Bi-level Positive Airway Pressure Ventilation Research Articles

Azithromycin for Pediatric Critical Asthma: A Multicenter Retrospective Cohort Study.

To characterize the prescribing trends and clinical outcomes related to azithromycin (AZI) among children hospitalized for critical asthma (CA). We performed a multicenter, retrospective cohort study using the Pediatric Health Information Systems registry of children 3 to 17 years of age hospitalized in a PICU for CA from January 2011 to December 2022. We excluded for alternative indications for AZI (eg, atypical pneumonia, B. pertussis infection, acute otitis media, acute sinusitis, pharyngitis/tonsillitis, and urethritis). The primary outcome was AZI prescribing rate by hospital and calendar year (trends assessed by Joinpoint regression). Cohorts with and without AZI exposure were further characterized by demographics, CA treatments, and inpatient outcomes using descriptive and comparative (ie, χ2 and Wilcoxon rank tests) statistics. Of the 47 797 children studied, 9901 (20.7%) were prescribed AZI with a downward annual trend noted from 34.7% in 2011% to 12.4% in 2022 (-1.7% per year, R2 = 0.91). Median institutional AZI prescribing rate was 19.2% (interquartile range [IQR] 11.7%-28%; total range 5.6%-60%). Compared with children not prescribed AZI, those prescribed AZI were older (median 8.3 [IQR 5.7-11.6] vs 7.3 [4.9-10.8] years, P < .001) and experienced a more severe clinical trajectory with greater rates of bilevel positive airway pressure ventilation (19.7% vs 12.6%, P < .001), invasive ventilation (22.1% vs 13.5%, P < .001), extracorporeal life support (0.8% vs 0.1%, P < .001), and median length of stay (4 [IQR 3-6] vs 3 [IQR 2-4] days, P < .001). Between 2011 and 2022, 20.7% of children hospitalized for CA were prescribed AZI notwithstanding the absence of trial-derived efficacy or safety data for this indication and population.

Bilevel positive airway pressure ventilation in patients susceptible to hypoxemia during procedural sedation for colonoscopy: a prospective randomized controlled study

Background and aimsHypoxemia is one of the most common adverse events during colonoscopy, particularly among patients who are diagnosed with obstructive sleep apnea (OSA) or are overweight. Consequently, the objective of this study is to evaluate the effectiveness of bilevel positive airway pressure (BPAP) ventilation for patients with high risk hypoxemia during colonoscopy with sedation. MethodsIn this trial, 127 patients who met the eligibility criteria were randomly assigned to the BPAP oxygen and nasal cannula (NC) group. The primary endpoint was the incidence of hypoxemia. ResultsCompared to the use of NC, BPAP ventilation exhibited a significant reduction in the incidence of hypoxemia, decreasing it from 23.8% to 6.3% (absolute risk difference [ARD]: 17.5% [95% confidence interval (CI), 5.4 to 29.6], p = 0.006). Importantly, BPAP ventilation prevented the occurrence of severe hypoxemia (9.5% vs. 0%, ARD: 9.5% [95% CI, 2.3 to 16.7], p = 0.035). Besides, the BPAP group required fewer airway interventions (p < 0.05). ConclusionsIn individuals with OSA or overweight status, the use of BPAP ventilation during colonoscopy significantly reduced the incidence of hypoxemia.

SNAP: Supportive Non-Invasive Ventilation for ACS Prevention in Hospitalized Children with Sickle Cell Disease: Perceptions of Patients, Caregivers, and the Health Care Team

