was also done. Review results Sixteen articles (five randomized trials) were analyzed. Other trials, guidelines, and reviews published over the last two decades were also discussed. The present review analysis suggests dexmedetomidine as the emerging sedative agent of choice based on the most recent trials because of better efficacy with an improved and predictable cardiorespiratory profile. Conclusion Current evidence suggests that sedation has a potentially beneficial role in patients at risk of NIV failure due to interface intolerance, anxiety, and pain. However, more randomized controlled trials are needed to comment on this issue and formulate strong evidence-based recommendations. How to cite this article Karim HMR, Šarc I, Calandra C, Spadaro S, Mina B, Ciobanu LD, et al. Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations. Indian J Crit Care Med 2022;26(8):938–948.
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Affiliation(s)
- Habib MR Karim
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
- Habib MR Karim, Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India, Phone: +91 9612372585, e-mail:
| | - Irena Šarc
- Department of Morphology, Surgery and Experimental Medicine, Section of Anesthesiology and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Camilla Calandra
- Department of Morphology, Surgery and Experimental Medicine, Section of Anesthesiology and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Savino Spadaro
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Northwell Health, Lenox Hill Hospital, New York, New York, United States
| | - Bushra Mina
- Department of Internal Medicine, University of Medicine and Pharmacy “Grigore T Popa”, Iasi, Romania; Consultant in Internal Medicine and Pulmonology, Clinical Hospital of Rehabilitation, Iasi, Romania
| | - Laura D Ciobanu
- Pulmonology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Gil Gonçalves
- Pulmonology Department, Santa Marta Hospital, Lisbon, Portugal
| | - Vania Caldeira
- Pulmonology Department, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Bruno Cabrita
- Department of Intensive Care Medicine EOC, Ospedale Regionale Bellinzona e Valli, Bellinzona, Switzerland
| | - Andreas Perren
- Respiratory Unit, AO dei Colli Monaldi Hospital, Naples, Italy
| | - Giuseppe Fiorentino
- Department of Anaesthesiology and Reanimation, General Intensive Care, Yeditepe University Medical Faculty, Istanbul, Turkey
| | - Tughan Utku
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Italy; Anesthesia, Emergency and Intensive Care Medicine, Agostino Gemelli University Policlinic, IRCCS, Italy
| | - Edoardo Piervincenzi
- Department of Anesthesiology, American University of Beirut-Medical Center, Beirut, Lebanon
| | - Mohamad El-Khatib
- Department of Anesthesiology and Reanimation, Cukurova University Faculty of Dentistry, Adana, Turkey
| | - Nilgün Alpay
- Emergency Department, Santa Maria della Scaletta Hospital, AUSL Imola, Imola, Italy
| | - Rodolfo Ferrari
- Noninvasive Ventilation Department, University Clinic for Pulmonary and Allergic Diseases, Golnik, Slovenia
| | - Mohamed EA Abdelrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Haitham Saeed
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Yasmin M Madney
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Hadeer S Harb
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Nicola Vargas
- Geriatric and Intensive Geriatric Cares Unit, Medicine Department, “San Giuseppe Moscati” Hospital, Avellino, Italy
| | - Hilmi Demirkiran
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Van Yuzuncu Yil University, Van, Turkey
| | - Pradipta Bhakta
- Department of Anaesthesia and Intensive Care, Cork University Hospital, Cork, Ireland
| | - Peter Papadakos
- Department of Anesthesiology, University of Rochester, Rochester, New York, United States
| | - Manuel Á Gómez-Ríos
- Department of Anesthesia and Perioperative Medicine, Complejo Hospitalario Universitario de A Coruña, Galicia, Spain
| | - Alfredo Abad
- Anestesia y Reanimación, Hospital Universitario La Paz, Madrid, Spain
| | - Jaber S Alqahtani
- Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dammam, Saudi Arabia
| | - Vijay Hadda
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Subrata K Singha
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
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Non-Invasive Ventilation as a Therapy Option for Acute Exacerbations of Chronic Obstructive Pulmonary Disease and Acute Cardiopulmonary Oedema in Emergency Medical Services. J Clin Med 2022; 11:jcm11092504. [PMID: 35566628 PMCID: PMC9102097 DOI: 10.3390/jcm11092504] [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: 03/24/2022] [Revised: 04/24/2022] [Accepted: 04/26/2022] [Indexed: 11/16/2022] Open
Abstract
In this observational prospective multicenter study conducted between October 2016 and October 2018, we tested the hypothesis that the use of prehospital non-invasive ventilation (phNIV) to treat patients with acute respiratory insufficiency (ARI) caused by severe acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and acute cardiopulmonary oedema (ACPE) is effective, time-efficient and safe. The data were collected at four different physician response units and three admitting hospitals in a German EMS system. Patients with respiratory failure due to acute exacerbation of chronic obstructive pulmonary disease and acute cardiopulmonary oedema were enrolled. A total of 545 patients were eligible for the final analysis. Patients were treated with oxygen supplementation, non-invasive ventilation or invasive mechanical ventilation. The primary outcomes were defined as changes in the clinical parameters and the in-hospital course. The secondary outcomes included time efficiency, peri-interventional complications, treatment failure rate, and side-effects. Oxygenation under phNIV improved equally to endotracheal intubation (ETI), and more effectively in comparison to standard oxygen therapy (SOT) (paO2 SOT vs. non-invasive ventilation (NIV) vs. ETI: 82 mmHg vs. 125 mmHg vs. 135 mmHg, p-value SOT vs. NIV < 0.0001). In a matched subgroup analysis phNIV was accompanied by a reduced time of mechanical ventilation (phNIV: 1.8 d vs. ETI: 4.2 d) and a shortened length of stay at the intensive care unit (3.4 d vs. 5.8 d). The data support the hypothesis that the treatment of severe AECOPD/ACPE-induced ARI using prehospital NIV is effective, time efficient and safe. Compared to ETI, a matched comparison supports the hypothesis that prehospital implementation of NIV may provide benefits for an in-hospital course.
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9
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Cammarota G, Simonte R, De Robertis E. Comfort During Non-invasive Ventilation. Front Med (Lausanne) 2022; 9:874250. [PMID: 35402465 PMCID: PMC8988041 DOI: 10.3389/fmed.2022.874250] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/28/2022] [Indexed: 01/03/2023] Open
Abstract
Non-invasive ventilation (NIV) has been shown to be effective in avoiding intubation and improving survival in patients with acute hypoxemic respiratory failure (ARF) when compared to conventional oxygen therapy. However, NIV is associated with high failure rates due, in most cases, to patient discomfort. Therefore, increasing attention has been paid to all those interventions aimed at enhancing patient's tolerance to NIV. Several practical aspects have been considered to improve patient adaptation. In particular, the choice of the interface and the ventilatory setting adopted for NIV play a key role in the success of respiratory assistance. Among the different NIV interfaces, tolerance is poorest for the nasal and oronasal masks, while helmet appears to be better tolerated, resulting in longer use and lower NIV failure rates. The choice of fixing system also significantly affects patient comfort due to pain and possible pressure ulcers related to the device. The ventilatory setting adopted for NIV is associated with varying degrees of patient comfort: patients are more comfortable with pressure-support ventilation (PSV) than controlled ventilation. Furthermore, the use of electrical activity of the diaphragm (EADi)-driven ventilation has been demonstrated to improve patient comfort when compared to PSV, while reducing neural drive and effort. If non-pharmacological remedies fail, sedation can be employed to improve patient's tolerance to NIV. Sedation facilitates ventilation, reduces anxiety, promotes sleep, and modulates physiological responses to stress. Judicious use of sedation may be an option to increase the chances of success in some patients at risk for intubation because of NIV intolerance consequent to pain, discomfort, claustrophobia, or agitation. During the Coronavirus Disease-19 (COVID-19) pandemic, NIV has been extensively employed to face off the massive request for ventilatory assistance. Prone positioning in non-intubated awake COVID-19 patients may improve oxygenation, reduce work of breathing, and, possibly, prevent intubation. Despite these advantages, maintaining prone position can be particularly challenging because poor comfort has been described as the main cause of prone position discontinuation. In conclusion, comfort is one of the major determinants of NIV success. All the strategies aimed to increase comfort during NIV should be pursued.
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Pierucci P, Di Lecce V, Carpagnano GE, Banfi P, Bach JR. The Intermittent Abdominal Pressure Ventilator as an Alternative Modality of Noninvasive Ventilatory Support: A Narrative Review. Am J Phys Med Rehabil 2022; 101:179-183. [PMID: 34091472 DOI: 10.1097/phm.0000000000001804] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Noninvasive ventilation has become the initial treatment for symptomatic ventilatory pump failure but, when used at ventilatory support settings, can be an alternative to tracheostomy mechanical ventilation. The intermittent abdominal pressure ventilator, a corset with an internal air sack inflated by a ventilator, allows to increase tidal volumes through the raising of the diaphragm and its consequent passive descent. It has been used for daytime support for more than 70 yrs, but its knowledge among clinicians is scarce. A narrative review was performed by searching PubMed, Medline, and the Cochrane Database of Systematic Reviews using the terms "IAPV" or "pneumobelt." One hundred forty patients were cited using the intermittent abdominal pressure ventilator from 1946 until it went off the market in the 1970s, although many continued to use it. There was only one publication on its use from 2003 to 2017, but three publications from 2017 through 2021. It has been used for full diurnal ventilatory support by some patients for more than 50 yrs and has even been used throughout the labor of a mother with no ventilator-free breathing ability. The intermittent abdominal pressure ventilator is a ventilatory support alternative for patients with ventilatory pump failure. It can be effective and well tolerated and maintain quality of life without facial interfaces. More widespread application is warranted.
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Affiliation(s)
- Paola Pierucci
- From the Institute of Respiratory Disease, Department of Basic Medical Science, Neuroscience and Sensory Organs, University of Bari "Aldo Moro," Bari, Italy (PP, VDL, GEC); Pulmonary Rehabilitation Unit, Don Carlo Gnocchi Foundation, Milan, Italy (PB); and Department of Physical Medicine and Rehabilitation, Rutgers University New Jersey Medical School, Newark, New Jersey (JRB)
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11
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Hovenier R, Goto L, Huysmans T, van Gestel M, Klein-Blommert R, Markhorst D, Dijkman C, Bem RA. Reduced Air Leakage During Non-Invasive Ventilation Using a Simple Anesthetic Mask With 3D-Printed Adaptor in an Anthropometric Based Pediatric Head-Lung Model. Front Pediatr 2022; 10:873426. [PMID: 35573957 PMCID: PMC9096156 DOI: 10.3389/fped.2022.873426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/29/2022] [Indexed: 11/16/2022] Open
Abstract
Non-invasive ventilation (NIV) is increasingly used in the support of acute respiratory failure in critically ill children admitted to the pediatric intensive care unit (PICU). One of the major challenges in pediatric NIV is finding an optimal fitting mask that limits air leakage, in particular for young children and those with specific facial features. Here, we describe the development of a pediatric head-lung model, based on 3D anthropometric data, to simulate pediatric NIV in a 1-year-old child, which can serve as a tool to investigate the effectiveness of NIV masks. Using this model, the primary aim of this study was to determine the extent of air leakage during NIV with our recently described simple anesthetic mask with a 3D-printed quick-release adaptor, as compared with a commercially available pediatric NIV mask. The simple anesthetic mask provided a better seal resulting in lower air leakage at various positive pressure levels as compared with the commercial mask. These data further support the use of the simple anesthetic mask as a reasonable alternative during pediatric NIV in the acute setting. Moreover, the pediatric head-lung model provides a promising tool to study the applicability and effectiveness of customized pediatric NIV masks in the future.
