A randomized crossover pilot study comparing the efficacy of an auto-demand oxygen delivery system with that of a conventional demand oxygen delivery system in patients with chronic respiratory failure

INTRODUCTION

: When using portable oxygen, a demand oxygen delivery system (DODS), which senses the beginning of inhalation and delivers a bolus of oxygen, is often used. However, conventional DODS may not supply sufficient oxygen when reduced tidal flow fails to trigger the flow sensor. Recently, "auto-DODS," which detects the negative pressure of inhalation and switches among 3 trigger sensitivity levels (standard, high, and extra high), has been developed to improve the efficacy of oxygenation. An auto-DODS can also supply pulsed-flow oxygen when it detects apnea, whereas a conventional DODS has only standard sensitivity. This randomized, open-label, crossover pilot study compared the performance of an auto-DODS with that of a conventional DODS.

METHODS

: We recruited patients with chronic obstructive pulmonary disease (COPD) or interstitial pneumonia receiving long-term oxygen therapy. Interventions were performed on 2 different days for each participant. On each day, an auto-DODS or a conventional DODS were tested at rest for 30 minutes and during the 6-minute walk test. The primary outcome was mean oxygen saturation (SpO2). Secondary outcomes were the ratios of time for each sensitivity level and pulsed-flow oxygen when using the auto-DODS, total time desaturated below SpO2 90%, percentage of time desaturated below SpO2 90%, minimum SpO2, mean and maximum pulse rate, six-minute walk distance, recovery time after 6-minute walk test, modified Borg scale, comfort, and discomfort index.

RESULTS

: When using the auto-DODS at rest, a high or extra high sensitivity level was observed in addition to standard sensitivity in 6 of 8 participants. During the 6-minute walk test, only standard sensitivity was observed in 6 participants. Mean SpO2 differences between the auto-DODS and conventional DODS at rest and during the 6-minute walk test were -0.6 [-4.5, 3.4] and 0.0 [-2.5, 2.5] ([95% confidence interval]), respectively, neither of which were significant (P = .73 and P = .99). There were no significant differences in secondary outcomes. There were no adverse events when using the auto-DODS.

CONCLUSIONS

: This study showed that the auto-DODS did not show superiority in oxygenation either at rest or during exercise compared to a conventional DODS. The auto-DODS was shown to supply oxygen safely and detect inhalations with various trigger sensitivities.

The occurrence of delayed neuropsychologic sequelae in acute carbon monoxide poisoning patients after treatment with hyperbaric or normobaric oxygen therapy

This study aimed at assessing which one of the 2 therapies is better for treating carbon monoxide (CO) poisoning from the perspective of reducing delayed neuropsychologic sequelae (DNS).We used Taiwan's National Health Insurance Research Database (NHIRD) to conduct a nationwide population-based cohort study to assess which therapy is better for CO poisoning patients. To accurately identify patients with DNS, the definition of DNS is included neurological sequelae, and cognitive and psychological sequele. The independent variable was therapy and the dependent variable was DNS occurred within 1 year after discharge from a medical institution. The control variables were age, gender, the severity of CO poisoning, and comorbidities present before CO poisoning admission.The risk of developing DNS in patients treated with Hyperbaric Oxygen (HBO) was 1.87-fold (P < .001) than normobaric oxygen (NBO) therapy. The severity of CO poisoning and comorbidities were also found to have significant influences on the risk of developing DNS.HBO may be a risk therapy for treating CO poisoning.

Home Oxygen Therapy for Adults with Chronic Lung Disease. An Official American Thoracic Society Clinical Practice Guideline

Background: Evidence-based guidelines are needed for effective delivery of home oxygen therapy to appropriate patients with chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD).Methods: The multidisciplinary panel created six research questions using a modified Delphi approach. A systematic review of the literature was completed, and the Grading of Recommendations Assessment, Development and Evaluation approach was used to formulate clinical recommendations.Recommendations: The panel found varying quality and availability of evidence and made the following judgments: 1) strong recommendations for long-term oxygen use in patients with COPD (moderate-quality evidence) or ILD (low-quality evidence) with severe chronic resting hypoxemia, 2) a conditional recommendation against long-term oxygen use in patients with COPD with moderate chronic resting hypoxemia, 3) conditional recommendations for ambulatory oxygen use in patients with COPD (moderate-quality evidence) or ILD (low-quality evidence) with severe exertional hypoxemia, 4) a conditional recommendation for ambulatory liquid-oxygen use in patients who are mobile outside the home and require >3 L/min of continuous-flow oxygen during exertion (very-low-quality evidence), and 5) a recommendation that patients and their caregivers receive education on oxygen equipment and safety (best-practice statement).Conclusions: These guidelines provide the basis for evidence-based use of home oxygen therapy in adults with COPD or ILD but also highlight the need for additional research to guide clinical practice.