Background: Acute chest syndrome (ACS), the second most common cause of hospitalization and leading cause of death in children with sickle cell disease (SCD), often develops during a hospitalization for acute SCD in the setting of chest wall splinting, hypoventilation, and atelectasis from pain and opioid use. While incentive spirometry is an important component of ACS prevention and management, additional strategies are needed to prevent atelectasis during sleep. Bi-level positive airway pressure ventilation (BiPAP) provides positive pressure breaths through a mask to support ventilation, and is most commonly used to treat respiratory failure and chronic obstructive sleep apnea,. In 2021, we published our clinical innovation using BiPAP during sleep as supportive care during 53 hospitalizations on the general pediatric inpatient unit for hospitalized children with SCD to prevent ACS and/or to prevent acute respiratory failure among children with mild-moderate ACS. We found that our novel use of BiPAP was safe and feasible on a general pediatric unit; when recommended, it was tolerated in 40/53 (75%) hospitalizations. The goal of the current qualitative study was to identify perceived benefits and harms, and facilitators and barriers to the use and widespread implementation of “supportive non-invasive ventilation for ACS prevention” (SNAP) on a general pediatric inpatient unit. Methods: We conducted semi-structured interviews with key implementation partners at Boston Medical Center (pediatric hospitalists and hematologists; nurses, respiratory therapists, child life specialists, clinical leadership, patients, and parents) about their experiences with and perceptions of SNAP. Interviews and a priori codes for the preliminary codebook were guided by the Promoting Action Research on Implementation in Health Services (PARiHS) framework using the Evidence, Context, and Facilitation constructs. Interviews were transcribed, checked for accuracy, and imported into NVivo 12 for analysis. Transcripts were double coded by three team members who independently coded the initial transcripts. The codebook was refined until consensus was reached. Team members independently reviewed data to identify preliminary themes and subsequently consolidated themes as a group. We were particularly interested in themes regarding benefits, advantages, disadvantages, facilitators, and barriers to individual use and institutional implementation of BiPAP as supportive care. Results: Interviews were completed with 16 participants until thematic saturation was reached, including: 5 physicians, 4 nurses, 1 respiratory therapist, 1 child life specialist, 3 parents, and 2 patients. One physician and one nurse had administrative leadership roles. Major themes included: 1) Participants believed that BiPAP is effective at preventing ACS and - when already present - effective at preventing ACS from getting worse. 2) Despite some initial hesitation, inpatient team members endorsed that use of BiPAP on the general pediatric inpatient unit is appropriate. 3) Improving the patient experience with BiPAP is essential and requires a multi-tiered approach including both physical and social components. 4) Communication among inpatient team members and between staff and patients was critical for BiPAP initiation and success. 5) Nurses were key to the intervention success and required additional support. 6) The size of clinical unit and a “buy-in” culture supported intervention success . See Table 1 for detailed subthemes. Conclusions/Future directions: Members of the health care team, patients, and parents perceive SNAP as effective at preventing ACS and respiratory decompensation, and believe that it is appropriate for use with stable hospitalized children at risk for ACS on a general pediatrics inpatient unit. Features of our inpatient pediatrics unit (small size and collaborative relationships between physicians, staff, and nursing leadership) facilitated successful implementation. Improving the patient experience remains a challenge, and will involve technical issues (mask comfort and pressure) and enhanced communication among health care team members and between staff, patients, and caregivers. We are utilizing these data to develop a protocol for a multicenter hybrid effectiveness/implementation trial of SNAP that incorporates these strategies.

Using a novel in-mask non-invasive ventilator microphone to improve talker intelligibility in healthy and hospitalised adults

Purpose: Non-invasive ventilation (NIV) provides respiratory support without invasive endotracheal intubation but can hinder patients’ ability to communicate effectively. The current study presents preliminary results using a novel in-mask ventilator microphone to enhance talker intelligibility while receiving NIV. Method: A proof-of-concept study assessed sentence intelligibility of five healthy adult talkers using a prototype model of the microphone under continuous positive airway pressure (CPAP; 5/5 cm H2O) and bilevel positive airway pressure (BiPAP; 8/4 cm H2O) ventilator conditions. A pilot study then assessed intelligibility, subjective comprehensibility and naturalness, and patient- and conversation partner-reported communication outcomes for eight patients undergoing therapeutic NIV while being treated in an intensive care unit (ICU). Result: Intelligibility increased significantly with the microphone on in the BiPAP condition for healthy volunteers. For patients undergoing NIV in an ICU, intelligibility, comprehensibility, and patient and conversation partner ratings of conversation satisfaction significantly improved with the microphone on. Patients with lower baselines without the microphone in certain measures (intelligibility, comprehensibility) generally showed a greater microphone benefit than patients with higher baselines. Conclusion: Use of a novel microphone integrated into NIV improved intelligibility during ventilation for both healthy volunteers and patients undergoing therapeutic NIV. Additional clinical studies will define precise benefits and implications of such improved intelligibility.

Effects of three spontaneous ventilation modes on respiratory drive and muscle effort in COVID-19 pneumonia patients

BackgroundHigh drive and high effort during spontaneous breathing can generate patient self-inflicted lung injury (P-SILI) due to uncontrolled high transpulmonary and transvascular pressures, with deterioration of respiratory failure. P-SILI has been demonstrated in experimental studies and supported in recent computational models. Different treatment strategies have been proposed according to the phenotype of elastance of the respiratory system (Ers) for patients with COVID-19. This study aimed to investigate the effect of three spontaneous ventilation modes on respiratory drive and muscle effort in clinical practice and their relationship with different phenotypes. This was achieved by obtaining the following respiratory signals: airway pressure (Paw), flow (V´) and volume (V) and calculating muscle pressure (Pmus).MethodsA physiologic observational study of a series of cases in a university medical-surgical ICU involving 11 mechanically ventilated patients with COVID-19 pneumonia at the initiation of spontaneous breathing was conducted. Three spontaneous ventilation modes were evaluated in each of the patients: pressure support ventilation (PSV), airway pressure release ventilation (APRV), and BiLevel positive airway pressure ventilation (BIPAP). Pmus was calculated through the equation of motion. For this purpose, we acquired the signals of Paw, V´ and V directly from the data transmission protocol of the ventilator (Dräger). The main physiological measurements were calculation of the respiratory drive (P0.1), muscle effort through the ΔPmus, pressure‒time product (PTP/min) and work of breathing of the patient in joules multiplied by respiratory frequency (WOBp, J/min).ResultsTen mechanically ventilated patients with COVID-19 pneumonia at the initiation of spontaneous breathing were evaluated. Our results showed similar high drive and muscle effort in each of the spontaneous ventilatory modes tested, without significant differences between them: median (IQR): P0.1 6.28 (4.92–7.44) cm H2O, ∆Pmus 13.48 (11.09–17.81) cm H2O, PTP 166.29 (124.02–253.33) cm H2O*sec/min, and WOBp 12.76 (7.46–18.04) J/min. High drive and effort were found in patients even with low Ers. There was a significant relationship between respiratory drive and WOBp and Ers, though the coefficient of variation widely varied.ConclusionsIn our study, none of the spontaneous ventilatory methods tested succeeded in reducing high respiratory drive or muscle effort, regardless of the Ers, with subsequent risk of P-SILI.