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Affiliation(s)
- Renée Hovenier
- Pediatric Intensive Care Unit, Emma Children's Hospital, Amsterdam University Medical Centers, Location AMC, Amsterdam, Netherlands.,Department of Technical Medicine, University of Twente, Enschede, Netherlands
| | - Lyè Goto
- Faculty of Industrial Design Engineering, Delft University of Technology, Delft, Netherlands
| | - Toon Huysmans
- Faculty of Industrial Design Engineering, Delft University of Technology, Delft, Netherlands.,Imec-Vision Lab, Department of Physics, University of Antwerp, Antwerp, Belgium
| | - Monica van Gestel
- Pediatric Intensive Care Unit, Emma Children's Hospital, Amsterdam University Medical Centers, Location AMC, Amsterdam, Netherlands
| | - Rozalinde Klein-Blommert
- Pediatric Intensive Care Unit, Emma Children's Hospital, Amsterdam University Medical Centers, Location AMC, Amsterdam, Netherlands
| | - Dick Markhorst
- Pediatric Intensive Care Unit, Emma Children's Hospital, Amsterdam University Medical Centers, Location AMC, Amsterdam, Netherlands
| | - Coen Dijkman
- Department for Medical Innovation and Development, Amsterdam University Medical Centers, Location AMC, Amsterdam, Netherlands
| | - Reinout A Bem
- Pediatric Intensive Care Unit, Emma Children's Hospital, Amsterdam University Medical Centers, Location AMC, Amsterdam, Netherlands
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12
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Agarwal KM, Sharma P, Bhatia D, Mishra A. Concept design of the physical structure for ICU ventilators for COVID-19 pandemic. SENSORS INTERNATIONAL 2021; 2:100092. [PMID: 34766052 PMCID: PMC8080500 DOI: 10.1016/j.sintl.2021.100092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 03/16/2021] [Accepted: 03/16/2021] [Indexed: 11/26/2022] Open
Abstract
A new disease known as COVID-19 caused by the SARS CoV2 virus has engulfed the entire world and led to a global pandemic situation. Till December 9, 2020, the disease has infected 68 million people worldwide and more than 1.56 million people have been killed. The origin of the COVID-19 disease has been traced back to the bats, but the intermediary contact is unknown. The disease spreads by respiratory droplets and contaminated surfaces. In most cases, the virus shows mild symptoms such as fever, fatigue, dyspnea, cough, etc. which may become severe if appropriate precautions are not adhered to. For people with comorbidities (usually elderly) the disease may turn deadly and cause pneumonia, Acute Respiratory Distress Syndrome (ARDS), and multi-organ failure, thereby affecting a person's ability to perform normal breathing which may put them on ventilator support. The virus causes Acute Respiratory Distress Syndrome (ARDS) that can lead to multi-organ failure in the most severe form. A patient suffering from ARDS must be put on a mechanical ventilator. These assistive devices help patients with respiratory disorders perform normal breathing. Presently nearly sixty thousand COVID-19 patients are in critical condition worldwide, fighting for survival requiring ventilator support. In India, the number stands close to eight thousand such individuals especially when the second wave of COVID-19 is expected to spread globally with initial signs arising from European and Middle East countries. With a large number of patients requiring ventilators, it puts a huge strain on the already weak health infrastructure of the developing countries. This is where some manufacturing and automobile companies have stepped in to help hospitals by developing ventilators at a faster rate and lower costs without comprising on the quality with the support of different government initiatives. This paper aims to study the basic requirements to be considered while designing the physical structure of an elementary level ICU ventilator for the hospital environment. The challenges related to research in electronic wiring of a mechanical ventilator, the overall structural design, and surrounding base could be appropriately done for different loads by simulating the conditions on tools like ANSYS software with accurate dimensions which could improve their future designs.
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Affiliation(s)
- Krishna Mohan Agarwal
- Mechanical Engineering Department, Amity University, Uttar Pradesh, Noida, 201313, India
| | - Prairit Sharma
- Mechanical Engineering Department, Amity University, Uttar Pradesh, Noida, 201313, India
| | - Dinesh Bhatia
- Department of Biomedical Engineering, North Eastern Hill University, Shillong, 793022, Meghalaya, India
| | - Animesh Mishra
- Department of Cardiology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, 793018, Meghalaya, India
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13
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Wolfe LF, Benditt JO, Aboussouan L, Hess DR, Coleman JM. Optimal NIV Medicare Access Promotion: Patients With Thoracic Restrictive Disorders: A Technical Expert Panel Report From the American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society. Chest 2021; 160:e399-e408. [PMID: 34339688 PMCID: PMC8828932 DOI: 10.1016/j.chest.2021.05.075] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 11/30/2022] Open
Abstract
The existing coverage criteria for noninvasive ventilation (NIV) do not recognize the benefits of early initiation of NIV for those with thoracic restrictive disorders and do not address the unique needs for daytime support as the patients progress to ventilator dependence. This document summarizes the work of the thoracic restrictive disorder Technical Expert Panel working group. The most pressing current coverage barriers identified were: (1) delays in implementing NIV treatment; (2) lack of coverage for many nonprogressive neuromuscular diseases; and (3) lack of clear policy indications for home mechanical ventilation (HMV) support in thoracic restrictive disorders. To best address these issues, we make the following key recommendations: (1) given the need to encourage early initiation of NIV with bilevel positive airway pressure devices, we recommend that symptoms be considered as a reason to initiate therapy even at mildly reduced FVCs; (2) broaden CO2 measurements to include surrogates such as transcutaneous, end-tidal, or venous blood gas; (3) expand the diagnostic category to include phrenic nerve injuries and disorders of central drive; (4) allow a bilevel positive airway pressure device to be advanced to an HMV when the vital capacity is < 30% or to address severe daytime respiratory symptoms; and (5) provide additional HMV when the patient is ventilator dependent with use > 18 h per day. Adoption of these proposed recommendations would result in the right device, at the right time, for the right type of patients with thoracic restrictive disorders.
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Affiliation(s)
- Lisa F Wolfe
- Pulmonary Medcine, Northwestern University, Chicago, IL.
| | | | | | - Dean R Hess
- Department of Respiratory Therapy, Massachusetts General Hospital, Boston, MA
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14
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Zhang R, Bai L, Han X, Huang S, Zhou L, Duan J. Incidence, characteristics, and outcomes of delirium in patients with noninvasive ventilation: a prospective observational study. BMC Pulm Med 2021; 21:157. [PMID: 33975566 PMCID: PMC8111378 DOI: 10.1186/s12890-021-01517-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 04/28/2021] [Indexed: 01/09/2023] Open
Abstract
Background Factors that may increase the risk for delirium and the firm knowledge around mechanism for delirium in noninvasive ventilation (NIV) patients is lacking. We investigated the incidence, characteristics, and outcomes of delirium in NIV patients. Methods A prospective observational study was performed in an intensive care unit (ICU) of a teaching hospital. Patients in whom NIV was used as a first-line intervention were enrolled. During NIV intervention, delirium was screened using the Confusion Assessment Method for the ICU each day. The association between delirium and poor outcomes (e.g., NIV failure, ICU and hospital mortality) was investigated using forward stepwise multivariate logistic regression analyses. Results We enrolled 1083 patients. Of these, 196 patients (18.1%) experienced delirium during NIV intervention. Patients with delirium had higher NIV failure rates (37.8% vs. 21.0%, p < 0.01), higher ICU mortality (33.2% vs. 14.3%, p < 0.01), and higher hospital mortality (37.2% vs. 17.0%, p < 0.01) than subjects without delirium. They also had a longer duration of NIV (median 6.3 vs. 3.7 days, p < 0.01), and stayed longer in the ICU (median 9.0 vs. 6.0 days, p < 0.01) and the hospital (median 14.5 vs. 11.0 days, p < 0.01). These results were confirmed in COPD and non-COPD cohorts. According to subtype, compared to hyperactive delirium patients, hypoactive and mixed delirium patients spent more days and many more days on NIV (median 3.4 vs. 6.5 vs. 10.1 days, p < 0.01). Similar outcomes were found for length of stay in the ICU and hospital. However, NIV failure, ICU mortality, and hospital mortality did not differ among the three subtypes. Conclusions Delirium is associated with increases in poor outcomes (NIV failure, ICU mortality, and hospital mortality) and the use of medical resources (duration of NIV, and lengths of stay in the ICU and hospital). Regarding subtype, hypoactive and mixed delirium are associated with higher, and much higher, consumption of medical resources, respectively, compared to hyperactive delirium. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01517-3.
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Affiliation(s)
- Rui Zhang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, 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, China
| | - Xiaoli Han
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, China
| | - Shicong Huang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, China
| | - Lintong Zhou
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, 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, China.
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15
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Lewis K, Piticaru J, Chaudhuri D, Basmaji J, Fan E, Møller MH, Devlin JW, Alhazzani W. Safety and Efficacy of Dexmedetomidine in Acutely Ill Adults Requiring Noninvasive Ventilation: A Systematic Review and Meta-analysis of Randomized Trials. Chest 2021; 159:2274-2288. [PMID: 33434496 DOI: 10.1016/j.chest.2020.12.052] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/24/2020] [Accepted: 12/26/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Although clinical studies have evaluated dexmedetomidine as a strategy to improve noninvasive ventilation (NIV) comfort and tolerance in patients with acute respiratory failure (ARF), their results have not been summarized. RESEARCH QUESTION Does dexmedetomidine, when compared with another sedative or placebo, reduce the risk of delirium, mortality, need for intubation and mechanical ventilation, or ICU length of stay (LOS) in adults with ARF initiated on NIV in the ICU? STUDY DESIGN AND METHODS We electronically searched MEDLINE, EMBASE, and the Cochrane Library from inception through July 31, 2020, for randomized clinical trials (RCTs). We calculated pooled relative risks (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes with the corresponding 95% CIs using a random-effect model. RESULTS Twelve RCTs were included in our final analysis (n = 738 patients). The use of dexmedetomidine, compared with other sedation strategies or placebo, reduced the risk of intubation (RR, 0.54; 95% CI, 0.41-0.71; moderate certainty), delirium (RR, 0.34; 95% CI, 0.22-0.54; moderate certainty), and ICU LOS (MD, -2.40 days; 95% CI, -3.51 to -1.29 days; low certainty). Use of dexmedetomidine was associated with an increased risk of bradycardia (RR, 2.80; 95% CI, 1.92-4.07; moderate certainty) and hypotension (RR, 1.98; 95% CI, 1.32-2.98; moderate certainty). INTERPRETATION Compared with any sedation strategy or placebo, dexmedetomidine reduced the risk of delirium and the need for mechanical ventilation while increasing the risk of bradycardia and hypotension. The results are limited by imprecision, and further large RCTs are needed. TRIAL REGISTRY PROSPERO; No.: 175086; URL: www.crd.york.ac.uk/prospero/.
