Assisted Mechanical Ventilation Research Articles

Impact of Platelet Transfusion on Pulmonary Function of Hematology Oncology Patients: The Piper Study

Background. Platelet transfusion is a critical therapy for hematology-oncology patients at risk of transfusion-transmitted infection (TTI) and pulmonary injury. Amotosalen-UVA pathogen reduction (PR) treatment of apheresis platelet components (PC) in plasma or additive solution (INTERCEPT Blood System for Platelets, Cerus, Concord, CA) is FDA approved to reduce risk of TTI and transfusion associated graft vs. host disease (TA-GVHD). PRPC meet the FDA bacteria risk reduction guidance, and approximately 50% of U.S. PC are PRPC. Amotosalen-UVA PR replaces bacteria screening, gamma irradiation, and CMV serology. PR is performed within 24 hours of collection enabling early release of PRPC with 5-day storage. We tested the hypothesis that PRPC were not inferior to conventional PC(CPC) for the incidence of pulmonary injury. Methods. An open-label sequential cohort study in platelet transfusion dependent hematology-oncology patients was conducted under routine practice conditions in 15 clinical centers. Each site enrolled a CPC cohort followed by a PRPC cohort using 4 primary therapy strata matched ± 10%: chemotherapy without hematopoietic cell transplant (HCT), HCT with myeloablation, HCT with non-myeloablative conditioning, and HCT with reduced intensity conditioning (RIC). Patients were supported with the assigned PC type for up to 21 days with 7 days of surveillance after the last PC exposure. Patients participated in only one cohort. The primary endpoint was treatment emergent assisted mechanical ventilation (TEAMV) by intubation or tight mask with positive end expiration pressure (5cm H 2O) after initiation of study PC. All endpoint patients were adjudicated by a blinded pulmonary expert panel (PEP) for diagnosis of acute respiratory distress syndrome (ARDS) by the Berlin Criteria. Secondary endpoints included: time to initiation of TEAMV, clinically significant pulmonary adverse events (CSPAE, CTCAE ≥ Grade 2), transfusion reactions, and mortality. The incidence of TEAMV by non-inferiority (margin = 2.3%), and secondary endpoints were analyzed by modified intention to treat (mITT) and per protocol (PP). Sensitivity analyses with propensity score matching for key variables were conducted for the primary endpoint. The associations between PC and categorical variables were tested by stratified Cochran-Mantel-Haenszel and continuous variables by ANOVA for two-sided significance p = 0.05. results. A total of 2291 pediatric and adult patients (1068 PRPC and 1223 CPC) were enrolled in the respective cohorts with transfusion of 5,277 PRPC and 5,491 CPC. PC assignment compliance and study completion were > 94%. For the mITT data set, the cumulative incidence of TEAMV was lower for the PRPC cohort (log rank p = 0.039) than the CPC cohort (2.9% versus 4.6%, HR = 0.633: 95% CI 0.408-0.982). PRPC by mITT were non-inferior to CPC for the incidence of TEAMV due to all indications, and for TEAMV with pulmonary dysfunction (PD) by PEP (Table). PP analyses were consistent with mITT. Relative risk (RR) of TEAMV showed significantly (p<0.05) decreased RR of PRPC respectively for baseline covariates: age < 65 (0.53), male (0.54), non-white (0.32), chemotherapy (0.40), prior pulmonary disease (0.55), and prior cardiac disease (0.58). Least squares (LS) mean days to initiation of TEAMV for patients with PD were longer for PRPC recipients. PEP adjudicated incidence of ARDS was not significantly different between cohorts (Table). Total and serious CSPAE were not different between the cohorts. There were no significant differences between cohorts in Respiratory, Thoracic, and Mediastinal Disorders, the most frequent system organ class event. Mortality was not different between cohorts. Multivariate analysis (mITT) for the probability of CSPAE or transfusion associated cardiac overload (TACO) showed PC type had no effect. The odds ratio (OR) of CSPAE or TACO during PC support was significantly increased (p< 0.05) in both cohorts for history of cardiac disease (1.35), history of pulmonary disease (2.57), diagnosis of Myelodysplasia (1.88), and diagnosis of Myelodysplasia/Myeloproliferative disease (2.27). There was a significant treatment interaction (p= 0.043) between PC type and acute myelogenous leukemia (AML), increased OR = 1.49 for CPC versus PRPC. Conclusions. PRPC did not potentiate pulmonary injury during PC support; and their use may decrease TEAMV risk with benefit of reduced TTI risk. [Display omitted] DisclosuresWheeler: Novo Nordisk A/S: Consultancy; Bayer: Consultancy; BioMarin: Consultancy; HEMA Biologics: Consultancy; Spark: Consultancy; Takeda: Consultancy; UniQure: Consultancy. Nooka: Janssen Oncology: Consultancy, Research Funding; Takeda: Consultancy, Research Funding; Sanofi: Consultancy; Oncopeptides: Consultancy; Amgen: Consultancy, Research Funding; Bristol-Myers Squibb: Consultancy; Adaptive technologies: Consultancy; GlaxoSmithKline: Consultancy, Other: Travel expenses; Karyopharm Therapeutics: Consultancy. Uhl: UpToDate: Patents & Royalties; Abbott: Consultancy, Speakers Bureau; Grifols: Consultancy, Speakers Bureau. Spinella: Secure Transfusion Services: Current Employment, Current holder of individual stocks in a privately-held company, Current holder of stock options in a privately-held company; Cerus Corporation: Consultancy, Research Funding. Liu: Cerus Corporation: Current Employment, Current equity holder in publicly-traded company. Benjamin: Cerus Corporation: Current Employment, Current equity holder in publicly-traded company. Corash: Cerus Corporation: Current Employment, Current equity holder in publicly-traded company.