The safety and effectiveness of heated humidified high-flow nasal cannula as an initial ventilation method in the treatment of neonatal respiratory distress syndrome: A protocol for systematic review and meta-analysis

BACKGROUND

This study uses a method of systematic evaluation to evaluate the safety and effectiveness of heated humidified high-flow nasal cannula (HHHFNC) as an initial ventilation method in the treatment of neonatal respiratory distress syndrome (NRDS) scientifically. In the field of evidence-based medicine, this study provides a theoretical reference and basis for choosing appropriate initial non-invasive ventilation methods in the treatment of NRDS, thereby providing assistance for clinical treatment.

METHODS

The main electronic network databases were searched by computer, including 4 Chinese databases: CNKI, WangFang Data, CQVIP, SinoMed and 3 English databases: PubMed, The Cochrane Library and EMBASE, the time range of retrieval from the beginning of each database to September 1, 2020. The content involves all the published randomized controlled trials on the effectiveness of HHHFNC compared with NCPAP as an initial ventilation method in the treatment of NRDS. Using a search method that combines medical subject words and free words. Based on the Cochrane risk bias assessment tool, 2 researchers independently screen the literature, and then extract the data we needed in the literature, and cross-check. If it is difficult to decide whether to include literature, then turning to a third researcher for help and making a final decision after discussion, and using RevMan 5.3 and STATA 13.0 to analyze the relative data.

RESULTS

Based on the method of meta-analysis, this study analyzes the pre-determined outcome indicators through scientific statistical analysis, and compares the effectiveness and safety of HHHFNC compared with NCPAP as an initial ventilation method in the treatment of NRDS. All results will be published in peer-reviewed high-quality professional academic journals.

CONCLUSION

Based on evidence-based medicine, this study will obtain the establishing evidence of comparison that the clinical effectiveness and safety of HHHFNC compared with NCPAP as an initial ventilation method in the treatment of NRDS through the existing data and data, which provides the evidence support of evidence-based medicine in the treatment of NRDS.

OSF REGISTRATION NUMBER

September 17, 2020. osf.io/f6at4 (https://osf.io/f6at4).

A Systematic Review of Clinical Practice Guidelines for the Diagnosis and Management of Bronchiolitis

BACKGROUND

Bronchiolitis is the leading cause of hospital admission for respiratory disease among infants aged <1 year. Clinical practice guidelines can benefit patients by reducing the performance of unnecessary tests, hospital admissions, and treatment with lack of a supportive evidence base. This review aimed to identify current clinical practice guidelines worldwide, appraise their methodological quality, and discuss variability across guidelines for the diagnosis and management of bronchiolitis.

METHODS

A systematic literature review of electronic databases EMBASE, Global Health, and Medline was performed. Manual searches of the gray literature, national pediatric society websites, and guideline-focused databases were performed, and select international experts were contacted to identify additional guidelines. The Appraisal of Guidelines for Research and Evaluation assessment tool was used by 2 independent reviewers to appraise each guideline.

RESULTS

Thirty-two clinical practice guidelines met the selection criteria. Quality assessment revealed significant shortcomings in a number of guidelines, including lack of systematic processes in formulating guidelines, failure to state conflicts of interest, and lack of consultation with families of affected children. There was widespread agreement about a number of aspects, such as avoidance of the use of unnecessary diagnostic tests, risk factors for severe disease, indicators for hospital admission, discharge criteria, and nosocomial infection control. However, there was variability, even within areas of consensus, over specific recommendations, such as variable thresholds for oxygen therapy. Guidelines showed significant variability in recommendations for the pharmacological management of bronchiolitis, with conflicting recommendations over whether use of nebulized epinephrine, hypertonic saline, or bronchodilators should be routinely trialled.

CONCLUSIONS

Future guidelines should aim to be compliant with international standards for clinical guidelines to improve their quality and clarity and to promote their adoption into practice. Variable recommendations between guidelines may reflect the evolving evidence base for bronchiolitis management, and platforms should be created to understand this variability and promote evidence-based recommendations.