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Affiliation(s)
- Kimberley Lewis
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Joshua Piticaru
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - John Basmaji
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Morten Hylander Møller
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, MA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
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16
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Sullivan DR, Kim H, Gozalo PL, Bunker J, Teno JM. Trends in Noninvasive and Invasive Mechanical Ventilation Among Medicare Beneficiaries at the End of Life. JAMA Intern Med 2021; 181:93-102. [PMID: 33074320 PMCID: PMC7573799 DOI: 10.1001/jamainternmed.2020.5640] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 07/29/2020] [Indexed: 01/06/2023]
Abstract
Importance End-of-life care is costly, and decedents often experience overtreatment or low-quality care. Noninvasive ventilation (NIV) may be a palliative approach to avoid invasive mechanical ventilation (IMV) among select patients who are hospitalized at the end of life. Objective To examine the trends in NIV and IMV use among decedents with a hospitalization in the last 30 days of life. Design, Setting, and Participants This population-based cohort study used a 20% random sample of Medicare fee-for-service beneficiaries who had an acute care hospitalization in the last 30 days of life and died between January 1, 2000, and December 31, 2017. Sociodemographic, diagnosis, and comorbidity data were obtained from Medicare claims data. Data analysis was performed from September 2019 to July 2020. Exposures Use of NIV or IMV. Main Outcomes and Measures Validated International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification procedure codes were reviewed to identify use of NIV, IMV, both NIV and IMV, or none. Four subcohorts of Medicare beneficiaries were identified using primary admitting diagnosis codes (chronic obstructive pulmonary disease [COPD], congested heart failure [CHF], cancer, and dementia). Measures of end-of-life care included in-hospital death (acute care setting), hospice enrollment at death, and hospice enrollment in the last 3 days of life. Random-effects logistic regression examined NIV and IMV use adjusted for sociodemographic characteristics, admitting diagnosis, and comorbidities. Results A total of 2 470 435 Medicare beneficiaries (1 353 798 women [54.8%]; mean [SD] age, 82.2 [8.2] years) were hospitalized within 30 days of death. Compared with 2000, the adjusted odds ratio (AOR) for the increase in NIV use was 2.63 (95% CI, 2.46-2.82; % receipt: 0.8% vs 2.0%) for 2005 and 11.84 (95% CI, 11.11-12.61; % receipt: 0.8% vs 7.1%) for 2017. Compared with 2000, the AOR for the increase in IMV use was 1.04 (95% CI, 1.02-1.06; % receipt: 15.0% vs 15.2%) for 2005 and 1.63 (95% CI, 1.59-1.66; % receipt: 15.0% vs 18.2%) for 2017. In subanalyses comparing 2017 with 2000, similar trends found increased NIV among patients with CHF (% receipt: 1.4% vs 14.2%; AOR, 14.14 [95% CI, 11.77-16.98]) and COPD (% receipt: 2.7% vs 14.5%; AOR, 8.22 [95% CI, 6.42-10.52]), with reciprocal stabilization in IMV use among patients with CHF (% receipt: 11.1% vs 7.8%; AOR, 1.07 [95% CI, 0.95-1.19]) and COPD (% receipt: 17.4% vs 13.2%; AOR, 1.03 [95% CI, 0.88-1.21]). The AOR for increased NIV use was 10.82 (95% CI, 8.16-14.34; % receipt: 0.4% vs 3.5%) among decedents with cancer and 9.62 (95% CI, 7.61-12.15; % receipt: 0.6% vs 5.2%) among decedents with dementia. The AOR for increased IMV use was 1.40 (95% CI, 1.26-1.55; % receipt: 6.2% vs 7.6%) among decedents with cancer and 1.28 (95% CI, 1.17-1.41; % receipt: 5.7% vs 6.2%) among decedents with dementia. Among decedents with NIV vs IMV use, lower rates of in-hospital death (50.3% [95% CI, 49.3%-51.3%] vs 76.7% [95% CI, 75.9%-77.5%]) and hospice enrollment in the last 3 days of life (57.7% [95% CI, 56.2%-59.3%] vs 63.0% [95% CI, 60.9%-65.1%]) were observed along with higher rates of hospice enrollment (41.3% [95% CI, 40.4%-42.3%] vs 20.0% [95% CI, 19.2%-20.7%]). Conclusions and Relevance This study found that the use of NIV rapidly increased from 2000 through 2017 among Medicare beneficiaries at the end of life, especially among persons with cancer and dementia. The findings suggest that trials to evaluate the outcomes of NIV are warranted to inform discussions about the goals of this therapy between clinicians and patients and their health care proxies.
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Affiliation(s)
- Donald R. Sullivan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Healthcare System, Portland, Oregon
| | - Hyosin Kim
- Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health and Science University, Portland
| | - Pedro L. Gozalo
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Jennifer Bunker
- Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health and Science University, Portland
| | - Joan M. Teno
- Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health and Science University, Portland
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17
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Custodero C, Gandolfo F, Cella A, Cammalleri LA, Custureri R, Dini S, Femia R, Garaboldi S, Indiano I, Musacchio C, Podestà S, Tricerri F, Pasa A, Sabbà C, Pilotto A. Multidimensional prognostic index (MPI) predicts non-invasive ventilation failure in older adults with acute respiratory failure. Arch Gerontol Geriatr 2020; 94:104327. [PMID: 33485005 DOI: 10.1016/j.archger.2020.104327] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/15/2020] [Accepted: 12/19/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Acute respiratory failure (ARF) is a very common complication among hospitalized older adults. Non-invasive ventilation (NIV) may avoid admission to intensive care units, intubation and their related complication, but still lacks specific indications in older adults. Multidimensional Prognostic Index (MPI) based on comprehensive geriatric assessment (CGA) could have a role in defining the short-term prognosis and the best candidates for NIV among older adults with ARF. METHODS This is a retrospective observational study which enrolled patients older than 70 years, consecutively admitted to an acute geriatric unit with ARF. A standardized CGA was used to calculate the MPI at admission. Multivariate Cox regression models were used to test if MPI score could predict in-hospital mortality and NIV failure. Receiver operator curve (ROC) analysis was used to identify the discriminatory power of MPI for NIV failure. RESULTS We enrolled 231 patients (88.2 ± 5.9 years, 47% females). Mean MPI at admission was 0.76±0.16. In-hospital mortality rate was 33.8%, with similar incidence in patients treated with and without NIV. Among NIV users (26.4%), NIV failure occurred in 39.3%. Higher MPI scores at admission significantly predicted in-hospital mortality (β=4.46, p<0.0001) among patients with ARF and NIV failure (β=7.82, p = 0.001) among NIV users. MPI showed good discriminatory power for NIV failure (area under the curve: 0.72, 95% CI: 0.58-0.85, p<0.001) with optimal cut-off at MPI value of 0.84. CONCLUSIONS MPI at admission might be a useful tool to early detect patients more at risk of in-hospital death and NIV failure among older adults with ARF.
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Affiliation(s)
- Carlo Custodero
- Department of Interdisciplinary Medicine, University of Bari, Italy
| | - Federica Gandolfo
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Alberto Cella
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Lisa A Cammalleri
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Romina Custureri
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Simone Dini
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Rosetta Femia
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Sara Garaboldi
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Ilaria Indiano
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Clarissa Musacchio
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Silvia Podestà
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Francesca Tricerri
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Ambra Pasa
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Carlo Sabbà
- Department of Interdisciplinary Medicine, University of Bari, Italy
| | - Alberto Pilotto
- Department of Interdisciplinary Medicine, University of Bari, Italy; Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy.
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18
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Scala R, Accurso G, Ippolito M, Cortegiani A, Iozzo P, Vitale F, Guidelli L, Gregoretti C. Material and Technology: Back to the Future for the Choice of Interface for Non-Invasive Ventilation - A Concise Review. Respiration 2020; 99:800-817. [PMID: 33207357 DOI: 10.1159/000509762] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/26/2020] [Indexed: 11/19/2022] Open
Abstract
Non-invasive ventilation (NIV) has dramatically changed the treatment of both acute and chronic respiratory failure in the last 2 decades. The success of NIV is correlated to the application of the "best ingredients" of a patient's "tailored recipe," including the appropriate choice of the selected candidate, the ventilator setting, the interface, the expertise of the team, and the education of the caregiver. The choice of the interface is crucial for the success of NIV. Type (oral, nasal, nasal pillows, oronasal, hybrid mask, helmet), size, design, material and headgears may affect the patient's comfort with respect to many aspects, such as air leaks, claustrophobia, skin erythema, eye irritation, skin breakdown, and facial deformity in children. Companies are paying great attention to mask development, in terms of shape, materials, comfort, and leak reduction. Although the continuous development of new products has increased the availability of interfaces and the chance to meet different requirements, in patients necessitating several daily hours of NIV, both in acute and in chronic home setting, the rotational use of different interfaces may remain an excellent strategy to decrease the risk of skin breakdown and to improve patient's tolerance. The aim of the present review was to give the readers a background on mask technology and materials in order to enhance their "knowledge" in making the right choice for the interface to apply during NIV in the different clinical scenarios.
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Affiliation(s)
- Raffaele Scala
- Pulmonology and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy,
| | - Giuseppe Accurso
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Mariachiara Ippolito
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Pasquale Iozzo
- Department of Anesthesia and Intensive Care, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Filippo Vitale
- Department of Anesthesia and Intensive Care, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Luca Guidelli
- Pulmonology and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy
| | - Cesare Gregoretti
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy.,, Cefalù, Italy
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19
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Chen T, Bai L, Hu W, Han X, Duan J. Risk Factors Associated with Late Failure of Noninvasive Ventilation in Patients with Chronic Obstructive Pulmonary Disease. Can Respir J 2020; 2020:8885464. [PMID: 33123301 PMCID: PMC7582075 DOI: 10.1155/2020/8885464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/25/2020] [Accepted: 09/29/2020] [Indexed: 11/26/2022] Open
Abstract
Background Risk factors for noninvasive ventilation (NIV) failure after initial success are not fully clear in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). Methods Patients who received NIV beyond 48 h due to acute exacerbation of COPD were enrolled. However, we excluded those whose pH was higher than 7.35 or PaCO2 was less than 45 mmHg which was measured before NIV. Late failure of NIV was defined as patients required intubation or died during NIV after initial success. Results We enrolled 291 patients in this study. Of them, 48 (16%) patients experienced late NIV failure (45 received intubation and 3 died during NIV). The median time from initiation of NIV to intubation was 4.8 days (IQR: 3.4-8.1). Compared with the data collected at initiation of NIV, the heart rate, respiratory rate, pH, and PaCO2 significantly improved after 1-2 h of NIV both in the NIV success and late failure of NIV groups. Nosocomial pneumonia (odds ratio (OR) = 75, 95% confidence interval (CI): 11-537), heart rate at initiation of NIV (1.04, 1.01-1.06 beat per min), and pH at 1-2 h of NIV (2.06, 1.41-3.00 per decrease of 0.05 from 7.35) were independent risk factors for late failure of NIV. In addition, the Glasgow coma scale (OR = 0.50, 95% CI: 0.34-0.73 per one unit increase) and PaO2/FiO2 (0.992, 0.986-0.998 per one unit increase) were independent protective factors for late failure of NIV. In addition, patients with late failure of NIV had longer ICU stay (median 9.5 vs. 6.6 days) and higher hospital mortality (92% vs. 3%) compared with those with NIV success. Conclusions Nosocomial pneumonia; heart rate at initiation of NIV; and consciousness, acidosis, and oxygenation at 1-2 h of NIV were associated with late failure of NIV in patients with COPD exacerbation. And, late failure of NIV was associated with increased hospital mortality.