Modeling the noninvasive bi-level positive airway pressure ventilation therapy system and simulated application

Without artificial airway though oral, nasal or airway incision, the bi-level positive airway pressure (Bi-PAP) has been widely employed for respiratory patients. In an effort to investigate the therapeutic effects and measures for the respiratory patients under the noninvasive Bi-PAP ventilation, a therapy system model was designed for virtual ventilation experiments. In this system model, it includes a sub-model of noninvasive Bi-PAP respirator, a sub-model of respiratory patient, and a sub-model of the breath circuit and mask. And based on the Matlab Simulink, a simulation platform for the noninvasive Bi-PAP therapy system was developed to conduct the virtual experiments in simulated respiratory patient with no spontaneous breathing (NSB), chronic obstructive pulmonary disease (COPD) and acute respiratory distress syndrome (ARDS). The simulated outputs such as the respiratory flows, pressures, volumes, etc, were collected and compared to the outputs which were obtained in the physical experiments with the active servo lung. By statistically analyzed with SPSS, the results demonstrated that there was no significant difference ( P > 0.1) and was in high similarity ( R > 0.7) between the data collected in simulations and physical experiments. The therapy system model of noninvasive Bi-PAP is probably applied for simulating the practical clinical experiment, and maybe conveniently applied to study the technology of noninvasive Bi-PAP for clinicians.

Evaluation of Biochemical Tests in Patients with Severe SARS-CoV 2 Infection and Need for Oxygen Therapy

Abstract Introduction: Since December 2019, when a cluster of pneumonia cases due to SARS-CoV-2 first appeared in China and then rapidly spread worldwide, the need for data on clinical but also paraclinical characteristics of patients with COVID-19 has been highlighted. Method: Between April 15, 2022, and July 31, 2022, 2583 RT-PCR tests were performed in the Emergency Clinical County Hospital Saint Andrei Constanta. Of these 463 were positive, 223 patients were hospitalized in different wards and 70 had severe forms requiring oxygen therapy. The present study aimed to evaluate laboratory data of patients diagnosed with severe SARS-COV2 infection requiring oxygen therapy to detect any parameters associated with more severe forms and reserved prognosis according to previous published research. Results: The patients in the study group were mostly from urban areas, had a mean age of 69.9 years (24-94), 59% were women, and 95.7% of them had associated comorbidities, (38.5% of them had 2 comorbidities and 30% even 3 comorbidities) the most common being hypertension (70%), diabetes mellitus (24.2%) and cardiovascular diseases (31.4%). In the group of patients analyzed showed increases in leukocyte count (48.5%), neutrophil count (52.9%) and decreases in lymphocyte count (72.8%), as well as a degree of anemia in 52.9% of patients. Increased values of inflammatory tests were also recorded: ESR (68.7%), CRP (77.6%), LDH (84%), Fibrinogen (59.3%). D dimers and ferritin were also detected with increased values in 85.7% and 84.2% of patients who had these parameters measured. Increases in urea (57.6%), creatinine (51.6%) and AST (51.6%) were detected but not in ALT. No notable changes in K, Na, AR were detected. Out of the total of 70 patients 45 patients received nasal tube oxygen therapy and the remaining 25 received bilevel positive airway pressure (BiPAP) ventilation. The death rate was 4.3% (3 patients died). CONCLUSIONS: the majority of patients with severe COVID 19 who required hospitalization and oxygen therapy were elderly, had at least one associated comorbidity, high levels of inflammatory tests and D-dimer and ferritin, and tests showing hepatic, renal or pulmonary damage.