Association between cycle threshold (Ct ) values and clinical and laboratory data in inpatients with COVID-19 and asymptomatic health workers.

In‐house assays for the diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) by quantitative reverse‐transcription polymerase chain reaction (qRT‐PCR), are feasible alternatives, particularly in developing countries. Cycle threshold (C t) values obtained by qRT‐PCR were compared with clinical and laboratory data from saliva of inpatients with COVID‐19 and asymptomatic health workers (AHW) were studied. Saliva specimens from 58 inpatients confirmed by qRT‐PCR for SARS‐CoV‐2 using nasopharyngeal specimens, and 105 AHW were studied by qRT‐PCR using three sets of primers for the N (N1, N2, and N3) gene of SARS‐CoV‐2, according to the CDC Diagnostic Panel protocol, showing a positivity of 88% for inpatients and 8% for AHW. Bivariate analysis revealed an association between C t < 38.0 values for N2 and mechanical ventilation assistance among patients (p = .013). In addition, values of aspartate‐transaminase, lactate dehydrogenase, and ferritin showed significant correlations with C t values of N1 and N3 genes in inpatients. Therefore, our results show that C t values correlate with some relevant clinical data for inpatients with COVID‐19.

Hypoventilation syndrome in neuromuscular disorders.

Hypoventilation syndrome in neuromuscular disorders (NMDs) is primarily due to respiratory muscle weakness and results in increased morbidity and mortality. This article highlights current aspects of neuromuscular hypoventilation syndrome, including pathophysiology, clinical symptoms, assessment, respiratory involvement in various NMD, and causal and symptomatic treatments with an emphasis on recent research and advances. New therapeutic agents have been developed within the last years, proving a positive effect on respiratory system. Symptomatic therapies, including mechanical ventilation and cough assistance approaches, are important in NMD and respiratory muscle training may have benefit in strengthening respiratory muscles and should be offered patients with respiratory muscle weakness the same way as physiotherapy. Correct respiratory assessments and their correct interpretation are hallmarks for early diagnosis of hypoventilation syndrome and treatment.

Expiratory Pause Maneuver to Assess Inspiratory Muscle Pressure During Assisted Mechanical Ventilation: A Bench Study.

The generation of excessive inspiratory muscle pressure (Pmus) during assisted mechanical ventilation in patients with respiratory failure may result in acute respiratory muscle injury and/or fatigue, and exacerbate ventilator-induced lung injury. A readily available noninvasive surrogate measure of Pmus may help in titrating both mechanical ventilation and sedation to minimize these risks. This bench study explored the feasibility and accuracy of using a ventilator's expiratory pause hold function to measure Pmus across multiple operators. A standardized technique for executing a brief (<1 s) expiratory pause maneuver was used to measure the airway occlusion pressure change (Δ Paw) by using 3 simulated Pmus (Δ Pmus: 5, 10, 15 cm H2O) under (1) pressure support ventilation (0, 10, 15 cm H2O), (2) volume and pressure-regulated volume ventilation, (3) flow and pressure-triggering, and (4) varying levels of PEEP and pressure-rise time. Individual and grouped measurements were made by 4-7 clinicians on 3 different ventilators. The concordance between occlusion Δ Paw and Δ Pmus was arbitrarily set at ≤ 2 cm H2O. Data were evaluated by using analysis of variance and the Tukey-Kramer posttest. Correlation was assessed by using the Pearson R test; bias and precision were assessed by using the Bland-Altman method. Alpha was set at 0.05. Grouped expiratory pause maneuver measurements of occlusion Δ Paw across simulated Δ Pmus, mode and level of ventilatory support showed reasonable concordance, regardless of the ventilator used. Occlusion Δ Paw accuracy frequently decreased by ∼3 cm H2O when both pressure support ventilation and Δ Pmus reached 15 cm H2O. Expiratory pause maneuver accuracy was not affected by trigger mechanism and/or sensitivity, PEEP, or the post-trigger pressurization rate. In general, only small differences in Δ Paw occurred among the individual operators. The expiratory pause maneuver generally provided reproducible, stable approximations of Δ Pmus across ventilators and ventilator settings, and a range of simulated effort. Technique standardization produced relatively consistent results across multiple operators. The expiratory pause maneuver seemed feasible for general use in monitoring inspiratory effort during assisted mechanical ventilation.