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Affiliation(s)
- Tao Chen
- The Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Linfu Bai
- The Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenhui Hu
- The Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaoli Han
- The Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jun Duan
- The Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Wong AKI, Cheung PC, Zhang J, Cotsonis G, Kutner M, Gay PC, Collop NA. Randomized Controlled Trial of a Novel Communication Device Assessed During Noninvasive Ventilation Therapy. Chest 2020; 159:1531-1539. [PMID: 33011202 DOI: 10.1016/j.chest.2020.09.250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 09/23/2020] [Accepted: 09/24/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Noninvasive ventilation (NIV), a form of positive airway pressure (PAP) therapy, is the standard of care for various forms of acute respiratory failure (ARF). Communication impairment is a side effect of NIV, impedes patient care, contributes to distress and intolerance, and potentially increases intubation rates. This study aimed to evaluate communication impairment during CPAP therapy and demonstrate communication device improvement with a standardized protocol. RESEARCH QUESTION How does an oronasal mask affect communication intelligibility? How does use of an NIV communication device change this communication intelligibility? STUDY DESIGN AND METHODS A single-center randomized controlled trial (36 outpatients with OSA on CPAP therapy) assessed exposure to CPAP 10 cm H2O and PAP communication devices (SPEAX, Ataia Medical). Communication impairment was evaluated by reading selected words and sentences for partners to record and were tabulated as %words correct. Each outpatient-partner pair performed three assessments: (1) baseline (conversing normally), (2) mask baseline (conversing with PAP), and (3) randomized to functioning device (conversing with PAP and device) or sham device. After each stage, both outpatients and partners completed Likert surveys regarding perceived intelligibility and comfort. RESULTS While conversing with PAP, word and sentence intelligibility decreased relatively by 52% (87% vs 41%) and relatively by 57% (94% vs 40%), respectively, compared with normal conversation. Word and sentence intelligibility in the intervention arm increased relatively by 75% (35% vs 61%; P < .001) and by 126% (33% vs 76%; P < .001) higher than the control arm, respectively. The device improved outpatient-perceived PAP comfort relatively by 233% (15% vs 50%, P = .042) and partner-perceived comfort by relatively 245% (20% vs 69%, P = .0074). INTERPRETATION Use of this PAP communication device significantly improves both intelligibility and comfort. This is one of the first studies quantifying communication impairment during PAP delivery. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT03795753; URL: www.clinicaltrials.gov.
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Affiliation(s)
- An-Kwok Ian Wong
- Emory University Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine; Emory University Department of Medicine.
| | | | | | - George Cotsonis
- Emory University Department of Biostatistics and Bioinformatics
| | - Michael Kutner
- Emory University Department of Biostatistics and Bioinformatics
| | - Peter C Gay
- Mayo Clinic Division of Pulmonary, Critical Care, and Sleep Medicine
| | - Nancy A Collop
- Emory University Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine; Emory University Department of Medicine
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21
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Ferrer M, Torres A. Noninvasive Ventilation and High-Flow Nasal Therapy Administration in Chronic Obstructive Pulmonary Disease Exacerbations. Semin Respir Crit Care Med 2020; 41:786-797. [PMID: 32725614 DOI: 10.1055/s-0040-1712101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Noninvasive ventilation (NIV) is considered to be the standard of care for the management of acute hypercapnic respiratory failure in patients with chronic obstructive pulmonary disease exacerbation. It can be delivered safely in any dedicated setting, from emergency rooms to high dependency or intensive care units and wards. NIV helps improving dyspnea and gas exchange, reduces the need for endotracheal intubation, and morbidity and mortality rates. It is therefore recognized as the gold standard in this condition. High-flow nasal therapy helps improving ventilatory efficiency and reducing the work of breathing in patients with severe chronic obstructive pulmonary disease. Early studies indicate that some patients with acute hypercapnic respiratory failure can be managed with high-flow nasal therapy, but more information is needed before specific recommendations for this therapy can be made. Therefore, high-flow nasal therapy use should be individualized in each particular situation and institution, taking into account resources, and local and personal experience with all respiratory support therapies.
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Affiliation(s)
- Miquel Ferrer
- Respiratory Intensive and Intermediate Care Unit, Department of Pneumology, Respiratory Institute, Hospital Clínic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Antoni Torres
- Respiratory Intensive and Intermediate Care Unit, Department of Pneumology, Respiratory Institute, Hospital Clínic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
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22
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Consequences and Solutions for the Impact of Communication Impairment on Noninvasive Ventilation Therapy for Acute Respiratory Failure: A Focused Review. Crit Care Explor 2020; 2:e0121. [PMID: 32695990 PMCID: PMC7314319 DOI: 10.1097/cce.0000000000000121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Objectives: With over 2 million cases of acute respiratory failure in the United States per year, noninvasive ventilation has become a leading treatment modality, often supplanting invasive mechanical ventilation as the initial treatment of choice. Most acute respiratory failure patients use a full face (oronasal) mask with noninvasive ventilation, which is known to impair communication, but its popularity and benefit has led many providers to accept the communication impairment. Medical staff periodically remove masks to communicate with patients, but patients are often limited to short utterances and risk lung derecruitment upon removal of positive pressure. These problems can lead to noninvasive ventilation failure, which is often linked to worse outcomes than first initiating invasive mechanical ventilation and can lead to increased hospitalization costs. Data Sources: We searched MEDLINE and Google Scholar for “speech,” “communication,” “impairment,” “failure,” “complications,” “NIPPV,” “NIV,” and “noninvasive ventilation.” Study Selection: We included articles with patients in acute respiratory failure. We excluded articles for patients using noninvasive ventilation therapy for obstructive sleep apnea. Data Synthesis: Communication impairment has been associated with increasing noninvasive ventilation anxiety (odds ratio, 1.25). Of patients using noninvasive ventilation, 48% require early discontinuation, 22% refuse noninvasive ventilation, and 9% are ultimately intubated. Improvements to communication have been shown to reduce fear and anxiety in invasive mechanical ventilation patients. Analogous communication problems exist with effective solutions in other fields, such as fighter pilot masks, that can be easily implemented to enhance noninvasive ventilation patient care, increase adherence to noninvasive ventilation treatment, and improve patient outcomes. Conclusions: Communication impairment is an underappreciated cause of noninvasive ventilation complications and failure and requires further characterization. Analogous solutions—such as throat microphones and mask-based microphones—that can be easily implemented show potential as cost-effective methods to reduce noninvasive ventilation failure.
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23
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de-Miguel-Díez J, Jiménez-García R, Hernández-Barrera V, Zamorano-Leon JJ, Villanueva-Orbaiz R, Albaladejo-Vicente R, López-de-Andrés A. Trends in mechanical ventilation use and mortality over time in patients receiving mechanical ventilation in Spain from 2001 to 2015. Eur J Intern Med 2020; 74:67-72. [PMID: 31822367 DOI: 10.1016/j.ejim.2019.11.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/11/2019] [Accepted: 11/30/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND We examined trends in the incidence of ventilator support with noninvasive ventilation (NIV) or invasive mechanical ventilation (IMV) among patients hospitalized in Spain from 2001 to 2015. We also assessed in-hospital mortality (IHM) after receiving these types of ventilator support. METHODS This study was an observational retrospective epidemiological study. Our data source was the Spanish National Hospital Discharge Database. RESULTS In total, 1,031,497 patients received ventilator support in Spain over the study period. NIV use increased from 18.8 patients per 100.000 inhabitants in 2001 to 108.7 in 2015. IMV utilization increased significantly from 2001 to 2003 and then decreased from 2003 until 2015. Patients who required NIV had the highest mean Charlson Comorbidity Index (CCI) score. Patients who received IMV had the highest in-hospital mortality. Factors associated with an increased risk for IHM were sex, age, conditions included in the CCI (except for COPD and diabetes), haemodialysis, presence of a peripheral arterial catheter, presence of a central venous catheter, readmission and emergency room admission. Undergoing a surgical procedure was a risk factor only for IMV. IHM decreased significantly from 2001 to 2015 in patients who underwent NIV or IMV. CONCLUSIONS We identified an increase in the utilization of NIV over time, whereas use of IMV decreased from 2003 until 2015 after an initial increase from 2001 to 2003. We also found a significant decrease in IHM over time.
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Affiliation(s)
- Javier de-Miguel-Díez
- Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Rodrigo Jiménez-García
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain.
| | - Valentín Hernández-Barrera
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty. Rey Juan Carlos University, Alcorcón, Madrid, Spain
| | - Jose J Zamorano-Leon
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Rosa Villanueva-Orbaiz
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Romana Albaladejo-Vicente
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Ana López-de-Andrés
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty. Rey Juan Carlos University, Alcorcón, Madrid, Spain
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24
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Scala R, Ciarleglio G, Maccari U, Granese V, Salerno L, Madioni C. Ventilator Support and Oxygen Therapy in Palliative and End-of-Life Care in the Elderly. Turk Thorac J 2020; 21:54-60. [PMID: 32163365 DOI: 10.5152/turkthoracj.2020.201401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/25/2019] [Indexed: 11/22/2022]
Abstract
Elderly patients suffering from chronic cardio-pulmonary diseases commonly experience acute respiratory failure. As in younger patients, a well-known therapeutic approach of noninvasive mechanical ventilation is able to prevent orotracheal intubation in a large number of severe scenarios in elderly patients. In addition, this type of ventilation is frequently applied in elderly patients who refuse intubation for invasive mechanical ventilation. The rate of failure of noninvasive ventilation may be reduced by means of the integration of new technological devices (i.e., high-flow nasal cannula, extracorporeal CO2 removal, cough assistance and high-frequency chest wall oscillation, and fiberoptic bronchoscopy). Ethical issues with end-of-life decisions and the choice of the environment are not clearly defined in the treatment of elderly with acute respiratory insufficiency.
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Affiliation(s)
- Raffaele Scala
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Giuseppina Ciarleglio
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Uberto Maccari
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Valentina Granese
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Laura Salerno
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Chiara Madioni
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
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25
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Castillo RL, Ibacache M, Cortínez I, Carrasco-Pozo C, Farías JG, Carrasco RA, Vargas-Errázuriz P, Ramos D, Benavente R, Torres DH, Méndez A. Dexmedetomidine Improves Cardiovascular and Ventilatory Outcomes in Critically Ill Patients: Basic and Clinical Approaches. Front Pharmacol 2020; 10:1641. [PMID: 32184718 PMCID: PMC7058802 DOI: 10.3389/fphar.2019.01641] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 12/16/2019] [Indexed: 12/11/2022] Open
Abstract
Dexmedetomidine (DEX) is a highly selective α2-adrenergic agonist with sedative and analgesic properties, with minimal respiratory effects. It is used as a sedative in the intensive care unit and the operating room. The opioid-sparing effect and the absence of respiratory effects make dexmedetomidine an attractive adjuvant drug for anesthesia in obese patients who are at an increased risk for postoperative respiratory complications. The pharmacodynamic effects on the cardiovascular system are known; however the mechanisms that induce cardioprotection are still under study. Regarding the pharmacokinetics properties, this drug is extensively metabolized in the liver by the uridine diphosphate glucuronosyltransferases. It has a relatively high hepatic extraction ratio, and therefore, its metabolism is dependent on liver blood flow. This review shows, from a basic clinical approach, the evidence supporting the use of dexmedetomidine in different settings, from its use in animal models of ischemia-reperfusion, and cardioprotective signaling pathways. In addition, pharmacokinetics and pharmacodynamics studies in obese subjects and the management of patients subjected to mechanical ventilation are described. Moreover, the clinical efficacy of delirium incidence in patients with indication of non-invasive ventilation is shown. Finally, the available evidence from DEX is described by a group of Chilean pharmacologists and clinicians who have worked for more than 10 years on DEX.