Understanding Clinicians' Perceived Barriers and Facilitators to Optimal Use of Acute Oxygen Therapy in Adults

Background

Supplemental oxygen is commonly administered to patients in acute care. It may cause harm when used inappropriately. Guidelines recommend prescription of acute oxygen, yet adherence is poor. We aimed to identify barriers and facilitators to practicing in accordance with the evidence-based Thoracic Society of Australia and New Zealand (TSANZ) oxygen guideline, and to determine the beliefs and attitudes relating to acute oxygen therapy.

Methods

A national cross-sectional survey was conducted. The survey consisted of 3 sections: (1) introduction and participant characteristics; (2) opinion/beliefs, knowledge and actions about oxygen therapy and other drugs; and (3) barriers and facilitators to use of the TSANZ guideline. Convenience sampling was employed. A paper-based survey was distributed at the TSANZ Annual Scientific Meeting. An online survey was emailed to the TSANZ membership and to John Hunter Hospital's clinical staff.

Results

Responses were received from 133 clinicians: 52.6% nurses, 30.1% doctors, and 17.3% other clinicians. Over a third (37.7%) were unaware/unsure of the oxygen guideline's existence. Most (79.8%) believe that oxygen is a drug and should be treated as one. Most (92.4%) stated they only administered it based on clinical need. For four hypothetical cases, there was only one where the majority of participants identified the optimal oxygen saturation. A number of barriers and facilitators were identified when asked about practicing in accordance with the TSANZ guideline. Lack of oxygen equipment, getting doctors to prescribe oxygen and oxygen being treated differently to other drugs were seen as barriers. The guideline itself and multiple clinician characteristics were considered facilitators.

Conclusion

There is discordance between clinicians' beliefs and actions regarding the administration of oxygen therapy and knowledge gaps about optimal oxygen therapy in acute care. Identified barriers and facilitators should be considered when developing evidence-based guidelines to improve dissemination and knowledge exchange.

Modified Anesthesia Protocol for Electroconvulsive Therapy Permits Reduction in Aerosol-Generating Bag-Mask Ventilation during the COVID-19 Pandemic

INTRODUCTION

Electroconvulsive therapy (ECT) is a critical procedure in psychiatric treatment, but as typically delivered involves the use of bag-mask ventilation (BMV), which during the COVID-19 pandemic exposes patients and treatment staff to potentially infectious aerosols.

OBJECTIVE

To demonstrate the utility of a modified anesthesia protocol for ECT utilizing preoxygenation by facemask and withholding the use of BMV for only those patients who desaturate during the apneic period.

METHODS

This chart review study analyzes patients who were treated with ECT using both the traditional and modified anesthesia protocols.

RESULTS

A total of 106 patients were analyzed, of whom 51 (48.1%) required BMV using the new protocol. Of clinical factors, only patient BMI was significantly associated with the requirement for BMV. Mean seizure duration reduced from 52.0 ± 22.4 to 46.6 ± 17.1 s, but seizure duration was adequate in all cases. No acute physical, respiratory, or psychiatric complications occurred during treatment.

CONCLUSIONS

A modified anesthesia protocol reduces the use of BMV by more than 50%, while retaining adequate seizure duration.

The Impact of High-Flow Nasal Cannula on the Outcome of Immunocompromised Patients with Acute Respiratory Failure: A Systematic Review and Meta-Analysis

Background and objectives: High-flow nasal cannula (HFNC) can be used as a respiratory support strategy for patients with acute respiratory failure (ARF). However, no clear evidence exists to support or oppose HFNC use in immunocompromised patients. Thus, this meta-analysis aims to assess the effects of HFNC, compared to conventional oxygen therapy (COT) and noninvasive ventilation (NIV), on the outcomes in immunocompromised patients with ARF. The Pubmed, Embase and Cochrane databases were searched up to November 2018. Materials and Methods: Only clinical studies comparing the effect of HFNC with COT or NIV for immunocompromised patients with ARF were included. The outcome included the rate of intubation, mortality and length of stay (LOS). Results: A total of eight studies involving 1433 immunocompromised patients with ARF were enrolled. The pooled analysis showed that HFNC was significantly associated with a reduced intubation rate (risk ratio (RR), 0.83; 95% confidence interval (CI), 0.74-0.94, I2 = 0%). Among subgroup analysis, HFNC was associated with a lower intubation rate than COT (RR, 0.86; 95% CI, 0.75-0.95, I2 = 0%) and NIV (RR, 0.59; 95% CI, 0.40-0.86, I2 = 0%), respectively. However, there was no significant difference between HFNC and control groups in terms of 28-day mortality (RR, 0.78; 95% CI, 0.58-1.04, I2 = 48%), and intensive care unit (ICU) mortality (RR, 0.87; 95% CI, 0.73-1.05, I2 = 57%). The ICU and hospital LOS were similar between HFNC and control groups (ICU LOS: mean difference, 0.49 days; 95% CI, -0.25-1.23, I2 = 69%; hospital LOS: mean difference, -0.12 days; 95% CI, -1.86-1.61, I2 = 64%). Conclusions: Use of HFNC may decrease the intubation rate in immunocompromised patients with ARF compared with the control group, including COT and NIV. However, HFNC could not provide additional survival benefit or shorten the LOS. Further large, randomized controlled trials are needed to confirm these findings.