Patients with hematologic cancers are more vulnerable to COVID-19 compared to patients with solid cancers.

Previous studies reported that COVID-19 patients with cancer had higher rates of severe events such as intensive care unit (ICU) admission, mechanical ventilation (MV) assistance, and death during the COVID-19 course compared to the general population. However, no randomized study compared the clinical course of COVID-19 in patients with hematologic cancers to patients with solid cancers. Thus, in this study, we intend to reveal the outcome of COVID-19 in hematologic cancer patients and compare their outcomes with COVID-19 patients with solid cancers. The data of 926 laboratory-confirmed COVID-19 patients, including 463 hematologic cancer patients and an age-gender paired cohort of 463 solid cancer patients, were investigated retrospectively. The frequencies of severe and critical disease, hospital and ICU admission, MV assistance were significantly higher in hematologic cancer patients compared with the solid cancer patients (p = 0.001, p = 0.045, p = 0.001, and p = 0.001, respectively). The hospital stay was longer in patients with hematologic cancers (p = 0.001); however, the median ICU stay was 6 days in both groups. The case fatality rate (CFR) was 14.9% in patients with hematologic cancers, and it was 4.8% in patients with solid cancers, and there was a statistically significant difference regarding CFR between groups (p = 0.001). Our study revealed that COVID-19 patients with hematologic cancers have a more aggressive course of COVID-19 and have higher CFR compared to COVID-19 patients with solid cancers and support the increased susceptibility of patients with hematologic cancers during the outbreak.

POS1233 USE OF BARICITINIB AND TOCILIZUMAB FOR THE TREATMENT OF MODERATE TO SEVERE COVID-19 IN HOSPITALIZED PATIENTS

Background:SARS-CoV2 infection and COVID-19 associated pneumonia are associated to a dysregulated inflammatory response known as cytokine storm and the use of cytokine inhibitors, especially those targeting IL-6, has been proposed as a therapeutic alternative in these patients. Janus Kinase (JAK) inhibitors in combination to the antiviral Remdesivir have shown evidence of reducing recovery time and accelerating improvement in clinical status among patients with COVID-19, notably among those receiving high-flow oxygen or noninvasive ventilation1.Objectives:To describe the outcomes associated with the use of Tocilizumab (TCZ) and Baricitinib (Bari) in patients hospitalized for COVID-19.Methods:Descriptive study nested in a cohort. Patients from the General Hospital of Cuernavaca who were hospitalized due to COVID-19 associated pneumonia and/or respiratory failure requiring supplemental oxygen or invasive/non-invasive assisted mechanical ventilation (AMV) were analyzed. All patients had a positive RT-PCR upon hospital admission, sampled under standardized conditions. The clinical and demographic data of the patients upon hospitalization were obtained from the instrument on a specific platform (SISVER) used on a national basis. Severe disease was considered as the need for any type of AMV. TCZ was used at 400-600 mg in two infusions (baseline and at 72 hours), Bari at 4 mg daily for 14 days. The outcomes were the need for AMV, death, or discharge. A p≤ 0.05 was considered statistically significant.Results:Data from 404 SARS-CoV2 positive patients were analyzed. 269 (65.9%) were men. The mean age of the patients was 57.5 years (18-94; SD 15.3). 59.6% of the patients had one or more comorbidities (Diabetes and Hypertension in most cases [31.8%]). 22.8% of the patients had a history of current or previous smoking. Mean hospital stay was 7.4 days (1-36; SD 5.9). 15.9% of the patients required invasive or non-invasive AMV. 11 patients were treated with TCZ and 30 patients received treatment with Baricitinib. 5 of the 11 patients with TCZ required AMV (all but one were intubated), but only 6 of the 30 (20%) with Bari required AMV (all except one received CPAP). The use of Baricitinib was correlated with a reduction in the use of AMV (p 0.01). 6 patients with TCZ were discharged due to improvement and 5 died. In the case of Bari, 19 improved and were discharged and 11 died, significantly correlating with lower mortality (p 0.05). The use TCZ was not associated with a reduced hospitalization (50% remained hospitalized for more than 10 days) but patients receiving Baricitinib had significantly shorter hospital stays (86.6% had a hospital stay of less than 10 days) than those receiving TCZ (p&lt;0.0001).Conclusion:The patients that were treated with Baricitinib and required AMV most often improved with non-invasive CPAP while the majority of the patients under AMV receiving TCZ were treated with an invasive mode, although this was due in part to the fact that TCZ can be employed intravenously and is more practical for intubated patients in whom oral drug administration is limited. Baricitinib was significantly associated with a better outcome (hospital discharge due to improvement) and a significantly shorter hospital stay.