718: UNITED STATES TRENDS FOR AZITHROMYCIN USE IN PEDIATRIC CRITICAL ASTHMA: A MULTICENTER COHORT STUDY

Introduction: Observation reports have suggested macrolides, such as azithromycin (AZI), may be used as immunomodulation for pediatric acute asthma exacerbations. To date, few studies have described AZI use for critical asthma (CA). We sought to estimate prescribing rates of AZI for CA and identify regional and chronologic trends using a large administrative registry. Methods: We performed a multicenter, retrospective cohort study using the Pediatric Health Information Systems registry of children 3-17 years of age with CA in the pediatric intensive care units (PICUs) of 47 United States (US) children’s hospitals from Jan 2011-Dec 2020. We excluded for alternative indications for AZI (e.g., B. pertussis infection, urethritis, pelvic inflammatory disease, and atypical pneumonia). The primary outcome was prescribing rates of AZI by hospital center and calendar year (via Joinpoint regression). Cohorts with and without AZI exposure were characterized by demographics, applied CA therapies, and routine clinical outcomes using descriptive and comparative (Chi-square and Wilcoxon rank-sum) statistics. Results: Of the 32,225 children studied, 6,641 (20.6%) were prescribed AZI with a downward trend from 31.3% in 2011 to 14.7% in 2020. A Joinpoint regression indicated a linear model was ideal (-1.7% annual slope, R2 = 0.857). Regional AZI prescribing rates by hospital center varied widely with a median of 19%, interquartile range (IQR) of 13.1% to 29.5%, and total range of 4.4% to 74.5%. Compared to children without exposure, those prescribed AZI were older (median 8.3 [IQR:5.8,11.6] vs 7.4 [5,10.9] years, P< 0.001) and more severely ill with a greater rates of bilevel positive airway pressure ventilation (13.1% vs 7.3% P< 0.001), invasive ventilation (18.8% vs 11.5%, P< 0.001), extracorporeal life support (0.5% vs 0.1%, P< 0.001), and longer median length of stay (4 [IQR:3,6] vs 3 [IQR:2,4] days, P< 0.001). Conclusions: In this multicenter study assessing children hospitalized for CA in the PICU from 47 U.S. Children’s hospitals, we observed a downward AZI prescribing trend (-1.7% annually from 31.3% in 2011 to 14.7% in 2020) and wide regional variation (range: 4.4% to 74.5% by center). Prospective clinical trials are needed to assess clinical and molecular efficacy endpoints of AZI immunomodulation in pediatric CA.

Man on Noninvasive Positive Airway Pressure Ventilation With Throat Pain.

Dentures dislodged into throat on bilevel positive airway pressure (BiPAP) ventilation can be overlooked and potentially compromise airway patency. An 81-year-old man with a history of chronic obstructive pulmonary disease (COPD) presented with increased shortness of breath and productive cough for 1 week. Inhaled bronchodilators, parenteral steroids, and BiPAP ventilation were administered for acute exacerbation of COPD complicated with acute hypercapnic respiratory failure. Fifty minutes after receiving BiPAP ventilation, his respiratory condition improved; however, he started to complain of neck pain. The patient remained intolerant to the device 3 hours later, despite receiving assurance that the discomfort might be caused by air pressure through mask ventilation. His throat did not exhibit any abnormality during visual examination. Neck radiographs were subsequently obtained and demonstrated a denture impacted in the hypopharynx. His neck pain resolved after the removal of the dislodged maxillary denture. Denture dislodgement can occur in mask ventilation and compromise airway patency if stuck in the hypopharynx or respiratory tract. Such adverse events may be overlooked on the coexistence of respiratory and pulmonary diseases. A precisely pharyngolaryngeal inspection and complete imaging studies must be performed to facilitate early identification and further retrieval intervention.

High-Flow Nasal Cannula Therapy for Respiratory Support in Adult Intensive Care Unit Patients