Oxygen alert wristbands (OxyBand) and controlled oxygen: a pilot study

Despite the introduction of Oxygen Alert Cards, guidelines and audits, oxygen therapy remains overused in NHS practice, and this may lead to iatrogenic mortality. This pilot study aimed to examine the use of Oxygen Alert Wristbands (OxyBand) designed to alert health professionals who are delivering oxygen to patients to ensure that the oxygen is administered and titrated safely to the appropriate target saturations. Patients at risk of hypercapnic acidosis were asked to wear OxyBands while presenting to paramedics and health professionals in hospitals. Inappropriate prescription of oxygen reduced significantly after the OxyBands were used. A questionnaire-based assessment showed that the clinicians involved had a good understanding of the risks of uncontrolled oxygen. Forty-two patients found the wrist band comfortable to wear, and only two did not. OxyBands may have the potential to improve patient safety over Oxygen Alert Cards.

Literature review of clinical benefits and reasons to prescribe palliative oxygen therapy in non-hypoxaemic patients

AIMS:

to review current guidelines and studies available to health professionals in the UK and explore the literature to identify reasons for the prescription of palliative oxygen therapy in non-hypoxaemic patients.

BACKGROUND:

oxygen therapy is often associated with the palliative treatment for breathlessness. Although prescription guidelines are available and the risks of oxygen therapy are known, the therapy is still prescribed for non-hypoxaemic patients.

DESIGN:

a literature search was conducted using relevant databases. Cited evidence from published guidelines was also consulted.

RESULTS:

the findings suggest that oxygen is no more effective than room air for treating dyspnoea for non-hypoxaemic patients, although two small studies of self-reported benefits from patients and carers indicate different perceptions of need.

CONCLUSION:

the findings suggest that there is a knowledge gap with regards understanding the reasons for the prescription of oxygen therapy for non-hypoxaemic patients.

Target Oxygen Saturation Among Preterm Neonates on Supplemental Oxygen Therapy: A Quality Improvement Study

OBJECTIVE

To avoid excessive oxygen exposure and achieve target oxygen saturation (SpO2) within intended range of 88%-95% among preterm neonates on oxygen therapy.

METHODS

20 preterm neonates receiving supplemental oxygen in the first week of life were enrolled. The percentage of time per epoch (a consecutive time interval of 10 hours/day) spent by them within the target SpO2 range was measured in phase 1 followed by implementation of a unit policy on oxygen administration and targeting in phase 2. In phase 3, oxygen saturation histograms constructed from pulse-oximeter data were used as daily feedback to nurses and compliance with oxygen-targeting was measured again.

RESULTS

48 epochs in phase 1 and 69 in phase 3 were analyzed. The mean (SD) percent time spent within target SpO2 range increased from 65.9% (21.4) to 76.5% (12.6) (P=0.001).

CONCLUSION

Effective implementation of oxygen targeting policy and feedback using oxygen saturation histograms may improve compliance with oxygen targeting.

Impact of the Neonatal Resuscitation Program-Recommended Low Oxygen Strategy on Outcomes of Infants Born Preterm

OBJECTIVE

To evaluate the impact of the Neonatal Resuscitation Program (NRP)-recommended low oxygen strategy (LOX) on neonatal morbidities, mortality, and neurodevelopmental outcomes in neonates born preterm.

STUDY DESIGN

In March 2011, Parkland Hospital changed from a high oxygen strategy (HOX) of resuscitation with initial 100% oxygen and targeting 85%-94% oxygen saturation for delivery room resuscitation to a LOX with initial 21% oxygen and titrating oxygen to meet NRP-recommended transitional target saturations. Neonates ≤28 weeks' gestational age born between August 2009 and April 2012 were identified. In this retrospective, observational study, neonates exposed to LOX vs HOX were compared for short-term morbidity, mortality, and long-term neurodevelopmental outcomes. Regression analysis was performed to control for confounding variables.