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Affiliation(s)
- Rodrigo L Castillo
- Departamento de Medicina Interna Oriente, Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Unidad de Paciente Crítico, Hospital del Salvador, Santiago, Chile
| | - Mauricio Ibacache
- Programa de Farmacología y Toxicología & División de Anestesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ignacio Cortínez
- Programa de Farmacología y Toxicología & División de Anestesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Catalina Carrasco-Pozo
- Discovery Biology, Griffith Institute for Drug Discovery, Griffith University, Nathan, QLD, Australia
| | - Jorge G Farías
- Departmento de Ingeniería Química, Facultad de Ingeniería y Ciencias, Universidad de La Frontera, Francisco Salazar, Chile
| | - Rodrigo A Carrasco
- Departamento de Cardiología, Clínica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Patricio Vargas-Errázuriz
- Unidad de Paciente Crítico, Hospital del Salvador, Santiago, Chile.,Unidad de Paciente Crítico Adulto, Clínica Universidad de Los Andes, Santiago, Chile.,Unidad de Paciente Crítico, Clínica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Daniel Ramos
- Departamento de Medicina Interna Oriente, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Rafael Benavente
- Departamento de Medicina Interna Oriente, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Daniela Henríquez Torres
- Departamento de Medicina Interna Oriente, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Aníbal Méndez
- Departamento de Medicina Interna Oriente, Facultad de Medicina, Universidad de Chile, Santiago, Chile
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Banfi P, Pierucci P, Volpato E, Nicolini A, Lax A, Robert D, Bach J. Daytime noninvasive ventilatory support for patients with ventilatory pump failure: a narrative review. Multidiscip Respir Med 2019; 14:38. [PMID: 31798866 PMCID: PMC6884796 DOI: 10.1186/s40248-019-0202-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 10/31/2019] [Indexed: 12/12/2022] Open
Abstract
Over the past three decades, the use of noninvasive ventilation or "NIV" to assuage symptoms of hypoventilation for patients with early onset or mild ventilatory pump failure has been extended to up to the use of continuous noninvasive ventilatory support (CNVS) at full ventilatory support settings as a definitive alternative to tracheostomy mechanical ventilation. NVS, along with mechanical insufflation-exsufflation, now provides a noninvasive option for the management of both chronic and acute respiratory failure for these patients. The most common diagnoses for which these methods are useful include chest wall deformities, neuromuscular diseases, morbid obesity, high level spinal cord injury and idiopathic, primary or secondary disorders of the ventilatory control. Thus, NVS is being used in diverse settings: critical care units, medical wards, at home, and in extended care. The aim of this review is to examine the techniques used for daytime support.
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Affiliation(s)
- Paolo Banfi
- IRCCS Fondazione Don Carlo Gnocchi, via Capecelatro, 66 20148 Milan, Italy
| | - Paola Pierucci
- Cardio Thoracic Department, Respiratory and Sleep Disorders Unit, Bari Policlinic, Bari, Italy
| | - Eleonora Volpato
- IRCCS Fondazione Don Carlo Gnocchi, via Capecelatro, 66 20148 Milan, Italy
- Department of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy
| | - Antonello Nicolini
- Respiratory Rehabilitation Unit, ASL 4 Chiavarese, Hospital of Sestri Levante, Sestri Levante, Italy
| | - Agata Lax
- IRCCS Fondazione Don Carlo Gnocchi, via Capecelatro, 66 20148 Milan, Italy
| | - Dominique Robert
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Réanimation Médicale, Lyon, France
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - John Bach
- Department of Physical Medicine and Rehabilitation, Rutgers University New Jersey Medical School, Newark, USA
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27
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Tams C, Stephan PJ, Euliano NR, Martin AD, Patel R, Ataya A, Gabrielli A. Breathing variability predicts the suggested need for corrective intervention due to the perceived severity of patient-ventilator asynchrony during NIV. J Clin Monit Comput 2019; 34:1035-1042. [PMID: 31664660 DOI: 10.1007/s10877-019-00408-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 10/21/2019] [Indexed: 10/25/2022]
Abstract
Patient-ventilator asynchrony is associated with intolerance to noninvasive ventilation (NIV) and worsened outcomes. Our goal was to develop a tool to determine a patient needs for intervention by a practitioner due to the presence of patient-ventilator asynchrony. We postulated that a clinician can determine when a patient needs corrective intervention due to the perceived severity of patient-ventilator asynchrony. We hypothesized a new measure, patient breathing variability, would indicate when corrective intervention is suggested by a bedside practitioner due to the perceived severity of patient-ventilator asynchrony. With IRB approval data was collected on 78 NIV patients. A panel of experts reviewed retrospective data from a development set of 10 NIV patients to categorize them into one of the three categories. The three categories were; "No to mild asynchrony-no intervention needed", "moderate asynchrony-non-emergent corrective intervention required", and "severe asynchrony-immediate intervention required". A stepwise regression with a F-test forward selection criterion was used to develop a positive linear logic model predicting the expert panel's categorizations of the need for corrective intervention. The model was incorporated into a software tool for clinical implementation. The tool was implemented prospectively on 68 NIV patients simultaneous to a bedside practitioner scoring the need for corrective intervention due to the perceived severity of patient-ventilator asynchrony. The categories from the tool and the practitioner were compared with the rate of agreement, sensitivity, specificity, and receiver operator characteristic analyses. The rate of agreement in categorizing the suggested need for clinical intervention due to the perceived presence of patient-ventilator asynchrony between the tool and experienced bedside practitioners was 95% with a Kappa score of 0.85 (p < 0.001). Further analysis found a specificity of 84% and sensitivity of 99%. The tool appears to accurately match the suggested need for corrective intervention by a bedside practitioner. Application of the tool allows for continuous, real time, and non-invasive monitoring of patients receiving NIV, and may enable early corrective interventions to ameliorate potential patient-ventilator asynchrony.
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Affiliation(s)
- Carl Tams
- Convergent Engineering, 107 SW 140th Terrace, STE 1, Newberry, FL, 32669, USA
| | - Paul J Stephan
- Convergent Engineering, 107 SW 140th Terrace, STE 1, Newberry, FL, 32669, USA
| | - Neil R Euliano
- Convergent Engineering, 107 SW 140th Terrace, STE 1, Newberry, FL, 32669, USA.
| | - A Daniel Martin
- Department of Physical Therapy, College of Public Health & Health Professions, University of Florida, Gainesville, FL, 32610, USA
| | - Rohit Patel
- Department of Anesthesiology and Department of Emergency Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, PO Box 100254, Gainesville, FL, 32610, USA
| | - Ali Ataya
- Department of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Gainesville, FL, 32610, USA
| | - Andrea Gabrielli
- Department of Anesthesiology Perioperative Medicine and Pain Management, University of Miami Health System, 1611 NW 12th Ave (C-301), Miami, FL, 33136, USA
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28
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Effect of oxygen therapy on the risk of mechanical ventilation in emergency acute pulmonary edema patients. Eur J Emerg Med 2019; 27:99-104. [PMID: 31633623 DOI: 10.1097/mej.0000000000000634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We investigated the effects of hyperoxemia on morbidity and mortality in acute cardiogenic pulmonary edema (ACPE). METHODS We conducted a retrospective cohort study of patients in our emergency department (ED) with ACPE who received arterial blood gases. Patients were classified based on the first PaO2 as hypoxemic (<75 mmHg), normoxemic (75-100 mmHg) and hyperoxemic (>100 mmHg). The primary outcome was the rates of mechanical ventilation (MV). We also reported adjusted odds ratios (AOR) and their 95% confidence intervals (CI) of the primary outcome after adjusting for predictors of MV determined a priori. Secondary outcomes were median hospital length of stay (LOS) and in-hospital mortality. RESULTS We recruited 335 patients; 34.0% had hyperoxemia. The rates of normoxemia and hypoxemia were 27.5% and 38.5%, respectively. The rates of MV were: hypoxemic 60/129 (46.5%) vs. normoxemic 41/92 (44.6%) vs. hyperoxemic 50/114 (43.9%); P = 0.62. The AORs for MV for the hyperoxemic and hypoxemic groups (reference: normoxemic group) were 0.98 (95% CI: 0.53-1.79) and 1.38 (95% CI: 0.77-2.48), respectively. Intubation rates for the groups were: hypoxemic 15/129 (11.6%) vs. normoxemic 6/92 (6.5%) vs. hyperoxemic 12/114 (10.6%); P = 0.43. The secondary outcomes were comparable among the groups. In-hospital mortality rates were: hypoxemic 6/129 (4.7%) vs. 6/92 (6.5%) vs. 10/114 (8.8%); P = 0.42. CONCLUSION Our exploratory study did not report effects on mechanical ventilation, median hospital LOS and in-hospital mortality from hyperoxemia compared to hypoxemic and normoxemic ED patients with ACPE. Further studies are warranted to prove or disprove our findings.
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29
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Sehgal IS, Kalpakam H, Dhooria S, Aggarwal AN, Prasad KT, Agarwal R. A Randomized Controlled Trial of Noninvasive Ventilation with Pressure Support Ventilation and Adaptive Support Ventilation in Acute Exacerbation of COPD: A Feasibility Study. COPD 2019; 16:168-173. [PMID: 31161812 DOI: 10.1080/15412555.2019.1620716] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Whether the use of adaptive support ventilation (ASV) during noninvasive ventilation (NIV) is as effective as pressure support ventilation (PSV) remains unknown. In this exploratory study, we compared the delivery of NIV with PSV vs. ASV. We randomized consecutive subjects with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) to receive NIV either with the PSV or the ASV mode. The primary outcome was NIV failure (endotracheal intubation, re-institution of NIV within 48 h of discontinuation or mortality). The secondary outcomes were the duration of mechanical ventilation (invasive and noninvasive), the number of NIV manipulations, the visual analogue score (VAS) for physician's ease of use and patient's comfort, and the complications of NIV use. We enrolled 74 subjects (n = 38, PSV; n = 36, ASV; 78.4% males) with a mean (SD) age of 60.5 (9.5) years. The baseline characteristics were similar between the two groups. The overall NIV failure rate was 28.4% and was similar between the two groups (PSV vs. ASV: 34.2% vs. 22.2%, p = 0.31). There was a 9% reduction in the intubation rate with ASV. There were six deaths (PSV vs. ASV: 2 vs 4, p =0.311). There was no difference in the secondary outcomes. The application of NIV using ASV was associated with a similar success rate as PSV in subjects with AECOPD. Due to the small sample size, the results of our study should be confirmed in a larger trial. Trial registry: ww.clinicaltrials.gov (NCT02877524).