Central venous pressure swing outperforms diaphragm ultrasound as a measure of inspiratory effort during pressure support ventilation in COVID-19 patients

PurposeThe COVID-19-related shortage of ICU beds magnified the need of tools to properly titrate the ventilator assistance. We investigated whether bedside-available indices such as the ultrasonographic changes in diaphragm thickening ratio (TR) and the tidal swing in central venous pressure (ΔCVP) are reliable estimates of inspiratory effort, assessed as the tidal swing in esophageal pressure (ΔPes).MethodsProspective, observational clinical investigation in the intensive care unit of a tertiary care Hospital. Fourteen critically-ill patients were enrolled (age 64 ± 7 years, BMI 29 ± 4 kg/m2), after 6 [3; 9] days from onset of assisted ventilation. A three-level pressure support trial was performed, at 10 (PS10), 5 (PS5) and 0 cmH2O (PS0). In each step, the esophageal and central venous pressure tidal swing were recorded, as well as diaphragm ultrasound.ResultsThe reduction of pressure support was associated with an increased respiratory rate and a reduced tidal volume, while minute ventilation was unchanged. ΔPes significantly increased with reducing support (5 [3; 8] vs. 8 [14; 13] vs. 12 [6; 16] cmH2O, p < 0.0001), as did the diaphragm TR (9.2 ± 6.1 vs. 17.6 ± 7.2 vs. 28.0 ± 10.0%, p < 0.0001) and the ΔCVP (4 [3; 7] vs. 8 [5; 9] vs. 10 [7; 11] cmH2O, p < 0.0001). ΔCVP was significantly associated with ΔPes (R2 = 0.810, p < 0.001), as was diaphragm TR, albeit with a lower coefficient of determination (R2 = 0.399, p < 0.001).ConclusionsIn patients with COVID-19-associated respiratory failure undergoing assisted mechanical ventilation, ΔCVP is a better estimate of inspiratory effort than diaphragm ultrasound.

ECMO Assistance during Mechanical Ventilation: Effects Induced on Energetic and Haemodynamic Variables

Background and ObjectiveSimulation in cardiovascular medicine may help clinicians understand the important events occurring during mechanical ventilation and circulatory support. During the COVID-19 pandemic, a significant number of patients have required hospital admission to tertiary referral centres for concomitant mechanical ventilation and extracorporeal membrane oxygenation (ECMO). Nevertheless, the management of ventilated patients on circulatory support can be quite challenging. Therefore, we sought to review the management of these patients based on the analysis of haemodynamic and energetic parameters using numerical simulations generated by a software package named CARDIOSIM©. MethodsNew modules of the systemic circulation and ECMO were implemented in CARDIOSIM© platform. This is a modular software simulator of the cardiovascular system used in research, clinical and e-learning environment. The new structure of the developed modules is based on the concept of lumped (0-D) numerical modelling. Different ECMO configurations have been connected to the cardiovascular network to reproduce Veno-Arterial (VA) and Veno-Venous (VV) ECMO assistance. The advantages and limitations of different ECMO cannulation strategies have been considered. We have used literature data to validate the effects of a combined ventilation and ECMO support strategy. ResultsThe results have shown that our simulations reproduced the typical effects induced during mechanical ventilation and ECMO assistance. We focused our attention on ECMO with triple cannulation such as Veno-Ventricular-Arterial (VV-A) and Veno-Atrial-Arterial (VA-A) configurations to improve the hemodynamic and energetic conditions of a virtual patient. Simulations of VV-A and VA-A assistance with and without mechanical ventilation have generated specific effects on cardiac output, coupling of arterial and ventricular elastance for both ventricles, mean pulmonary pressure, external work and pressure volume area. ConclusionThe new modules of the systemic circulation and ECMO support allowed the study of the effects induced by concomitant mechanical ventilation and circulatory support. Based on our clinical experience during the COVID-19 pandemic, numerical simulations may help clinicians with data analysis and treatment optimisation of patients requiring both mechanical ventilation and circulatory support.