RESULTS

Of 199 neonates, 110 were resuscitated with HOX and 89 with LOX. Compared with HOX, neonates exposed to LOX had lower oxygen exposure in the delivery room (5.2 ± 1.5 vs 7.8 ± 2.8 [∑FiO2 × time min], P < .01), spent fewer days on oxygen (30 [5, 54] vs 46 [11, 82], P = .01), and had lower odds of developing bronchopulmonary dysplasia (aOR 0.4 [0.2, 0.9]). There was no difference in mortality (17 [20%] vs 20 [18%]), but neonates exposed to LOX had greater motor composite scores on Bayley Scales of Infant and Toddler Development-Third edition assessment (91 [85, 97] vs 88 [76, 94], P < .01).

CONCLUSION

The NRP-recommended LOX strategy was associated with improved respiratory morbidities and neurodevelopmental outcomes with no increase in mortality. Prospective trials to confirm the optimal oxygen strategy for the resuscitation of neonates born preterm are needed.

Apneic oxygenation is associated with a reduction in the incidence of hypoxemia during the RSI of patients with intracranial hemorrhage in the emergency department

Critically ill patients undergoing emergent intubation are at risk of oxygen desaturation during the management of their airway. Patients with intracranial hemorrhage (ICH) are particularly susceptible to the detrimental effects of hypoxemia. Apneic oxygenation (AP OX) may be able to reduce the occurrence of oxygen desaturation during the emergent intubation of these patients. We sought to assess the effect AP OX on oxygen desaturation during the rapid sequence intubation (RSI) of patients with ICH in the emergency department (ED). We prospectively collected data on all patients intubated in an urban academic ED over the 2-year period from July 1, 2013 to June 30, 2015. Following each intubation, the operator completed a standardized continuous quality improvement (CQI) data form, which included information on patient, operator and intubation characteristics. Operators recorded data on the use of AP OX, the oxygen flow rate used for AP OX, and the starting and lowest saturations during intubation. Adult patients with ICH who underwent RSI by emergency medicine (EM) residents were included in the analyses. The primary outcome variable was any oxygen saturation <90 % during the intubation. We performed a backward stepwise multivariate logistic regression analysis to identify variables associated with oxygen desaturation. The primary independent variable of interest was the use of AP OX during the intubation. Inclusion criteria for the study was met by 127 patients. AP OX was used in 72 patients (AP OX group) and was not used in 55 patients (NO AP OX group). The incidence of desaturation was 5/72 (7 %) in the AP OX group and was 16/55 (29 %) in the NO AP OX group. In the multivariate logistic regression analysis the use of AP OX was associated with a reduced odds of desaturation (aOR 0.13; 95 % CI 0.03-0.53). Patients with ICH who received AP OX during RSI in the ED were seven times less likely to have an oxygen saturation of <90 % during the intubation compared to patients who did not receive AP OX. AP OX is a simple intervention that may minimize the risk of oxygen desaturation during the RSI of patients with ICH.

Oxygen Targeting in Extremely Low Birth Weight Infants

The use of supplemental oxygen plays a vital role in the care of the critically ill preterm infant, but the unrestricted use of oxygen can lead to unintended harms, such as chronic lung disease and retinopathy of prematurity. An overly restricted use of supplemental oxygen may have adverse effects as well. Ideally, continuous monitoring of tissue and cellular oxygen delivery would allow clinicians to better titrate the use of supplemental oxygen, but such monitoring is not currently feasible in the clinical setting. The introduction of pulse oximetry has greatly aided the clinician by providing a relatively easy and continuous estimate of arterial oxygen saturation, but pulse oximetry has several practical, technical, and physiologic limitations. Recent randomized clinical trials comparing different pulse oximetry targets have been conducted to better inform the practice of supplemental oxygen use. This clinical report discusses the benefits and limitations of pulse oximetry for assessing oxygenation, summarizes randomized clinical trials of oxygen saturation targeting, and addresses implications for practice.

Oxygen for children and newborns in non-tertiary hospitals in South-west Nigeria: A needs assessment

BACKGROUND

Oxygen is important for the treatment of hypoxaemia associated with pneumonia, malaria, and other medical, obstetric, and surgical conditions. Access to oxygen therapy is limited in many of the high mortality settings where it would be of most benefit.