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Affiliation(s)
- Inderpaul Singh Sehgal
- a Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Hariprasad Kalpakam
- a Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Sahajal Dhooria
- a Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Ashutosh N Aggarwal
- a Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Kuruswamy Thurai Prasad
- a Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Ritesh Agarwal
- a Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
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Physiopathological rationale of using high-flow nasal therapy in the acute and chronic setting: A narrative review. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.1016/j.tacc.2019.02.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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McKinstry S, Singer J, Baarsma JP, Weatherall M, Beasley R, Fingleton J. Nasal high‐flow therapy compared with non‐invasive ventilation in COPD patients with chronic respiratory failure: A randomized controlled cross‐over trial. Respirology 2019; 24:1081-1087. [DOI: 10.1111/resp.13575] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 02/26/2019] [Accepted: 04/16/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Steven McKinstry
- Medical Research Institute of New Zealand Wellington New Zealand
- Victoria University of Wellington Wellington New Zealand
- Capital and Coast District Health Board Wellington New Zealand
| | - Joseph Singer
- Medical Research Institute of New Zealand Wellington New Zealand
| | - Jan Pieter Baarsma
- Medical Research Institute of New Zealand Wellington New Zealand
- University of Groningen Groningen The Netherlands
| | - Mark Weatherall
- Capital and Coast District Health Board Wellington New Zealand
- University of Otago Wellington Wellington New Zealand
| | - Richard Beasley
- Medical Research Institute of New Zealand Wellington New Zealand
- Victoria University of Wellington Wellington New Zealand
- Capital and Coast District Health Board Wellington New Zealand
| | - James Fingleton
- Medical Research Institute of New Zealand Wellington New Zealand
- Victoria University of Wellington Wellington New Zealand
- Capital and Coast District Health Board Wellington New Zealand
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Wang J, Shang H, Yang X, Guo S, Cui Z. Procalcitonin, C-reactive protein, PaCO2, and noninvasive mechanical ventilation failure in chronic obstructive pulmonary disease exacerbation. Medicine (Baltimore) 2019; 98:e15171. [PMID: 31027061 PMCID: PMC6831316 DOI: 10.1097/md.0000000000015171] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
It is unclear whether procalcitonin (PCT) is correlated with noninvasive ventilation (NIV) failure. This retrospective case-control study aimed to compare PCT levels, C-reactive protein (CRP) levels, and PaCO2 in patients (05/2014-03/2015 at the Harrison International Peace Hospital, China) with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and NIV failure/success.This was a retrospective case-control study of patients with AECOPD who required NIV between May 2014 and March 2015. All consecutive patients with AECOPD admitted at the Department of Critical Care Medicine and transferred from the general ward were included in the study. Hemogram, PCT, erythrocyte sedimentation rate (ESR), arterial blood gas (ABG), and CRP levels were measured ≤1 hour before NIV was used. NIV was considered to have failed if at least one of the following criteria was met: cardiac arrest or severe hemodynamic instability; respiratory arrest or gasping; mask intolerance; difficulty in clearing bronchial secretions; or worsening of ABGs or sensorium level during NIV. The factors associated with NIV failure were determined.A total of 376 patients were included: 286 with successful NIV and 90 wither NIV failure. The multivariate analysis showed that PCT (OR = 2.0, 95%CI: 1.2-3.2, P = .006), CRP (OR = 1.2, 95%CI: 1.1-1.3, P < .001), and PaCO2 (OR = 1.1, 95%CI: 1.1-1.2, P < .001) ≤1 hour before NIV were independently associated with NIV failure. The optimal cutoff were 0.31 ng/mL for PCT (sensitivity, 83.3%; specificity, 83.7%), 15.0 mg/mL for CRP (sensitivity, 75.6%; specificity, 93.0%), and 73.5 mm Hg for PaCO2 (sensitivity, 71.1%; specificity, 100%). The area under the curve (AUC) was 0.854 for PCT, 0.849 for CRP, and 0.828 for PaCO2. PCT, CRP, and PaCO2 were used to obtain a combined prediction factor, which achieved an AUC of 0.978 (95%CI: 0.961-0.995).High serum PCT, CRP, and PaCO2 levels predict NIV failure for patients with AECOPD. The combination of these three parameters might enable even more accurate prediction.
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Reis NFD, Gazola NLG, Bündchen DC, Bonorino KC. Ventilação não invasiva na unidade de terapia intensiva de um hospital universitário: características relacionadas ao sucesso e insucesso. FISIOTERAPIA E PESQUISA 2019. [DOI: 10.1590/1809-2950/17000626012019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO O objetivo deste estudo foi descrever características de sucesso e insucesso do uso da ventilação não invasiva (VNI) na unidade de terapia intensiva (UTI) de um hospital universitário. Trata-se de um estudo observacional prospectivo no qual foram incluídos 75 pacientes, com idade média de 58,3±18,8 anos. Desses, doze necessitaram do uso da VNI por mais de uma vez, totalizando 92 utilizações. Evidenciou-se que, delas, a taxa de sucesso foi de 60,9% (56). O grupo insucesso apresentou mais indivíduos do sexo masculino (p=0,006) e número maior de pacientes com diagnóstico de infecção extrapulmonar (p=0,012). Não foram encontradas diferenças entre os grupos de sucesso e insucesso nos quesitos de modo, modelo, máscara, tempo total de permanência e razões para a instalação da VNI. No grupo insucesso, a pressão positiva inspiratória nas vias aéreas (Ipap) e o volume corrente (VC) foram superiores (p=0,029 e p=0,011, respectivamente). A saturação periférica de oxigênio (p=0,047), o pH (p=0,004), base excess (p=0,006) e o bicarbonato (p=0,013) apresentaram valores inferiores. Concluiu-se que os indivíduos do sexo masculino com diagnóstico de infecção extrapulmonar e que evoluíram com acidose metabólica evoluíram com mais insucesso na utilização da VNI. Esses, necessitaram de parâmetros elevados de Ipap e VC.
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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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Messika J, Martin Y, Maquigneau N, Puechberty C, Henry-Lagarrigue M, Stoclin A, Panneckouke N, Villard S, Dechanet A, Lafourcade A, Dreyfuss D, Hajage D, Ricard JD. A musical intervention for respiratory comfort during noninvasive ventilation in the ICU. Eur Respir J 2018; 53:13993003.01873-2018. [DOI: 10.1183/13993003.01873-2018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 10/31/2018] [Indexed: 01/29/2023]
Abstract
Discomfort associated with noninvasive ventilation (NIV) may participate in its failure. We aimed to determine the effect of a musical intervention on respiratory discomfort during NIV in patients with acute respiratory failure (ARF).An open-label, controlled trial was performed over three centres. Patients requiring NIV for ARF were randomised to either a musical intervention group (where they received a musical intervention and were subjected to visual deprivation during the first 30 min of each NIV session), a sensory deprivation group (where they wore insulating headphones and were subjected to visual deprivation during the first 30 min of each NIV session), or a control group (where they received NIV as routinely performed). The primary outcome was the change in respiratory discomfort before and after 30 min of the first NIV session.A total of 113 patients were randomised (36 in the musical intervention group, 38 in the sensory deprivation group and 39 in the control group). Median (interquartile range (IQR)) change in respiratory discomfort was 0 (−1; 1) between the musical intervention and control groups (p=0.7). Between groups comparison did not evidence any significant variation of respiratory parameters across time or health-related quality of life (HRQoL) at day-90. The Peri-traumatic Distress Inventory (PDI) at intensive care unit (ICU) discharge was reduced in musical intervention group patients. However, a 30 min musical intervention did not reduce respiratory discomfort during NIV for ARF in comparison to conventional care or sensory deprivation.
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Luo Z, Wu C, Li Q, Zhu J, Pang B, Shi Y, Ma Y, Cao Z. High-intensity versus low-intensity noninvasive positive pressure ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease (HAPPEN): study protocol for a multicenter randomized controlled trial. Trials 2018; 19:645. [PMID: 30463622 PMCID: PMC6249746 DOI: 10.1186/s13063-018-2991-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 10/16/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Despite the positive outcomes of the use of noninvasive positive pressure ventilation (NPPV) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), NPPV fails in approximately 15% of patients with AECOPD, possibly because the inspiratory pressure delivered by conventional low-intensity NPPV is insufficient to improve ventilatory status for these patients. High-intensity NPPV, a novel form that delivers high inspiratory pressure, is believed to more efficiently augment alveolar ventilation than low-intensity NPPV, and it has been shown to improve ventilatory status more than low-intensity NPPV in stable AECOPD patients. Whether the application of high-intensity NPPV has therapeutic advantages over low-intensity NPPV in patients with AECOPD remains to be determined. The high-intensity versus low-intensity NPPV in patients with AECOPD (HAPPEN) study will examine whether high-intensity NPPV is more effective for correcting hypercapnia than low-intensity NPPV, hence reducing the need for intubation and improving survival. METHODS/DESIGN The HAPPEN study is a multicenter, two-arm, single-blind, prospective, randomized controlled trial. In total, 600 AECOPD patients with low to moderate hypercapnic respiratory failure will be included and randomized to receive high-intensity or low-intensity NPPV, with randomization stratified by study center. The primary endpoint is NPPV failure rate, defined as the need for endotracheal intubation and invasive ventilation. Secondary endpoints include the decrement of arterial carbon dioxide tension from baseline to 2 h after randomization, in-hospital and 28-day mortality, and 90-day survival. Patients will be followed up for 90 days after randomization. DISCUSSION The HAPPEN study will be the first randomized controlled study to investigate whether high-intensity NPPV better corrects hypercapnia and reduces the need for intubation and mortality in AECOPD patients than low-intensity NPPV. The results will help critical care physicians decide the intensity of NPPV delivery to patients with AECOPD. TRIAL REGISTRATION ClinicalTrials.gov, NCT02985918 . Registered on 7 December 2016.
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Affiliation(s)
- Zujin Luo
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, 5 Jingyuan Road, Shijingshan District, Beijing, 100043 China
| | - Chao Wu
- Department of Respiratory and Critical Care Medicine, People’s Hospital of Xinjiang Uygur Autonomous Region, No. 91 Tianchi Road, Tianshan District, Urumqi, 830001 China
| | - Qi Li
- Department of Respiratory and Critical Care Medicine, Army Institute of Respiratory Disease, Chongqing Xin-Qiao Hospital, Army Military Medical University, 183 Xinqiao Main Street, Shapingba District, Chongqing, 400073 China
| | - Jian Zhu
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, 5 Jingyuan Road, Shijingshan District, Beijing, 100043 China
| | - Baosen Pang
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, 5 Jingyuan Road, Shijingshan District, Beijing, 100043 China
| | - Yan Shi
- School of Automation Science and Electrical Engineering, Beihang University, No. 37 Xueyuan Road, Haidian District, Beijing, 100191 China
| | - Yingmin Ma
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, 5 Jingyuan Road, Shijingshan District, Beijing, 100043 China
| | - Zhixin Cao
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, 5 Jingyuan Road, Shijingshan District, Beijing, 100043 China
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AlAhmari MD, Al-Otaibi H, Qutub H, AlBalawi I, Alqahtani A, Almasoudi B. Noninvasive ventilation utilization in the Kingdom of Saudi Arabia: Results of a national survey. Ann Thorac Med 2018; 13:237-242. [PMID: 30416596 PMCID: PMC6196671 DOI: 10.4103/atm.atm_116_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Noninvasive ventilation (NIV) has been extensively used globally and is often administered as the first-line treatment. Currently, data regarding the utilization of NIV in the Kingdom of Saudi Arabia (KSA) is scarce. The present study aimed to assess and quantify the utilization of NIV in clinical practice across the KSA and investigate obstacles that may cause NIV underutilization. METHODS A web-based survey composed of a 31-item, self-administered questionnaire was developed and validated. The questionnaire was designed to obtain general information about each hospital, availability of NIV practice, use of NIV, and obstacles that can hinder NIV use in clinical settings; the survey was sent to senior respiratory therapists (RTs) of 76 hospitals. Descriptive statistics were used to analyze the data. RESULTS Sixty-one hospitals (80.3%) responded to the survey (47 governmental and 14 private). NIV was available in all hospitals and all the Intensive Care Units. The majority of RTs (85%) reported having a good experience with NIV, with a confidence rate of 60%; however, only 22% of the RTs had received formal training. Although NIV setup was the sole responsibility of RTs, only 69% participated in NIV management. Moreover, 72% of hospitals had an NIV setup protocol in place. However, 50% of them lacked a protocol for NIV failure. NIV protocols for specific indications were present in 64% of the hospitals: 47.2% for monitoring and 42% for weaning. The perceived efficiency of NIV practice was low in the medical wards, with a <49% success rate in 39% of the hospitals. Shortage of staff and lack of formal training were the most common reasons for NIV underutilization. CONCLUSION The efficiency of NIV in the KSA was low. The RTs expressed moderate confidence in administering NIV. Lack of appropriate exposure and formal training could have negative impacts on NIV practice.