What is the effectiveness of high-flow nasal cannula (HFNC) therapy compared with standard oxygen therapy, noninvasive ventilation, or noninvasive positive pressure (NIPPV) ventilation for respiratory support in adults in the intensive care unit?Critically ill patients are at high risk for severe hypoxemia that can lead to significant tissue damage and death if not corrected. Supplemental oxygen can be delivered via multiple methods, including mechanical ventilation, noninvasive ventilation, NIPPV, HFNC therapy, and low-flow nasal cannula (LFNC) therapy.1 Up to 40% of all patients admitted to the intensive care unit (ICU) receive mechanical ventilation; although this method is often necessary, it presents risks and potential complications, including trauma to the pulmonary system and increased mortality.2,3To avoid these complications, the use of alternative methods of respiratory support that can provide adequate oxygen levels is often considered. Use of LFNC therapy can be helpful but often cannot provide a sufficiently high level of oxygen for critically ill patients. However, HFNC therapy can provide high levels of oxygen, and its use in the ICU has been growing in recent years.4High-flow nasal cannula therapy delivers heated and humidified oxygen via the nose at high flow rates of up to 60 L/min. The high flow rates produce low levels of positive pressure in the upper airways, which can clear out expired carbon dioxide, leading to reduced work of breathing and decreased respiratory rate.5 Noninvasive positive pressure ventilation, which refers primarily to continuous positive airway pressure or bilevel positive airway pressure ventilation, can be used when patients require high levels of supplemental oxygen and need some level of mechanical support. The oxygen is delivered via a tight-fitting mask, typically over the nose, mouth, or both; this mask can be uncomfortable and make it difficult to maintain adequate positioning.6The purpose of this review was to compare the efficacy and safety of HFNC therapy with those of the other common noninvasive respiratory support methods in the ICU setting.This summary was based on an update to a previously published systematic review conducted in 2017.7 As new evidence on a topic becomes available, updates are necessary to account for the results that the new evidence presents. This update, conducted by Lewis et al,8 included 31 randomized controlled trials comprising 5136 adult participants. The authors of this review investigated several outcomes, with the primary ones being treatment failure (need to escalate to invasive ventilation), in-hospital mortality, and adverse events (pneumonia).The authors independently assessed the risk of bias for each study, including selection, performance, detection, attrition, reporting, and publication biases. They resolved any disagreements by reviewing the data together and through discussion.Lewis et al8 used risk ratios (RRs) with 95% CIs for dichotomous outcomes as measures of treatment effect between various comparisons and outcomes. They used the internationally approved Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to determine the certainty of evidence—high, moderate, low, or very low—for each outcome9: This review showed that, overall, there was little or no difference in the evidence when comparing HFNC use with standard oxygen therapy or NIPPV in the outcomes explored. There was low-certainty evidence showing that HFNC therapy may lead to less treatment failure compared with standard oxygen therapy, with the classification of low certainty based on heterogeneity (differences in how the studies were conducted) and an unclear risk of bias in the studies.Currently, more than 50 studies are being conducted on the use of HFNC therapy; this high level of research activity is likely related to the increase in the use of HFNC therapy resulting from the COVID-19 pandemic. Upon publication, these studies can be added to the evaluation to provide additional guidance.The evidence from this systematic review can affect the decisions of clinical care teams when they are creating treatment plans for critically ill patients. Advocating for the best evidence-based treatment remains an important part of the role of critical care nurses. We must always consider the best available evidence and understand the feasibility, appropriateness, meaningfulness, and effectiveness of any intervention to determine whether it is suitable to implement in our individual context.

Acute respiratory distress syndrome following administration of gadolinium contrast agent: a case report

BackgroundGadolinium-based contrast agents are used extensively in magnetic resonance imaging to assist diagnosis of medical conditions. Despite their documented safety profile, severe adverse events do occur, and their documentation may serve to raise the awareness of the medical community.Case presentationWe report the case of a 15-year-old white Latin American female patient admitted to the intensive care unit for acute respiratory distress syndrome following administration of gadolinium. She did not have rash or tongue swelling but developed hypotension responsive to fluid administration and severe hypoxemia. Chest computed tomography revealed bilateral pulmonary compromise with multiple confluent consolidations. She received methylprednisolone and noninvasive ventilatory support including bilevel positive airway pressure ventilation and high-flow nasal cannula, and underwent a rapid recovery.ConclusionGadolinium-based contrast agent-induced acute respiratory distress syndrome, albeit rare, should be included in the differential diagnosis of respiratory failure shortly after magnetic resonance imaging, which is nowadays a frequent diagnostic procedure, potentially increasing the awareness of this serious complication.

Pneumothorax in Critically Ill COVID-19 Patients: Prevalence, Analysis of Risk Factors and Clinical Outcomes.

Previous studies have been conducted to assess pneumothorax. However, few studies were done to assess pneumothorax in COVID-19 patients in the intensive care unit (ICU). Our aim is to describe and analyze the prevalence, clinical characteristics, risk factors, and outcomes of COVID-19 pneumothorax patients in the intensive care unit. We performed a retrospective review of the medical records of 418 patients, who tested positive for COVID-19 by polymerase chain reaction test and required ICU admission in King Fahad Hospital of The University from 02/01/2020 to 01/09/2021. A total number of 36 pneumothorax patients were included in the study. Of 418 patients who were followed up in the intensive care unit as COVID-19 cases, 36 patients developed a pneumothorax (8.61%). The mean age of the patients was 55.6 ± 15.06 years, 23 patients were male, and 13 were female. Seventeen patients were obese, and only one patient was an active smoker. Twenty-four patients had at least one comorbidity; hypertension was the most common. Thirty-two patients were intubated, and the duration of intubation was 23.23 ±15.9 days. The time from intubation to pneumothorax development was 8.8 ± 9.3 days. Six patients were on bilevel positive airway pressure ventilation (BIPAP), 2 patients on continuous positive airway pressure ventilation (CPAP), 3 patients on High-Flow Nasal Cannula ventilation (HFNC), 9 patients on pressure-control ventilation (PC), and 16 patients on pressure regulated volume control ventilation (PRVC). Of 36 patients, 26 died, and the mortality rate was 72.2%. Our study showed that risk factors of pneumothorax occurrence in COVID-19 critically ill patients include male patients, hypertension, diabetes mellitus, endotracheal intubation and mechanical ventilation. More efforts should be made to determine the risk factors and assess the outcomes of those patients to develop preventive measures and management guidelines.