METHODS

A needs assessment of 12 non-tertiary hospitals in south-west Nigeria, assessing structural, technical and clinical barriers to the provision of safe and effective oxygen therapy.

RESULTS

Oxygen supply was reported to be a major challenge by hospital directors. All hospitals had some access to oxygen cylinders, which were expensive and frequently ran out. Nine (75%) hospitals used oxygen concentrators, which were limited by inadequate power supply and lack of maintenance capacity. Appropriate oxygen delivery and monitoring devices (nasal prongs, catheters, pulse oximeters) were poorly available, and no hospitals had clinical guidelines pertaining to the use of -oxygen for children. Oxygen was expensive to patients (median US$20/day) and to hospitals. Estimated oxygen demand is reported using both a constant mean-based estimate and adjustment for seasonal and other variability.

CONCLUSIONS

Making oxygen available to sick children and neonates in Nigerian hospitals will require: improving detection of hypoxaemia through routine use of pulse oximetry; improving access to oxygen through equipment, training, and maintenance structures; and commitment to building hospital and state structures that can sustain and expand oxygen initiatives.

Practical procedures: oxygen therapy

Knowing when to start patients on oxygen therapy can save lives, but ongoing assessment and evaluation must be carried out to ensure the treatment is safe and effective. This article outlines when oxygen therapy should be used and the procedures to follow. It also describes the delivery methods applicable to different patient groups, along with the appropriate target saturation ranges, and details relevant nurse competencies.

Study on Oxygen Supply Standard for Physical Health of Construction Personnel of High-Altitude Tunnels

The low atmospheric pressure and low oxygen content in high-altitude environment have great impacts on the functions of human body. Especially for the personnel engaged in complicated physical labor such as tunnel construction, high altitude can cause a series of adverse physiological reactions, which may result in multiple high-altitude diseases and even death in severe cases. Artificial oxygen supply is required to ensure health and safety of construction personnel in hypoxic environments. However, there are no provisions for oxygen supply standard for tunnel construction personnel in high-altitude areas in current tunnel construction specifications. As a result, this paper has theoretically studied the impacts of high-altitude environment on human bodies, analyzed the relationship between labor intensity and oxygen consumption in high-altitude areas and determined the critical oxygen-supply altitude values for tunnel construction based on two different standard evaluation systems, i.e., variation of air density and equivalent PIO₂. In addition, it has finally determined the oxygen supply standard for construction personnel in high-altitude areas based on the relationship between construction labor intensity and oxygen consumption.

De novo acute heart failure and acutely decompensated chronic heart failure

BACKGROUND

Heart failure is one of the most common diseases of adults in Europe, with an overall prevalence of 1-2%. Among persons aged 60 and above, its prevalence is above 10% in men and 8% in women. Acute heart failure has a poor prognosis; it is associated with a high rate of rehospitalization and a 1-year mortality of 20-30%.

METHODS

This review is based on pertinent literature, including guidelines, retrieved by a selective search in PubMed.

RESULTS

There are different types of acute heart failure; the basic diagnostic assessment is performed at once and consists of ECG, echocardiography, and the measurement of N-terminal pro-brain natriuretic peptide (NTproBNP) and troponin levels. The most common causes of decompensation are arrhythmia, valvular dysfunction, and acute cardiac ischemia, each of which accounts for 30% of cases. The potential indication for immediate revascularization should be carefully considered in cases where acute heart failure is due to coronary heart disease. The basic treatment of acute heart failure is symptomatic, with the administration of oxygen, diuretics, and vasodilators. Ino-tropic agents, vasopressors, and temporary mechanical support for the circulatory system are only used to treat cardiogenic shock.

CONCLUSION

The treatment of acute heart failure is markedly less evidence-based than that of chronic heart failure. Newer treatment approaches that are intended to improve outcomes still need to be tested in multicenter trials.

[Long-term home oxygen therapy in children: evidences and open issues]

INTRODUCTION

Long-term home oxygen therapy is indicated for patients with chronic hypoxemia. We intend to describe pediatric population on long-term home oxygen therapy followed-up at Pediatric Respiratory Unit of a tertiary care hospital between 2003-2012 and to compare with previous 1991-2000 review; to verify conformity with international and national recommendations and need for specific pediatric national guidelines, non-existent in Portugal.

