Noninvasive Ventilation for Acute Respiratory Failure due to Noncystic Fibrosis Bronchiectasis

Statistical analysis plan for the replacing protein via enteral nutrition in a stepwise approach in critically ill patients (REPLENISH) randomized clinical trial

BACKGROUND

The optimal amount and timing of protein intake in critically ill patients are unknown. REPLENISH (Replacing Protein via Enteral Nutrition in a Stepwise Approach in Critically Ill Patients) trial evaluates whether supplemental enteral protein added to standard enteral nutrition to achieve a high amount of enteral protein given from ICU day five until ICU discharge or ICU day 90 as compared to no supplemental enteral protein to achieve a moderate amount of enteral protein would reduce all-cause 90-day mortality in adult critically ill mechanically ventilated patients.

METHODS

In this multicenter randomized trial, critically ill patients will be randomized to receive supplemental enteral protein (1.2 g/kg/day) added to standard enteral nutrition to achieve a high amount of enteral protein (range of 2-2.4 g/kg/day) or no supplemental enteral protein to achieve a moderate amount of enteral protein (0.8-1.2 g/kg/day). The primary outcome is 90-day all-cause mortality; other outcomes include functional and health-related quality-of-life assessments at 90 days. The study sample size of 2502 patients will have 80% power to detect a 5% absolute risk reduction in 90-day mortality from 30 to 25%. Consistent with international guidelines, this statistical analysis plan specifies the methods for evaluating primary and secondary outcomes and subgroups. Applying this statistical analysis plan to the REPLENISH trial will facilitate unbiased analyses of clinical data.

CONCLUSION

Ethics approval was obtained from the institutional review board, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia (RC19/414/R). Approvals were also obtained from the institutional review boards of each participating institution. Our findings will be disseminated in an international peer-reviewed journal and presented at relevant conferences and meetings.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04475666 . Registered on July 17, 2020.

Bronchiectasis

Bronchiectasis is a final common pathway of a wide variety of underlying conditions including infectious, autoimmune, allergic, genetic and inflammatory conditions. Patients experience a chronic disease with variable clinical symptoms and course, but most experience cough, sputum production and recurrent exacerbations. Symptoms of bronchiectasis lead to poor quality of life and exacerbations are the major driver of morbidity and mortality. Patients are often chronically infected with bacteria with the most common being Pseudomonas aeruginosa and Haemophilus influenzae. Treatment of bronchiectasis includes standardised testing to identify the underlying cause with targeted treatment if immune deficiency, allergic bronchopulmonary aspergillosis or non-tuberculous mycobacterial infection, for example, are identified. Airway clearance is the mainstay of therapy for patients with symptoms of cough and sputum production. Frequently exacerbating patients may benefit from long term antibiotic or mucoactive therapies. Bronchiectasis is a heterogeneous disease and increasingly precision medicine approaches are advocated to target treatments most appropriately and to limit the emergence of antimicrobial resistance.

Prediction of Noninvasive Ventilation Failure in a Mixed Population Visiting the Emergency Department in a Tertiary Care Center in India

Background

Noninvasive ventilation (NIV) is an established first-line treatment of acute respiratory failure both in emergency departments (ED) and intensive care unit (ICU) settings. It is however not always successful.

Materials and methods

Prospective, observational study was done among patients above 18 years presenting with acute respiratory failure initiated on NIV. Patients were placed in one of two groups covering successful NIV treatment and NIV failure. Two groups were compared on four variables: initial respiratory rate (RR), initial high-sensitivity C-reactive protein (hs-CRP), PaO₂/FiO₂ ratio (p/f ratio), and heart rate, acidosis, consciousness, oxygenation, and respiratory rate (HACOR) score at the end of 1 hour of initiation of NIV.

Results

A total of 104 patients fulfilling the inclusion criteria were included in the study, of which 55 (52.88%) were exclusively treated with NIV (NIV success group), and 49 (47.11%) required endotracheal intubation and mechanical ventilation (NIV failure group). Noninvasive ventilation failure group had a higher mean initial RR compared with NIV success group (40.65 ± 3.88 vs 31.98 ± 3.15, p <0.001). Mean initial PaO₂/FiO₂ ratio was also significantly lower in the NIV failure group (184.57 ± 50.33 vs 277.29 ± 34.70, p <0.001). Odds ratio for successful NIV treatment with a high initial RR was 0.503 (95% confidence interval (CI), 0.390-0.649) and with a higher initial PaO₂/FiO₂ ratio was 1.053 (95% CI: 1.032-1.071 and with a HACOR score of >5 at the end of 1 hour of initiation of NIV was highly associated with NIV failure (p <0.001). A high initial level of hs-CRP was 0.949 (95% CI: 0.927-0.970).