A POTENTIALLY UNDER-RECOGNIZED COMPLICATION OF POSITIVE PRESSURE VENTILATION: ACUTE HYPOCALCEMIA

A POTENTIALLY UNDER-RECOGNIZED COMPLICATION OF POSITIVE PRESSURE VENTILATION: ACUTE HYPOCALCEMIA

Macroglossia: A potentially severe complication of late-onset Pompe disease.

Pompe disease is a rare neuromuscular disorder caused by a deficiency of a lysosomal enzyme, acid α-glucosidase. Macroglossia is a classic clinical sign of several inherited myopathies and has also been reported to occur progressively in late-onset Pompe disease (LOPD). We describe patients with LOPD and macroglossia included in the French national Pompe disease registry. Clinical, functional, and radiological data were collected during periodic follow-up and analyzed retrospectively. These cases were compared with 15 previously reported cases. Five patients, three females and twomales, aged 71-88years, were included in this study. All but one of the patients suffered from symptoms related to macroglossia before the diagnosis of Pompe disease. Three had localized tongue atrophy and one had significant localized tongue hypertrophy which led to glossectomy 10years before diagnosis. Two patients had severe dysphagia, one of whom underwent gastrostomy for enteral nutritional support. One patient experienced the persistence of numerous sleep apneas despite nocturnal bilevel positive airway pressure (BiPAP) ventilation. All our patients had dysarthria, and two required speech therapy. Four patients had a tongue hypersignal on magnetic resonance imaging (MRI) T1sequences. Detection of macroglossia should be part of the clinical diagnosis and follow-up of patients with LOPD, with a careful evaluation of its main consequences. Macroglossia can have severe functional impacts on speech, swallowing, and sleep. Whole-body MRI with facial sections may facilitate the early diagnosis of Pompe disease with the "bright tongue sign".

Abstract No.: ABS1288: A multicentric research study on correlation between covid 19 vaccination status and severity of disease

Background & Aims:To correlate the severity of coronavirus disease (COVID) with vaccination status in COVID 19 pandemics. The Primary Objective of the present study was to know occurrence of Post vaccination breakthrough infections in hospitalized patients and the Secondary Objective was to assess the severity of COVID-19 infection amongst vaccinated patients.Methods:The present study was a retrospective observational multicentric study performed on 325 covid positive patients admitted in High dependency units (HDUs) and Intensive care units (ICUs) and were either on Non rebreather mask (NRBM) or Bilevel positive airway pressure (Bipap) or invasive Ventilation. These patients were then divided as per severity of their symptoms into severe or non severe in correlation with their vaccination status. The study included covid positive as well as High resolution computed tomography (HRCT) thorax suggestive of covid ground glass appearance with age above 18 years and excluded patients who developed adverse reaction post vaccination, pediatric age group, pregnant and lactating females.Mild Symptoms VS Vaccination Symptoms1st Dose2nd DoseNo Doseχ2 test statistics (P)Fever60717127.08 (0.040)Headache516Cold20027Weakness301102Dry cough1085177Runny nose10124Body ache17033Sore Throat000Loss of smell and taste14221Results:Total 325 confirmed covid positive patients were studied. Statistical analysis was done with SPSS version 26 and data were analysed by Chi-square test & P value< 0.05 was considered as significant. Total duration of hospital stay was less in vaccinated patients compared to non vaccinated patients and also oxygen requirement was much less in vaccinated patients. The severity of covid infection was also less in vaccinated than amongst non vaccinated.Conclusion:Covid 19 vaccination is very effective in preventing severity of infection.

Clinical Study on Early Extubation and Sequential Non-Invasive Respiratory Support for Children with Acute Respiratory Failure Receiving Invasive Mechanical Ventilation