MATERIAL AND METHODS

Retrospective, descriptive and comparative study based on clinical files review. Review the guidelines for oxygen therapy in pediatric population.

RESULTS

We studied 86 patients (59.3% males). The median age at the beginning of oxygen therapy was 0.0 (0.0-216.0) months, with a median duration of 15.0 (3.0-223.0) months. The most frequent diagnosis was bronchopulmonary dysplasia (53.5%), followed by bronchiolitis obliterans (14.0%), neurologic disorders (10.5%), cystic fibrosis (8.1%), miscellaneous syndromes (5.8%), sickle-cell disease (3.5%), other neonatal lung diseases (2.3%) and interstitial lung diseases (2.3%). Are maintained on follow-up 53 (61.6%) patients, 38 on oxygen therapy; 12 (13.9%) died. The median time of follow-up was 39.5 (1.0-246.0) months, minim on other neonatal lung diseases and maximum on cystic fibrosis. Comparing with previous review, this shows a relative increase in bronchiolitis obliterans and bronchopulmonary dysplasia patients, with increased duration in the latter, and inclusion of neurologic and hematologic patients.

DISCUSSION

Prescription of long-term oxygen therapy in pediatric age mainly occurs in specific diseases of infants and pre-school aged. Neurologic and hematologic patients represent new indications, similarly to international publications.

CONCLUSION

The knowledge of national reality and pediatric orientations are needed for care plans and rational prescription.

Poor adherence to guidelines for long-term oxygen therapy (LTOT) in two Italian university hospitals

Long-term oxygen therapy (LTOT) improves survival in patients with chronic obstructive pulmonary disease (COPD) and severe hypoxemia. Adherence to LTOT guidelines is problematic, both because efficacy has been demonstrated only in specific groups of COPD patients, and because it implies high costs. Introduces treatment high costs. The aim of our study was to examine retrospectively the adherence to LTOT guidelines in a sample of medical records of patients prescribed LTOT between January 2005 and December 2006 in two Italian university hospitals (Ferrara and Modena). Out of a total of 191 medical records of patients prescribed LTOT, only 157 had adequate clinical data considering the three main criteria for appropriateness (arterial blood gas and/or pulse oximetry measurement, oxygen administration, smoking status). Out of these 157 patients, only 73 (46.5 %) fulfilled all three criteria recommended by the guidelines. Adherence was higher for LTOT prescribed by pulmonologists compared to internists. This survey showed that the adherence to LTOT guidelines in a sample of medical records of patients prescribed LTOT is poor. Considering the high costs and the impact on the patients' quality of life of LTOT, these results suggest that the adherence should be carefully monitored.

Impact of highly concentrated contaminants on the quality of oxygen 93 % produced by pressure swing adsorption

A zeolite based pressure swing adsorption (PSA) module designed to produce medicinal oxygen with 90 - 96 % oxygen content was exposed to high input concentrations and high total amounts of CO (17.7 %, 44 mol), CO2 (16.5 %, 23 mol), NO2 (0.98 %, 2 mol), NO (6.2 %, 6 mol) and SO2 (4.2 %, 6 mol). In addition the system was operated with up to 35 % argon in the feed gas. An empirical model was developed to describe the dependence of the oxygen concentration in the product on the oxygen concentration in the input. If the oxygen concentration in the feed gas was reduced below 18 % by dilution, the oxygen concentration in the product fell under the 90 % threshold. Additional effects were observed with NO, NO2 and SO2 which are apparently due to chemical reactions on the adsorbent. These effects consisted of a further decrease in the oxygen concentration measured in the product and could not be reversed by excessive regeneration of the module with air. Under the experimental conditions used, only CO was detected in the product. Appropriate CO monitoring of the input gas is considered a possible remedy for PSA modules in order to ascertain the pharmaceutical quality of the oxygen produced.

Pediatric postoperative cardiac care

Postoperative care of cardiac patients requires a comprehensive and multidisciplinary approach to critically ill patients with cardiac disease whose care requires a clear understanding of cardiovascular physiology. When a patient fails to progress along the projected course or decompensates acutely, prompt evaluation with bedside assessment, laboratory evaluation, and echocardiography is essential. When things do not add up, cardiac catheterization must be seriously considered. With continued advancements in the field of neonatal and pediatric postoperative cardiac care, continued improvements in overall outcomes for this specialized population are anticipated.