Modified Negative Pressure Enclosure During Tracheostomy in Patients With COVID-19.

COVID-19 also known as severe acute respiratory syndrome coronavirus 2 is the result of a highly transmissible coronavirus which can result in severe infection of the respiratory tract. The global pandemic which began in early 2020 has created a number of challenges for the medical community to contain the rate of transmission, especially to health care workers. A minority of the infected population will progress toward severe respiratory distress ultimately requiring mechanical ventilator assistance. Although preliminary data suggest a poor prognosis for those requiring ventilation support, there is a subgroup who will eventually be weaned off. As the pandemic evolves, this cohort of infected, chronically intubated and ventilated individuals will become more prevalent and may require tracheostomy to aid in recovery. Unfortunately, tracheostomy is an aerosol-generating procedure which poses high risks to all members within the operating room, as described by previous authors. There is an urgent need to explore and develop methods to maximize the safety of tracheostomy and other aerosol-generating procedures in order to reduce intraoperative transmission. In the present article, we present a modified technique for negative pressure enclosure in patients with COVID-19 who underwent tracheostomy.

Community-acquired methicillin-resistant Staphylococcus aureus pneumonia in a children's hospital. Our ten-year experience.

Community-acquired methicillinresistant Staphylococcus aureus (CA-MRSA) infections have increased in recent years. CAMRSA necrotizing pneumonia and empyema are now more common in children. To determine the prevalence of CA-MRSA pneumonia and its clinical and epidemiological characteristics compared to Streptococcus pneumoniae (SP) pneumonia in the same population. Descriptive, observational, cross-sectional study of patients hospitalized due to CA-MRSA pneumonia at Hospital de Niños Víctor J. Vilela (period: January 2008-December 2017). Out of 54 Staphylococcus aureus pneumonia cases, 46 (85 %) corresponded to CA-MRSA. The rate of CA-MRSA pneumonia ranged from 4.9/10 000 (2008) to 10/10 000 hospital discharges (2017). Sepsis/septic shock was observed in 41 %; empyema, in 96 %; pneumothorax, in 35 %; 90 % of cases required pleural drainage and 55 %, surgical debridement. Also, 65 % of patients were admitted to the intensive care unit (ICU); half of them required assisted mechanical ventilation. Two patients died. Strain resistance: 17 %, gentamicin; 13 %, erythromycin; and 11 %, clindamycin. Compared to SP pneumonia, CAMRSA pneumonia showed a higher risk for sepsis (95 % confidence interval; relative risk: 7.38; 3.32- 16.38) and admission to the ICU (RR: 4.29; 2.70- 6.83). No patient died due to SP pneumonia. The prevalence of CA-MRSA pneumonia doubled in the past decade. Compared to SP pneumonia, CA-MRSA pneumonia was more commonly accompanied by sepsis and septic shock, admission to the ICU, and ventilatory support requirement.

Yüksek Riskli Hastalarda Weaning Başarısızlığı Açısından Noninvaziv Ventilasyon, Yüksek Akışlı Oksijen Tedavisi ve Konvansiyonel Oksijen Tedavisinin Karşılaştırılması

Objective: The most common reason for intensive care unit admission is acute respiratory failure and after extubation mainly three methods are used to bring the PaO2 level to a sufficient level: conventional oxygen therapy (COT), high flow oxygen therapy (HFO), and non-invasive ventilation (NIV). The aim of this study was to determine if NIV or HFO is beneficial in decreasing weaning failure in high-risk patient population (HRP) and compare these noninvasive methods. Methods: This prospective, observational cohort study was conducted between March 2019 and March 2020 in a tertiary state hospital in Turkey. Our study included 3 main groups as COT, HFO, and NIV. Results: During the study period, 71 patients were enrolled in this study and 24 patients were in the COT group, 22 HFO group, and 25 in the NIV group. The mean duration of mechanical ventilation assistance (MVA) before extubation was 5.8 days and the mean PaO2 was highest in the HFO group 6 hours after extubation with a statistically significant difference (p&lt;0.001). The HFO group had the highest PaO2/FiO2 immediately before and 6 hours after extubation. The reintubation rate was lowest in the HFO group and the other outcomes as total MVA duration, length of stay in ICU and hospital also differed between groups favoring the HFO group. Conclusion: The results of our study suggest that NIV and HFO were beneficial in decreasing weaning failure and 30-day mortality rate among HRP compared to COT. When these noninvasive methods were compared, it was observed that HFO was preferable because of these advantages although the main characteristics of the groups were different.