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Affiliation(s)
- Mohammed Dhafer AlAhmari
- Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dhahran, Saudi Arabia
| | - Hajed Al-Otaibi
- Department of Respiratory Care, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Hatem Qutub
- Department of Medicine, Imam Abdulrahman Alfaisal University, Dammam, Saudi Arabia
| | - Ibrahim AlBalawi
- Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dhahran, Saudi Arabia
| | - Abdullah Alqahtani
- Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dhahran, Saudi Arabia
| | - Bandar Almasoudi
- Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dhahran, Saudi Arabia
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Skoczyński S, Scala R, Navalesi P. Survey on accessibility and real-life application of noninvasive ventilation. ERJ Open Res 2018; 4:00062-2018. [PMID: 30402452 PMCID: PMC6213288 DOI: 10.1183/23120541.00062-2018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 09/07/2018] [Indexed: 11/05/2022] Open
Abstract
Noninvasive mechanical ventilation (NIV) is an accepted method of respiratory failure treatment; however, at present, little is known about the global factors limiting NIV application. A survey designed to determine NIV accessibility and limiting factors in world economies and regions was developed. The questionnaire was sent to members of the European Respiratory Society (ERS) Respiratory Intensive Care Assembly and all ERS National Delegates. Replies to the survey were collected from 161 respondents from 46 countries. NIV was found to be provided most frequently by pulmonologists and intensivists. In high-income economies (HIEs), NIV reimbursement in chronic respiratory failure treatment was found to be independent of the underlying disease and supplementary insurance (p<0.0001), whereas in upper-middle-income economies (UMIEs) it was found to be dependent on the underlying disease (p<0.0001). In chronic respiratory failure, NIV was not reimbursed in lower-middle-income economies (LMIEs) (p<0.0001). In LMIEs and UMIEs, the lack of financial resources was the main limiting factor in acute (p=0.007) and chronic respiratory failure (p<0.0001). In the income-level-based assessment, financing was recognised as relevant in LMIEs and UMIEs (p<0.0001), equipment in LMIEs and UMIEs (p=0.03), medical staff in all economies (p=0.02), and legal regulations in LMIEs (p=0.0005). It was confirmed that NIV in acute and chronic respiratory failure is reimbursed based on government regulations in UMIEs and HIEs (p<0.0001), and is not reimbursed and probably will not be reimbursed in the near future in LMIEs (p<0.0001). We conclude that financial constraints are still considered a major limiting factor for NIV use.
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Affiliation(s)
- Szymon Skoczyński
- Dept of Pulmonology, School of Medicine in Katowice, The Medical University of Silesia, Katowice, Poland
| | - Raffaele Scala
- Pulmonology and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy
| | - Paolo Navalesi
- Anesthesia and Intensive Care, Dept of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
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Bello G, De Santis P, Antonelli M. Non-invasive ventilation in cardiogenic pulmonary edema. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:355. [PMID: 30370282 DOI: 10.21037/atm.2018.04.39] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cardiogenic pulmonary edema (CPE) is among the most common causes of acute respiratory failure (ARF) in the acute care setting and often requires ventilatory assistance. In patients with ARF due to CPE, use of non-invasive positive airway pressure can decrease the systemic venous return and the left ventricular (LV) afterload, thus reducing LV filling pressure and limiting pulmonary edema. In these patients, either non-invasive ventilation (NIV) or continuous positive airway pressure (CPAP) can improve vital signs and physiological parameters, decreasing the need for endotracheal intubation (ETI) and hospital mortality when compared to conventional oxygen therapy. Results on the use of NIV or CPAP in patients with CPE prior to hospitalization are not homogeneous among studies, hampering any conclusive recommendation regarding their role in the pre-hospital setting.
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Affiliation(s)
- Giuseppe Bello
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Paolo De Santis
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Massimo Antonelli
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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Kogo M, Nagata K, Morimoto T, Ito J, Fujimoto D, Nakagawa A, Otsuka K, Tomii K. What Is the Impact of Mildly Altered Consciousness on Acute Hypoxemic Respiratory Failure with Non-invasive Ventilation? Intern Med 2018; 57:1689-1695. [PMID: 29434147 PMCID: PMC6047975 DOI: 10.2169/internalmedicine.9355-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 09/21/2017] [Indexed: 11/21/2022] Open
Abstract
Objective A severely altered level of consciousness (ALC) is considered to be a possible contraindication to non-invasive ventilation (NIV). We investigated the association between mild ALC and NIV failure in patients with hypoxemic respiratory failure. Methods A retrospective study was conducted by reviewing the medical charts of patients with de novo hypoxemic respiratory failure who received NIV treatment. The clinical background and the outcomes of patients with and without ALC were compared. Patients Patients who were admitted to our hospital for acute hypoxemic respiratory failure between July 2011 and May 2015 were included in the present study. Results Sixty-six of the 148 patients had ALC. In comparison to the patients without ALC, the patients with ALC were older (median: 72 vs. 78 years, p=0.02), had a higher Acute Physiology and Chronic Health Evaluation II score (18 vs. 19, p=0.02), and received a higher level of inspiratory pressure (8 cmH2O vs. 8, p<0.01). The median Glasgow Coma Scale score of the patients with ALC was 14 (interquartile range, 11-14). There were no significant differences between the groups in the rates of NIV failure (24% vs. 30%, p=0.4) and in-hospital mortality (13% vs. 16%, p=0.3). Conclusion NIV may be successfully applied to treat acute hypoxemic respiratory failure with mild ALC. NIV may be performed, with careful attention to the appropriate timing for intubation.
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Affiliation(s)
- Mariko Kogo
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Japan
| | - Kazuma Nagata
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Japan
| | - Takeshi Morimoto
- Clinical Research Center, Kobe City Medical Center General Hospital, Japan
- Department of Clinical Epidemiology, Hyogo College of Medicine, Japan
| | - Jiro Ito
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Japan
| | - Daichi Fujimoto
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Japan
| | - Atsushi Nakagawa
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Japan
| | - Kojiro Otsuka
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Japan
| | - Keisuke Tomii
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Japan
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Ergan B, Nasiłowski J, Winck JC. How should we monitor patients with acute respiratory failure treated with noninvasive ventilation? Eur Respir Rev 2018; 27:27/148/170101. [PMID: 29653949 DOI: 10.1183/16000617.0101-2017] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 12/21/2017] [Indexed: 12/12/2022] Open
Abstract
Noninvasive ventilation (NIV) is currently one of the most commonly used support methods in hypoxaemic and hypercapnic acute respiratory failure (ARF). With advancing technology and increasing experience, not only are indications for NIV getting broader, but more severe patients are treated with NIV. Depending on disease type and clinical status, NIV can be applied both in the general ward and in high-dependency/intensive care unit settings with different environmental opportunities. However, it is important to remember that patients with ARF are always very fragile with possible high mortality risk. The delay in recognition of unresponsiveness to NIV, progression of respiratory failure or new-onset complications may result in devastating and fatal outcomes. Therefore, it is crucial to understand that timely action taken according to monitoring variables is one of the key elements for NIV success. The purpose of this review is to outline basic and advanced monitoring techniques for NIV during an ARF episode.
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Affiliation(s)
- Begum Ergan
- Division of Intensive Care, Dept of Pulmonary and Critical Care, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey .,Both authors contributed equally
| | - Jacek Nasiłowski
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Warsaw, Poland.,Both authors contributed equally
| | - João Carlos Winck
- Northern Rehabilitation Centre Cardio-Pulmonary Group, Vila Nova de Gaia, Respiratory Medicine Units of Trofa-Saúde Alfena Hospital and Braga-Centro Hospital and Faculty of Medicine University of Porto, Porto, Portugal
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Arakelian E, Laurssen E, Öster C. Older Patients' Worries in Connection With General Anesthesia and Surgery-A Qualitative Study. J Perianesth Nurs 2018; 33:822-833. [PMID: 29548667 DOI: 10.1016/j.jopan.2018.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 01/18/2018] [Accepted: 01/20/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE To examine anxiety and what older patients worry about related to anesthesia and colorectal surgery, and their perceptions regarding nurses' ability to ease preoperative worry. DESIGN Qualitative individual face-to-face interviews. METHODS The study included 18 patients aged between 62 and 91 years with lower abdominal tumors. The study was conducted in two day-surgery wards in Sweden. Interview data were analyzed with Malterud's systematic text condensation. FINDINGS Four themes were identified: (1) losing control of one's body, leaving one's life in someone else's hands, and the feeling that there is no going back, (2) claustrophobia and anticipated pain in an unknown environment, (3) unknown and frightening vocabulary concerning the surgery, and (4) what can happen if something goes wrong. CONCLUSIONS Patients worry about a number of things. If preoperative worry could be identified, actions taken to reduce worry could be personalized and patients' own strategies to reduce worries may be helpful for them.
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Pettenuzzo T, Fan E, Del Sorbo L. Extracorporeal carbon dioxide removal in acute exacerbations of chronic obstructive pulmonary disease. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:31. [PMID: 29430448 PMCID: PMC5799148 DOI: 10.21037/atm.2017.12.11] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 11/30/2017] [Indexed: 01/15/2023]
Abstract
Extracorporeal carbon dioxide removal (ECCO2R) has been proposed as an adjunctive intervention to avoid worsening respiratory acidosis, thereby preventing or shortening the duration of invasive mechanical ventilation (IMV) in patients with exacerbation of chronic obstructive pulmonary disease (COPD). This review will present a comprehensive summary of the pathophysiological rationale and clinical evidence of ECCO2R in patients suffering from severe COPD exacerbations.
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Affiliation(s)
- Tommaso Pettenuzzo
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- The Extracorporeal Life Support Program and Department of Medicine, University Health Network, Toronto, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- The Extracorporeal Life Support Program and Department of Medicine, University Health Network, Toronto, Canada
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- The Extracorporeal Life Support Program and Department of Medicine, University Health Network, Toronto, Canada
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Belenguer-Muncharaz A, Mateu-Campos L, González-Luís R, Vidal-Tegedor B, Ferrándiz-Sellés A, Árguedas-Cervera J, Altaba-Tena S, Casero-Roig P, Moreno-Clarí E. Non-Invasive Mechanical Ventilation Versus Continuous Positive Airway Pressure Relating to Cardiogenic Pulmonary Edema in an Intensive Care Unit. Arch Bronconeumol 2017; 53:561-567. [PMID: 28689679 DOI: 10.1016/j.arbres.2017.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 02/06/2017] [Accepted: 02/08/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND To compare the application of non-invasive ventilation (NIV) versus continuous positive airway pressure (CPAP) in the treatment of patients with cardiogenic pulmonary edema (CPE) admitted to an intensive care unit (ICU). METHODS In a prospective, randomized, controlled study performed in an ICU, patients with CPE were assigned to NIV (n=56) or CPAP (n=54). Primary outcome was intubation rate. Secondary outcomes included duration of ventilation, length of ICU and hospital stay, improvement of gas exchange, complications, ICU and hospital mortality, and 28-day mortality. The outcomes were analyzed in hypercapnic patients (PaCO2>45mmHg) with no underlying chronic lung disease. RESULTS Both devices led to similar clinical and gas exchange improvement; however, in the first 60min of treatment a higher PaO2/FiO2 ratio was observed in the NIV group (205±112 in NIV vs. 150±84 in CPAP, P=.02). The rate of intubation was similar in both groups (9% in NIV vs. 9% in CPAP, P=1.0). There were no differences in duration of ventilation, ICU and length of hospital stay. There were no significant differences in ICU, hospital and 28-d mortality between groups. In the hypercapnic group, there were no differences between NIV and CPAP. CONCLUSIONS Either NIV or CPAP are recommended in patients with CPE in the ICU. Outcomes in the hypercapnic group with no chronic lung disease were similar using NIV or CPAP.