Hyperoxia in the term newborn: more evidence is still needed for optimal oxygen therapy

It took more than 30 years from the first observations that oxygen may be toxic during resuscitation till international guidelines changed to recommend that term and near term newborn infants should be resuscitated with air instead of 100% oxygen. There are still a number of unanswered questions related to oxygen therapy of the newborn infant. The newborn brain, lungs and other organs are susceptible to oxygen injury, and newborns still develop injury caused by hyperoxia.

Evidence for oxygen use in preterm infants

AIM

To review the evidence for optimal oxygen use in preterm infants.

RESULTS

Clinicians have embraced lower saturation targets to minimize retinopathy of prematurity (ROP). Large randomized trials now have shown that while such targets reduce ROP, neonatal mortality is increased significantly.

CONCLUSIONS

Preterm infants should be resuscitated with blended oxygen (30-90%) targeted to avoid hyperoxia. Later, saturation management remains uncertain. Until ongoing trials and follow-up are complete, it is prudent to avoid saturation of 85-89%.

An observational study to quantify manual adjustments of the inspired oxygen fraction in extremely low birth weight infants

AIM

To quantify manual fraction of inspired oxygen (FiO(2)) adjustments performed by caregivers in extremely low birth weight (ELBW; ≤1000 g) infants, in relation to oxygen saturation (SpO(2)) and bedside care.

METHODS

In a single-centre study, FiO(2) , SpO(2) and alarm limits of ELBW infants were collected for 3 days continuously, while caregivers were filmed. A descriptive analysis, focused on manual FiO(2) adjustments, was performed.

RESULTS

Twelve ELWB infants were included. Total recording time was 726 h. FiO(2) was increased 851 times and decreased 1309 times; median (range) step size was 5% (1% to 65%) and -3% (-1% to -65%), respectively. Wide variation of FiO(2) adjustments for equal levels of SpO(2) was observed in all included infants. One hundred and twenty-six of 136 FiO(2) adjustments with a step size ≥15% and 111 of 171 desaturations <70% were associated with medical or nursing procedures. When FiO(2) was >21%, alarm limits for SpO(2) were set according to protocol (88-94%) in 64% of the time. Within these periods, SpO(2) was >94% for 30% and <88% for 16% of the time.

CONCLUSIONS

Manual FiO(2) adjustments varied widely in frequency and step size. Deep desaturations and large FiO(2) adjustments were associated with medical or nursing procedures. When large adjustments are really necessary, it will be challenging to implement them in an automatic adjustment device.

Reviewing home oxygen services

Home oxygen therapy costs millions of pounds every year and demand for the service is growing. As part of the Department of Health's respiratory programme, NHS Improvement--Lung works with several clinical teams in England to address variations in patient care. This article discusses how oxygen service assessment and review can save money and raise the quality of care.

British Thoracic Society emergency oxygen audits

The British Thoracic Society (BTS) guideline for emergency oxygen use in adult patients was commissioned by the BTS and developed in conjunction with 21 other colleges and societies prior to publication in 2008. One of the specific aims of the Guideline Development Group was to audit the use of oxygen in UK hospitals before the guideline was published and at intervals afterwards.

American Association for Respiratory Care. AARC Clinical Practice Guidelines. Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010

An electronic literature search for articles published between January 1990 and October 2009 was conducted by using MEDLINE, CINAHL, and Cochrane Library databases. The update of this clinical practice guideline is the result of reviewing a total of 114 clinical trials, 62 reviews and 6 meta-analyses on endotracheal suctioning. The following recommendations are made following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria: (1) It is recommended that endotracheal suctioning should be performed only when secretions are present, and not routinely; (2) It is suggested that pre-oxygenation be considered if the patient has a clinically important reduction in oxygen saturation with suctioning; (3) Performing suctioning without disconnecting the patient from the ventilator is suggested; (4) Use of shallow suction is suggested instead of deep suction, based on evidence from infant and pediatric studies; (5) It is suggested that routine use of normal saline instillation prior to endotracheal suction should not be performed; (6) The use of closed suction is suggested for adults with high F(I)O2, or PEEP, or at risk for lung de-recruitment, and for neonates; (7) Endotracheal suctioning without disconnection (closed system) is suggested in neonates; (8) Avoidance of disconnection and use of lung recruitment maneuvers are suggested if suctioning-induced lung de-recruitment occurs in patients with ; (9) It is suggested that a suction catheter is used that occludes less than 50% the lumen of the endotracheal tube in children and adults, and less than 70% in infants; (10) It is suggested that the duration of the suctioning event be limited to less than 15 seconds.