Effect of a Nutritional Support System to Increase Survival and Reduce Mortality in Patients with COVID-19 in Stage III and Comorbidities: A Blinded Randomized Controlled Clinical Trial.

The COVID-19 evolution depends on immunological capacity. The global hospital mortality rate is 15-20%, but in México it is 46%. There are several therapeutic protocols, however, integral nutrition is not considered. In this study, a Nutritional Support System (NSS) was employed to increase survival and reduce mortality in patients with stage III COVID-19. A randomized, blinded, controlled clinical trial was performed. Eighty patients (aged 30 to 75 years, both sexes) were assigned to 1) “Control Group” (CG) hospital diet and medical treatment or 2) “Intervention Group” (IG) hospital diet, medical treatment, and the NSS (vitamins, minerals, fiber, omega-3, amino acids, B-complex, and probiotics). IG significantly increased survival and reduced mortality compared to CG (p=0·027). IG decreased progression to Mechanical Ventilation Assistance (MVA) by 10%, reduced the intubation period by 15 days, and increased survival in intubated patients by 38% compared to CG. IG showed improvement compared to CG in: decrease of supplemental oxygen (p=0·014), the qSOFA test (p=0·040), constipation (p=0·014), the PHQ-9 test (p=0·003), and in the follow-up, saturation with oxygen (p=0·030). The NSS increases survival and decreases mortality in patients with stage III COVID-19.Trial Registration: Clinical Trials registration code: NCT 04507867.Funding: This research was funded by Centro de Investigación en Ciencias de la Salud (CICSA),Universidad Anáhuac México Campus Norte grant number 2017/202036.Declaration of Interest: The authors declare that they have no conflicts of interest.Ethical Approval: The study was conducted according to the guidelines of the Declaration of Helsinki, the Nuremberg Code, and the Mexican Standard NOM-012-SSA3-2012. The research was approved by the research committee of the Faculty of Health Sciences of the Universidad Anáhuac México Norte, registration number: 202036, CONBIOETICA-15-CEI-004- 20160729, the research committee of the CMI Toluca, registration number: 207C0401010201S / JIC / 155/2020

Study of clinical profile and short-term outcome of neonates requiring assisted mechanical ventilation

Study of clinical profile and short-term outcome of neonates requiring assisted mechanical ventilation

Clinical risk profile associated with SARS-CoV-2 infection and complications in the emergency area of a pediatric COVID-19 center.

In February 2020, the disease caused by the novel coronavirus (SARS-CoV-2), was classified as a pandemic. In the pediatric population, coronavirus disease (COVID)-19 has a reported mortality of less than 6% in complicated cases; however, the clinical characteristics and severity are not the same as those presented in the adult population. This study aimed to describe the clinical manifestations of patients younger than 18 years old and their association with the confirmation of the test and outcomes. We conducted an analytical cross-sectional study of symptoms suggestive for SARS-CoV-2 infection. All subjects with a confirmatory test for SARS-CoV-2 were included. Initial symptoms, history of influenza vaccination, and previous contact were documented, and mortality and the requirement for assisted mechanical ventilation were identified. The proportions of the variables were compared with the χ2 test. The odds ratio for a positive test and the requirement of intubation was calculated. Of a total of 510 subjects, 76 (15%) were positive for SARS-CoV-2. The associated symptoms were chest pain, sudden onset of symptoms, and general malaise. The variable most associated with contagion was the exposure to a relative with a confirmed diagnosis of COVID-19. Infants and subjects without the influenza vaccine showed an increased risk for respiratory complications. The frequency of positivity in the test was 15% (infants and adolescents represented 64% of the confirmed cases), and the associated factors identified were contact with a confirmed case, sudden onset of symptoms, and chest pain.

"Current concepts in assisted mechanical ventilation in the neonate" - Part 2: Understanding various modes of mechanical ventilation and recommendations for individualized disease-based approach in neonates.

Mechanical ventilation is a lifesaving intervention in critically ill preterm and term neonates. However, it has the potential to cause significant damage to the lungs resulting in long-term complications. Understanding the pathophysiological process and having a good grasp of the basic concepts of conventional and high-frequency ventilation is essential for any medical or allied healthcare practitioner involved in the neonates’ respiratory management. This review aims to describe the various types and modes of ventilation usually available in neonatal units. It also describes recommendations of an individualized disease-based approach to mechanical ventilation strategies implemented in the authors’ institutions.