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Affiliation(s)
- Alberto Belenguer-Muncharaz
- Intensive Care Unit, Hospital General Universitario de Castelló, Spain; Unidad Predepartamental Medicina, Facultad Ciencias de la Salud, Universitat Jaume I de Castelló, Spain.
| | - Lidón Mateu-Campos
- Intensive Care Unit, Hospital General Universitario de Castelló, Spain; Unidad Predepartamental Medicina, Facultad Ciencias de la Salud, Universitat Jaume I de Castelló, Spain
| | | | | | - Amparo Ferrándiz-Sellés
- Intensive Care Unit, Hospital General Universitario de Castelló, Spain; Unidad Predepartamental Medicina, Facultad Ciencias de la Salud, Universitat Jaume I de Castelló, Spain
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Ozsancak Ugurlu A, Habesoglu MA. Epidemiology of NIV for Acute Respiratory Failure in COPD Patients: Results from the International Surveys vs. the "Real World". COPD 2017. [PMID: 28636452 DOI: 10.1080/15412555.2017.1336527] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Non-invasive ventilation (NIV) has been recommended as the first-line ventilation modality for acute respiratory failure (ARF) due to acute exacerbation of chronic obstructive pulmonary disease (AECOPD) based on strong evidence. However, everyday clinical practice may differ from findings of multiple randomized controlled trials. Physicians and respiratory therapists involved in NIV management have been queried about its utilization and effectiveness. In addition to these estimates, cohort studies and analysis of large inpatient dataset of patients with AECOPD and ARF managed with NIV have been extensively published over the last two decades. This review summarizes the perception of medical staff vs. the "real life" data about NIV use for ARF in AECOPD patients.
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New Setting of Neurally Adjusted Ventilatory Assist during Noninvasive Ventilation through a Helmet. Anesthesiology 2017; 125:1181-1189. [PMID: 27649505 DOI: 10.1097/aln.0000000000001354] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Compared to pneumatically controlled pressure support (PSP), neurally adjusted ventilatory assist (NAVA) was proved to improve patient-ventilator interactions, while not affecting comfort, diaphragm electrical activity (EAdi), and arterial blood gases (ABGs). This study compares neurally controlled pressure support (PSN) with PSP and NAVA, delivered through two different helmets, in hypoxemic patients receiving noninvasive ventilation for prevention of extubation failure. METHODS Fifteen patients underwent three (PSP, NAVA, and PSN) 30-min trials in random order with both helmets. Positive end-expiratory pressure was always set at 10 cm H2O. In PSP, the inspiratory support was set at 10 cm H2O above positive end-expiratory pressure. NAVA was adjusted to match peak EAdi (EAdipeak) during PSP. In PSN, the NAVA level was set at maximum matching the pressure delivered during PSP by limiting the upper pressure. The authors assessed patient comfort, EAdipeak, rates of pressurization (i.e., airway pressure-time product [PTP] of the first 300 and 500 ms after the initiation of patient effort, indexed to the ideal pressure-time products), and measured ABGs. RESULTS PSN significantly increased comfort to (median [25 to 75% interquartile range]) 8 [7 to 8] and 9 [8 to 9] with standard and new helmets, respectively, as opposed to both PSP (5 [5 to 6] and 7 [6 to 7]) and NAVA (6 [5 to 7] and 7 [6 to 8]; P < 0.01 for all comparisons). Regardless of the interface, PSN also decreased EAdipeak (P < 0.01), while increasing PTP of the first 300 ms from the onset of patient effort, indexed to the ideal PTP (P < 0.01) and PTP of the first 500 ms from the onset of patient effort, indexed to the ideal PTP (P < 0.001). ABGs were not different among trials. CONCLUSIONS When delivering noninvasive ventilation by helmet, compared to PSP and NAVA, PSN improves comfort and patient-ventilator interactions, while not ABGs. (Anesthesiology 2016; 125:1181-9).
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Navarro-Sune X, Hudson AL, Fallani FDV, Martinerie J, Witon A, Pouget P, Raux M, Similowski T, Chavez M. Riemannian Geometry Applied to Detection of Respiratory States From EEG Signals: The Basis for a Brain–Ventilator Interface. IEEE Trans Biomed Eng 2017; 64:1138-1148. [DOI: 10.1109/tbme.2016.2592820] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Wang J, Cui Z, Liu S, Gao X, Gao P, Shi Y, Guo S, Li P. Early use of noninvasive techniques for clearing respiratory secretions during noninvasive positive-pressure ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease and hypercapnic encephalopathy: A prospective cohort study. Medicine (Baltimore) 2017; 96:e6371. [PMID: 28328824 PMCID: PMC5371461 DOI: 10.1097/md.0000000000006371] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Noninvasive positive-pressure ventilation (NPPV) might be superior to conventional mechanical ventilation (CMV) in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPDs). Inefficient clearance of respiratory secretions provokes NPPV failure in patients with hypercapnic encephalopathy (HE). This study compared CMV and NPPV combined with a noninvasive strategy for clearing secretions in HE and AECOPD patients.The present study is a prospective cohort study of AECOPD and HE patients enrolled between October 2013 and August 2015 in a critical care unit of a major university teaching hospital in China.A total of 74 patients received NPPV and 90 patients received CMV. Inclusion criteria included the following: physician-diagnosed AECOPD, spontaneous airway clearance of excessive secretions, arterial blood gas analysis requiring intensive care, moderate-to-severe dyspnea, and a Kelly-Matthay scale score of 3 to 5. Exclusion criteria included the following: preexisting psychiatric/neurological disorders unrelated to HE, upper gastrointestinal bleeding, upper airway obstruction, acute coronary syndromes, preadmission tracheostomy or endotracheal intubation, and urgent endotracheal intubation for cardiovascular, psychomotor agitation, or severe hemodynamic conditions.Intensive care unit participants were managed by NPPV. Participants received standard treatment consisting of controlled oxygen therapy during NPPV-free periods; antibiotics, intravenous doxofylline, corticosteroids (e.g., salbutamol and ambroxol), and subcutaneous low-molecular-weight heparin; and therapy for comorbidities if necessary. Nasogastric tubes were inserted only in participants who developed gastric distension. No pharmacological sedation was administered.The primary and secondary outcome measures included comparative complication rates, durations of ventilation and hospitalization, number of invasive devices/patient, and in-hospital and 1-year mortality rates.Arterial blood gases and sensorium levels improved significantly within 2 hours in the NPPV group with lower hospital mortality, fewer complications and invasive devices/patient, and superior weaning off mechanical ventilation. Mechanical ventilation duration, hospital stay, or 1-year mortality was similar between groups.NPPV combined with a noninvasive strategy to clear secretions during the first 2 hours may offer advantages over CMV in treating AECOPD patients complicated by HE.
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Affiliation(s)
- Jinrong Wang
- Southern Medical University, Guangzhou, Guangdong
- Department of Critical Care Medicine
| | | | | | - Xiuling Gao
- Department of Respiratory and Critical Care Medicine, Harrison International Peace Hospital, Hengshui, Hebei
| | - Pan Gao
- Department of Critical Care Medicine
| | - Yi Shi
- Southern Medical University, Guangzhou, Guangdong
- Department of Respiratory and Critical Care Medicine, Nanjing General Hospital of Nanjing Military Command, Nanjing, Jiangsu, China
| | | | - Peipei Li
- Department of Respiratory and Critical Care Medicine, Harrison International Peace Hospital, Hengshui, Hebei
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Valley TS, Walkey AJ, Lindenauer PK, Wiener RS, Cooke CR. Association Between Noninvasive Ventilation and Mortality Among Older Patients With Pneumonia. Crit Care Med 2017; 45:e246-e254. [PMID: 27749319 PMCID: PMC5315597 DOI: 10.1097/ccm.0000000000002076] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Despite increasing use, evidence is mixed as to the appropriate use of noninvasive ventilation in patients with pneumonia. We aimed to determine the relationship between receipt of noninvasive ventilation and outcomes for patients with pneumonia in a real-world setting. DESIGN, SETTING, PATIENTS We performed a retrospective cohort study of Medicare beneficiaries (aged > 64 yr) admitted to 2,757 acute-care hospitals in the United States with pneumonia, who received mechanical ventilation from 2010 to 2011. EXPOSURES Noninvasive ventilation versus invasive mechanical ventilation. MEASUREMENT AND MAIN RESULTS The primary outcome was 30-day mortality with Medicare reimbursement as a secondary outcome. To account for unmeasured confounding associated with noninvasive ventilation use, an instrumental variable was used-the differential distance to a high noninvasive ventilation use hospital. All models were adjusted for patient and hospital characteristics to account for measured differences between groups. Among 65,747 Medicare beneficiaries with pneumonia who required mechanical ventilation, 12,480 (19%) received noninvasive ventilation. Patients receiving noninvasive ventilation were more likely to be older, male, white, rural-dwelling, have fewer comorbidities, and were less likely to be acutely ill as measured by organ failures. Results of the instrumental variable analysis suggested that, among marginal patients, receipt of noninvasive ventilation was not significantly associated with differences in 30-day mortality when compared with invasive mechanical ventilation (54% vs 55%; p = 0.92; 95% CI of absolute difference, -13.8 to 12.4) but was associated with significantly lower Medicare spending ($18,433 vs $27,051; p = 0.02). CONCLUSIONS Among Medicare beneficiaries hospitalized with pneumonia who received mechanical ventilation, noninvasive ventilation use was not associated with a real-world mortality benefit. Given the wide CIs, however, substantial harm associated with noninvasive ventilation could not be excluded. The use of noninvasive ventilation for patients with pneumonia should be cautioned, but targeted enrollment of marginal patients with pneumonia could enrich future randomized trials.
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Affiliation(s)
- Thomas S Valley
- 1Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI. 2Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI. 3Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI. 4The Pulmonary Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Center for Implementation and Improvement Sciences, Boston, MA. 5Center for Quality of Care Research and Division of General Medicine and Community Health, Baystate Medical Center, Springfield, MA. 6Tufts Clinical and Translational Science Institute, Tufts University School of Medicine, Boston, MA. 7Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA. 8Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI
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Murata H, Inoue T, Takahashi O. What prevents critically ill patients with respiratory failure from using non-invasive positive pressure ventilation: A mixed-methods study. Jpn J Nurs Sci 2017; 14:297-310. [PMID: 28105784 DOI: 10.1111/jjns.12159] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 10/07/2016] [Accepted: 10/13/2016] [Indexed: 01/07/2023]
Abstract
AIM To identify the factors that prevent patients in respiratory failure from using noninvasive positive pressure ventilation (NPPV). The following were evaluated: (i) the patients who converted from NPPV to endotracheal intubation; and (ii) the patients who abandoned NPPV. METHODS Patients were interviewed regarding their experience with NPPV. Next, the factors that prevented the continuation of NPPV were identified and those data were collected retrospectively from medical records. The participants included adult patients in intensive care who were undergoing NPPV. The data from the interviews of nine participants were analyzed by using content analysis. Data that were collected from the medical records of 126 participants contributed to the identification of the characteristics that affected the implementation of NPPV. The factors were entered into a model by using logistic regression and decision-tree analysis. RESULTS An interview content analysis revealed eight aspects of the patients' experiences. In the medical record analysis, the specific factors that were associated with the conversion to intubation were the Acute Physiology and Chronic Health Evaluation II scores, breathing becoming easier, arterial oxygen partial pressure to fractional inspired oxygen ratio, and realizing the necessity of NPPV. The factors that were associated with the abandonment of NPPV included sleep loss, delirium, discomfort, and the arterial oxygen partial pressure to fractional inspired oxygen ratio. Realizing the necessity of NPPV was not statistically significant. With regard to the decision-tree analysis, the factors that were selected were similar to those that were selected in the factor analysis. CONCLUSION In the initial stage of NPPV, focusing on dyspnea, sleep loss, discomfort, delirium, and the realization of the necessity of NPPV were critical in deciding on continuing this intervention or the early conversion to intubation.
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Affiliation(s)
- Hiroaki Murata
- Department of Critical and Invasive-Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomoko Inoue
- National College of Nursing, Tokyo, Japan.,Tokyo Medical and Dental University, Tokyo, Japan
| | - Osamu Takahashi
- Internal Medicine, St. Luke's International Hospital, Tokyo, Japan
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