To explore the treatment outcome of the strategy of early extubation and then switching to non-invasive mechanical ventilation in children with acute respiratory failure, and the safety and feasibility of using the strategy to replace traditional methods. A total of 102 children, aged between 1 month to 14 years old, who had acute respiratory failure and were admitted to the pediatric ICU of West China Second University Hospital, Sichuan University between January 2019 and December 2020 were enrolled and randomly assigned to treatment group 1 (n=55) and treatment group 2 (n=47). In addition, 53 children who had the same condition in the 12 month prior to the beginning of the study were included in the control group. In the two treatment groups, the patients were extubated first, and then weaned off the ventilator. In group 1, when the patient met the invasive-non-invasive switching criteria, the tracheal tube was pulled out and non-invasive bi-level positive airway pressure (BiPAP) ventilation was used for respiratory support. In group 2, high-flow nasal cannula (HFNC) oxygen therapy was used for respiratory support. The traditional progressive weaning method was adopted for the control group (extubing and weaning were performed at the same time). The incidence of ventilator-associated pneumonia (VAP) during the period of tracheal intubation was compared and the mortality of the two groups was evaluated from the point when the patients were recruited. At the time of extubation in the treatment groups and extubation plus weaning in the control group, the pressure support levels, or PC above PEEP, intubation time, sequential time (between 2 treatment groups only), weaning failure rate, and the incidence of laryngeal edema and nasal pressure ulcer were compared. The subjects of the study were predominantly infants (93 cases, 60%) and young children (31 cases, 20%). Among the 155 cases, 82 (53%) were male. There was no statistical difference in age distribution or gender among the groups. There was no significant difference in the clinical indicators among the three groups before tracheal intubation. At the time of extubation, the PC above PEEP in the two treatment groups was higher than that in the control group, and higher in group 1 than that of group 2, the difference being statistically significant (P<0.05). The intubation time of the two treatment groups was shorter than that of the control group, and shorter in group 1 than that of group 2 (P<0.05). The sequential time of group 2 was shorter than that of group 1 (P<0.05). The extubation failure rate and the incidence of VAP in the two treatment groups were lower than those in the control group, and there was no statistically significant difference between the two treatment groups. The incidence of nasal pressure ulcers in group 1 was higher than that in the other two groups (P<0.05). There was 1 death in treatment group 1, and no deaths in treatment group 2 or the control group. There was no significant difference in mortality or the incidence of laryngeal edema after extubation in the three groups. Early extubation and then switching to non-invasive mechanical ventilation can be well tolerated by the patients, and can be used in clinical practice as an effective weaning method for children with acute respiratory failure.

Cardiac Arrhythmias and COVID-19: Correlation With Disease Severity.

BackgroundCardiac arrhythmia is one of the life-threatening cardiovascular complications commonly reported in patients hospitalized with coronavirus disease 2019 (COVID-19). We aimed to evaluate the association between cardiac arrhythmias and disease severity based on oxygen requirement.MethodsIn this retrospective observational chart review-based study we recruited 396 patients hospitalized with COVID-19 from March 2020 to May 2020 from two regional medical centers in New Jersey, USA. Patients’ baseline characteristics, secondary diagnoses, and laboratory findings were manually extracted and compared among two groups: patients with cardiac arrhythmias and those without. Poisson regression analysis was used to evaluate the correlation of cardiac arrhythmias and increased oxygen requirement, which are: room air (RA), nasal cannula (NC), high flow nasal cannula (HFNC), and bi-level positive airway pressure ventilation or invasive mechanical ventilation (BIPAP/MV).ResultsThe demographic characteristics of the patients were: aged 61 +/- 18.7 years (mean +/- standard deviation); with 56% being male, and 44.9% of African American race. There were 16% patients on RA, 40% on NC, 15% on HFNC, and 29% on BIPAP/MV. The incidence of cardiac arrhythmias was 36.7% (20% pulseless electrical activity (PEA), 13.5% atrial fibrillation (AF). 56% of AF was new-onset arrhythmia. Compared to the RA group, the risk of cardiac arrhythmias was significantly higher in BIPAP/MV (OR 3.3; 95% CI 1.8 - 6.2, p <0.001) and HFNC (OR 2.9; 95% CI 1.5-5.7, p0.001), but not in NC group (OR 0.95; 95% CI 0.4-1.8, p0.89).Compared to patients without arrhythmias, patients with arrhythmias were older (mean age 71 vs. 56 years, p <0.001) and had more comorbidities (Charlson comorbidity index (CCI), 4.7 vs. 2.9, p <0.001). The continued therapy of angiotensin-converting enzyme inhibitors or angiotensin-II receptor blockers did not seem to be associated with increased or decreased risk of cardiac arrhythmias.ConclusionThe incidence of cardiac arrhythmias among hospitalized COVID-19 patients was 36.7% with PEA being common in patients who succumbed to death, and AF in those patients who survived. The incidence of cardiac arrhythmias positively correlated with disease severity based on oxygen requirement and was higher among patients requiring HFNC or BIPAP/MV.

Comparison of Clinical Characteristics and Outcome of Critically Ill Patients Admitted to Tertiary Care Intensive Care Units in India during the Peak Months of First and Second Waves of COVID-19 Pandemic: A Retrospective Analysis.