EL PERSONAL DE ENFERMERÍA EN LA APLICACIÓN DEL PROTOCOLO DE VENTILACIÓN MECÁNICA

La ventilación mecánica es un tratamiento de soporte vital, en el que se utiliza una máquina que suministra un soporte ventilatorio y oxigenatorio, facilitando el intercambio gaseoso y el trabajo respiratorio de los pacientes con insuficiencia respiratoria. Un protocolo es un documento que se desarrolla para orientar la toma de decisiones entorno a problemas específicos, ya sea como diagnosticar, tratar y cuidar a alguien con una afección específica. En este documento se describe si el personal de Enfermería aplica el Protocolo de Ventilación Mecánica propio de la unidad o del Ministerio de Salud Pública en la Unidad de Cuidados Intensivos. ). Por tal motivo resulta importante resaltar el papel que el personal de enfermería desempeña en las áreas de cuidados intensivos brindando la atención especializada e individualizada que requiere el paciente aportando a su progresiva recuperación El tipo de investigación realizada es de carácter observacional, de campo y prospectivo, Participaron en el estudio un total de 11 profesionales de enfermería del área de la Unidad de Cuidados Intensivos del Hospital Napoleón Dávila Córdova de Chone. De acuerdo con las encuestas realizadas el 100% del personal refiere que aplican el protocolo de Ventilación Mecánica del MSP, utilizando con mayor frecuencia el modo de ventilación mecánica asistida. Previo al procedimiento de ventilación mecánica el personal de enfermería aplica las debidas normas de bioseguridad. La implementación del protocolo del de VM invasiva y no invasiva al momento de realizar el procedimiento es esencial porque de esta manera se va a trabajar con una guía específica la cual evitará posibles complicaciones en la UCI.

Advanced COPD in a patient treated in the Intensive Care Unit

Chronic obstructive pulmonary disease (COPD) is the 3rd leading cause of death worldwide and 7th in the classification of years of life lost or lived with disability. Indeed, COPD prevalence is still increasing. Moreover, chronic respiratory failure in advanced COPD is one of the most common indications for palliative care. The deterioration of general health, including respiratory failure, raises many doubts as to the need for hospitalization, prognosis and medical interventions. The decision to start palliative care provision in COPD patients is based on poor prognosis, but it is not clear when it should be started. Proper and specialized palliative care in this patient population can limit hospital, Intensive Care Unit (ICU), and emergency admissions. A case of a patient with advanced COPD receiving palliative care and the treatment in the ICU is presented. Due to pneumonia with permanent respiratory hypercapnia, the patient was hospitalized and qualified to tracheostomy and invasive ventilation. In bronchofiberoscopy granulation tissue narrowing the airways below the tracheotomy tube, confirmed by the CT scan. The patient was qualified for rigid bronchofiberoscopy to widen the trachea. Antibiotic therapy with multidirectional pharmacological treatment was provided at the ICU. The patient was discharged home in a fairly good general condition, on his breathing with passive oxygen therapy, periodically requiring assisted mechanical ventilation, without carbon dioxide retention, and with effective cough reflexes. Mechanical causes of respiratory failure in ventilated advanced COPD patients should be considered. Short–time-intensive therapy treatment may improve the general condition of ventilated advanced COPD patients.

Comparative effects of neurally adjusted ventilatory assist and variable pressure support on lung and diaphragmatic function in a model of acute respiratory distress syndrome: A randomised animal study.

Variable assisted mechanical ventilation has been shown to improve lung function and reduce lung injury. However, differences between extrinsic and intrinsic variability are unknown. To investigate the effects of neurally adjusted ventilatory assist (NAVA, intrinsic variability), variable pressure support ventilation (Noisy PSV, extrinsic variability) and conventional pressure-controlled ventilation (PCV) on lung and diaphragmatic function and damage in experimental acute respiratory distress syndrome (ARDS). Randomised controlled animal study. University Hospital Research Facility. A total of 24 juvenile female pigs. ARDS was induced by repetitive lung lavage and injurious ventilation. Animals were randomly assigned to 24 h of either: 1) NAVA, 2) Noisy PSV or 3) PCV (n=8 per group). Mechanical ventilation settings followed the ARDS Network recommendations. The primary outcome was histological lung damage. Secondary outcomes were respiratory variables and patterns, subject-ventilator asynchrony (SVA), pulmonary and diaphragmatic biomarkers, as well as diaphragmatic muscle atrophy and myosin isotypes. Global alveolar damage did not differ between groups, but NAVA resulted in less interstitial oedema in dorsal lung regions than Noisy PSV. Gas exchange and SVA incidence did not differ between groups. Compared with Noisy PSV, NAVA generated higher coefficients of variation of tidal volume and respiratory rate. During NAVA, only 40.4% of breaths were triggered by the electrical diaphragm signal. The IL-8 concentration in lung tissue was lower after NAVA compared with PCV and Noisy PSV, whereas Noisy PSV yielded lower type III procollagen mRNA expression than NAVA and PCV. Diaphragmatic muscle fibre diameters were smaller after PCV compared with assisted modes, whereas expression of myosin isotypes did not differ between groups. Noisy PSV and NAVA did not reduce global lung injury compared with PCV but affected different biomarkers and attenuated diaphragmatic atrophy. NAVA increased the respiratory variability; however, NAVA yielded a similar SVA incidence as Noisy PSV. This trial was registered and approved by the Landesdirektion Dresden, Germany (AZ 24-9168.11-1/2012-2).