Conclusion

Noninvasive ventilation failure could be predicted with information available at presentation in ED, and unnecessary delay in endotracheal intubation could possibly be prevented.

How to cite this article

Mathen PG, Kumar KPG, Mohan N, Sreekrishnan TP, Nair SB, Krishnan AK, et al. Prediction of Noninvasive Ventilation Failure in a Mixed Population Visiting the Emergency Department in a Tertiary Care Center in India. Indian J Crit Care Med 2022;26(10):1115-1119.

The Deteriorating Patient: Therapies Including Lung Transplantation

In this review paper, we discuss the characteristics that define severe bronchiectasis and which may lead to deterioration of noncystic fibrosis bronchiectasis. These characteristics were used to establish the current severity scores: bronchiectasis severity index (BSI), FACED, and E-FACED (exacerbation frequency, forced expiratory volume in 1 second, age, colonization, extension and dyspnea score). They can be used to predict mortality, exacerbation rate, hospital admission, and quality of life. Furthermore, there are different treatable traits that contribute to severe bronchiectasis and clinical deterioration. When present, they can be a target of the treatment to stabilize bronchiectasis.One of the first steps in treatment management of bronchiectasis is evaluation of compliance to already prescribed therapy. Several factors can contribute to treatment adherence, but to date no real interventions have been published to ameliorate this phenomenon. In the second step, treatment in deteriorating patients with bronchiectasis should be guided by the predominant symptoms, for example, cough, sputum, difficulty expectoration, exacerbation rate, or physical impairment. In the third step, we evaluate treatable traits that could influence disease severity in the deteriorating patient. Finally, in patients who are difficult to treat despite maximum medical treatment, eligibility for surgery (when disease is localized), should be considered. In case of end-stage disease, the evaluation for lung transplantation should be performed. Noninvasive ventilation can serve as a bridge to lung transplantation in patients with respiratory failure.

Non-invasive Ventilation for Children With Chronic Lung Disease

Advances in medical care and supportive care options have contributed to the survival of children with complex disorders, including children with chronic lung disease. By delivering a positive pressure or a volume during the patient's inspiration, NIV is able to reverse nocturnal alveolar hypoventilation in patients who experience hypoventilation during sleep, such as patients with chronic lung disease. Bronchopulmonary dysplasia (BPD) is a common complication of prematurity, and despite significant advances in neonatal care over recent decades its incidence has not diminished. Most affected infants have mild disease and require a short period of oxygen supplementation or respiratory support. However, severely affected infants can become dependent on positive pressure support for a prolonged period. In case of established severe BPD, respiratory support with non-invasive or invasive positive pressure ventilation is required. Patients with cystic fibrosis (CF) and advanced lung disease develop hypoxaemia and hypercapnia during sleep and hypoventilation during sleep usually predates daytime hypercapnia. Hypoxaemia and hypercapnia indicates poor prognosis and prompts referral for lung transplantation. The prevention of respiratory failure during sleep in CF may prolong survival. Long-term oxygen therapy has not been shown to improve survival in people with CF. A Cochrane review on the use NIV in CF concluded that NIV in combination with oxygen therapy improves gas exchange during sleep to a greater extent than oxygen therapy alone in people with moderate to severe CF lung disease. Uncontrolled, non-randomized studies suggest survival benefit with NIV in addition to being an effective bridge to transplantation. Complications of NIV relate mainly to prolonged use of a face or nasal mask which can lead to skin trauma, and neurodevelopmental delay by acting as a physical barrier to social interaction. Another associated risk is pulmonary aspiration caused by vomiting whilst wearing a face mask. Adherence to NIV is one of the major barriers to treatment in children. This article will review the current evidence for indications, adverse effects and long term follow up including adherence to NIV in children with chronic lung disease.