BackgroundCoronavirus disease-2019 (COVID-19) continues to pose serious challenges to healthcare systems globally with the disease progressing over time in crest-trough pattern of waves. We compared the patient characteristics and outcomes of critically ill patients admitted during the first and second waves of COVID-19 pandemic.Materials and MethodsWe did a retrospective analysis of medical records of critically ill patients admitted to intensive care unit (ICU) at the peak period of both waves. The data on demographics, symptoms, treatment received, and outcomes of patients were recorded.ResultsCompared to first wave, significantly more females, younger age group, and those without underlying comorbidities required ICU admission during the second wave. The treatments received during both periods were similar except for preferential use of methylprednisolone over dexamethasone and proclivity of bilevel positive airway pressure (BiPAP) ventilation over high-flow nasal cannula (HFNC). There was no significant difference in the duration of ICU stay and mortality of patients. During the first wave, the factors associated with nonsurvival of patients were advanced age, comorbidities, severe disease, and a lesser number of days on HFNC. All these factors along with higher Sequential Organ Failure Assessment (SOFA) score were observed to be linked with patient nonsurvival during the second wave.ConclusionIn India, the second wave of COVID-19 significantly influenced ICU demographics with a predominance of females and young adults requiring critical care. During both time periods, patients received similar treatment except for the propensity to use methylprednisolone and BiPAP as opposed to dexamethasone and HFNC in second wave. No significant difference in ICU mortality was noted.How to cite this articleKerai S, Singh R, Dutta S, Mahajan A, Agarwal M. Comparison of Clinical Characteristics and Outcome of Critically Ill Patients Admitted to Tertiary Care Intensive Care Units in India during the Peak Months of First and Second Waves of COVID-19 Pandemic: A Retrospective Analysis. Indian J Crit Care Med 2021;25(12):1349–1356.

A Quantitative Study of Particle Dispersion due to Respiratory Support Modalities in PC-12 Aircraft: Prehospital Patient Transport

ObjectiveIt is unclear whether supplemental oxygen and noninvasive ventilation respiratory support devices increase the dispersion of potentially infectious bioaerosols in a pressurized air medical cabin. This study quantitatively compared particle dispersion from respiratory support modalities in an air medical cabin during flight. MethodsDispersion was measured in a fixed wing air ambulance during flight with a breathing medical mannequin simulator exhaling nebulized saline from the lower respiratory tract with the following respiratory support modalities: a nasal cannula with a surgical mask, high-flow nasal oxygen (HFNO) with a surgical mask, and noninvasive bilevel positive airway pressure (BiPAP) ventilation. ResultsNasal cannula oxygen with a surgical mask was associated with the highest particle concentrations. In the absence of mask seal leaks, BiPAP was associated with 1 order of magnitude lower particle concentration compared with a nasal cannula with a surgical mask. Particle concentrations associated with HFNO with a surgical mask were lower than a nasal cannula with a surgical mask but higher than BiPAP. ConclusionsParticle dispersion associated with the use of BiPAP and HFNO with a surgical mask is lower than nasal cannula oxygen with a surgical mask. These findings may assist air medical organizations with operational decisions where little data exist about respiratory particle dispersion.

Преоксигенация: терминология, физиологические основы, техники проведения, методики повышения эффективности, особенности у критических пациентов, возможные риски

Преоксигенация является широко распространенным приемом перед индукцией в анестезию и интубацией трахеи, предназначенным для увеличения запасов кислорода в организме и, таким образом, замедления начала десатурации гемоглобина во время апноэ. Показателями эффективности преоксигенации являются увеличение фракции альвеолярного кислорода, увеличение напряжения кислорода в артериальной крови и снижение фракции альвеолярного азота. Конечная точка максимальной преоксигенации — концентрация кислорода в конце выдоха 90 % или концентрация азота в конце выдоха 5 %. Для проведения преоксигенации используются две техники: по дыхательному объему и путем глубоких вдохов. Существуют различные методики для улучшения эффекта преоксигенации. Они включают поднятие головы, апнойную диффузную оксигенацию, использование постоянного положительного давления/положительного давления конца выдоха, двухуровневое положительное давление в дыхательных путях и трансназальную увлажненную быструю инсуффляцию. Преоксигенация с высоким риском включает таких пациентов, как беременные женщины, пациенты, страдающие ожирением, дети, лица пожилого возраста, пациенты с сопутствующими легочными заболеваниями, пациенты на большой высоте. Потенциальные риски преоксигенации включают отсроченное определение пищеводной интубации, абсорбционный ателектаз, продукцию частиц активного кислорода и нежелательные гемодинамические эффекты. Так как преоксигенация по времени не продолжительна, гемодинамические эффекты и накопление частиц активного кислорода незначительны. Абсорбционный ателектаз является следствием преоксигенации. Для снижения риска возникновения абсорбционного ателектаза во время преоксигенации предложено два подхода: умеренное снижение фракции кислорода до 0,8 и использование рекрутмент-маневров, таких как постоянное положительное давление, положительное давление конца выдоха и/или маневры с жизненной емкостью легких. Хотя незначительное давление фракции кислорода уменьшает риск ателектазирования, это происходит за счет снижения кислородного резерва. Техника преоксигенации должна использоваться правильно, с мониторированием концентрации кислорода в конце выдоха. Анестезиолог должен быть ознакомлен с различными методиками проведения преоксигенации, выбирая наиболее подходящую.