Feasibility of using esophageal balloon pressure-volume curve to calibrate esophageal pressure during assisted mechanical ventilation

To evaluate the feasibility of esophageal pressure (Pes) calibration by the esophageal balloon pressure-volume (P-V) curve during assisted mechanical ventilation. A prospective study was conducted. The postoperative patients admitted to intensive care unit of Beijing Tiantan Hospital Affiliated to Capital Medical University from June 2017 to January 2019 who needed pressure support ventilation by tracheal intubation and Pes monitoring with stable breath were enrolled. The Pes monitoring was performed by the esophageal balloon with a small geometric volume (2.8 mL). (1) Balloon volume tests of esophageal balloon were performed by inflating intermittently 0.5 mL increments up to 2.5 mL, the end-expiratory and end-inspiratory Pes were recorded to obtain end-expiratory and end-inspiratory P-V curves. The intermediate section in end-expiatory P-V curve that showed linear correlation was identified (as intermediate linear section), whose volume range was balloon working volume (Vwork) and slope was esophageal wall elastance (Ees), the balloon volume with the largest difference between end-expiratory and end-inspiratory Pes was the best balloon volume (Vbest), and the product of Ees and Vbest was esophageal wall recoil pressure reacting to balloon filling. To minimize the effect of esophageal wall on Pes, the calibrated Pes was the difference of Pes and esophageal wall recoil pressure. The consistency of calibrated Pes obtained by balloon volume at Vbest and other Vwork were analyzed. (2) For the convenience of clinical application, a simplified method was introduced to calibrate Pes. Based on all Vwork of patients located in 0.5-1.5 mL, the difference of end-expiratory Pes between balloon volume at 0.5 mL and 1.5 mL divided by 1.0 mL was used to estimate Ees, and the Pes among 0.5-1.5 mL was calibrated by Ees obtained by the simple method. The consistency of calibrated Pes obtained by the simple method and standard method were observed. Totally 30 patients were enrolled, all end-expiratory and end-inspiratory P-V curves existed the intermediate linear section, the calibrated Pes at Vwork did not increase with the balloon being inflated and had a good consistency with the calibrated Pes at Vbest, mean difference and 95% confidence interval (95%CI) was -0.02 (-1.50-1.50) cmH2O (1 cmH2O = 0.098 kPa). The Ees and calibrated Pes estimated by the simple method had a good agreement with the standard method, mean difference and 95%CI was -0.2 (-1.0-0.6) cmH2O/mL and 0.2 (-1.1-1.4) cmH2O, respectively. During assisted mechanical ventilation, the use of a small geometric volume esophageal balloon to monitor Pes and balloon P-V curve to calibrate Pes is feasible. The simple method can be used for simplifying clinical application, that's only by monitoring Pes at balloon volume at 0.5, 1.0 and 1.5 mL to evaluate the Ees and calibrate Pes.

A machine learning method for automatic detection and classification of patient-ventilator asynchrony.

Patients suffering from respiratory failure are often put on assisted mechanical ventilation. Patient-ventilator asynchrony (PVA) can occur during mechanical ventilation, which cause damage to the lungs and has been linked to increased mortality in the intensive care unit. In current clinical practice PVA is still detected using visual inspection of the air pressure, flow, and volume curves, which is time-consuming and sensitive to subjective interpretation. Correct detection of the patient respiratory efforts is needed to properly asses the type of asynchrony. Therefore, we propose a method for automatic detection of the patient respiratory efforts using a one-dimensional convolution neural network. The proposed method was able to detect patient efforts with a sensitivity and precision of 98.6% and 97.3% for the inspiratory efforts, and 97.7% and 97.2% for the expiratory efforts. Besides allowing detection of PVA, combining the estimated timestamps of patient's inspiratory and expiratory efforts with the timings of the mechanical ventilator further allows for classification of the asynchrony type. In the future, the proposed method could support clinical decision making by informing clinicians on the quality of ventilation and providing actionable feedback for properly adjusting the ventilator settings.