Continuous Positive Pressure Ventilation Research Articles

Non-invasive positive pressure ventilation in pneumonia outside Intensive Care Unit: An Italian multicenter observational study

Background and objectiveNon-Invasive Ventilation (NIV) represents a standard of care to treat some acute respiratory failure (ARF). Data on its use in pneumonia are lacking, especially in a setting outside the Intensive Care Unit (ICU). The aims of this study were to evaluate the use of NIV in ARF due to pneumonia outside the ICU, and to identify risk factors for in-hospital mortality. MethodsProspective, observational study performed in 19 centers in Italy. Patients with ARF due to pneumonia treated outside the ICU with either continuous positive airway pressure (CPAP) or noninvasive positive pressure ventilation (NPPV) were enrolled over a period of at least 3 consecutive months in 2013. Independent factors related to in-hospital mortality were evaluated. ResultsAmong the 347 patients enrolled, CPAP was applied as first treatment in 176 (50.7%) patients,NPPV in 171 (49.3%). The NPPV compared with CPAP group showed a significant higher PaCO2 (55 [47–78] vs 37 [32–43] mmHg, p < 0.001), a lower arterial pH (7.30 [7.21–7.37] vs 7.43 [7.35–7.47], p < 0.001), higher HCO3– (28 [24–33] vs 24 [21–27] mmol/L, p < 0.001). De-novo ARF was more prevalent in CPAP group than in NPPV group (86/176 vs 31/171 patients,p < 0.001). In-hospital mortality was 23% (83/347). Do Not Intubate (DNI) order and Charlson Comorbidity Index (CCI) ≥3 were independent risk factors for in-hospital mortality. ConclusionsOutside ICU setting, CPAP was used mainly for hypoxemic non-hypercapnic ARF, NPPV for hypercapnic ARF. In-hospital mortality was mainly associated to patients' basal status (DNI status, CCI) rather than the baseline degree of ARF.

UNUSUAL ETIOLOGY OF DIAPHRAGM WEAKNESS: NIVOLUMAB-INDUCED MYOPATHY

SESSION TITLE: Pulmonary SESSION TYPE: Global Case Reports PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM INTRODUCTION: Nivolumab is programmed death-1 (PD-1) inhibitors. It has been used for various cancers, including melanoma, non-small cell lung carcinoma, and renal cell carcinoma since 2015. PD-1 is expressed on activated T cells, B cells, natural killer cells and monocytes, therefore, use of nivolumab results in an enhanced immune response to both tumor cells and normal host tissues. The known adverse effects include hepatitis, pneumonitis, acute renal failure and other immune-related adverse events, such as myositis or rhabdomyolysis. We here report a case of bilateral diaphragm weakness secondary to inflammatory myopathy induced by nivolumab. CASE PRESENTATION: A 78-year-old male with recent history of stage 3 melanoma presented with few weeks duration of progressive dyspnea, orthopnea. Melanoma was removed surgically and he was recently started on adjuvant therapy with nivolumab. After 2 doses of nivolumab, he developed shortness of breath, orthopnea and required hospitalization. He was diagnosed with pneumonitis, thought to be induced by nivolumab, and received high dose steroid with clinical improvement. The CK level was high and improved after taking steroid. He was discharged on stable condition. However, he continued to have progressive respiratory symptoms and required second admission. He had acute hypercapnic respiratory failure and continuous noninvasive positive pressure ventilation (NIPPV) was placed. Image studies of the chest revealed elevation of both hemidiaphragms with compressive atelectatic changes. Diaphragm fluoroscopy showed markedly diminished excursion with free breathing and rapid inspiratory maneuvers, consistent with bilateral diaphragmatic paresis. There were no other neurologic deficits or signs suggesting neuromuscular disease. CT of cervical spine was negative for any lesions. Electromyography revealed necrotizing features in the low cervical paraspinal muscle, compatible with a proximal myopathy. Work-up for other necrotizing autoimmune myopathies was negative. As he required NIPPV continuously without improvement, aggressive treatment including methylprednisolone 1g/day and IVIG started. Unfortunately, he didn’t respond to treatment and transition to hospice care. DISCUSSION: Based on clinical feature following the use of nivolumab, negativity for autoantibodies and exclusion of other diagnoses, we diagnosed this patient with nivolumab induced myopathy, leading to diaphragms weakness. Although myopathy is rare among the patients treated with PD-1 inhibitor, it is potentially fatal in those who have necrotizing myopathy. Unfortunately patients with necrotizing myopathy can be refractory to aggressive immunotherapy and the most appropriate treatment has not been determined. CONCLUSIONS: This report highlights the importance of awareness of this rare adverse effect and considering not only pneumonitis but also myopathy in the patient with dyspnea after use of nivolumab. Reference #1: Liewluck T, Kao JC, Mauermann ML. PD-1 Inhibitor-associated Myopathies: Emerging Immune-mediated Myopathies. Journal of Immunotherapy 2017 Dec 1. Reference #2: Topalian SL, Hodi FS, Brahmer JR et al. Safety, activity, and immune correlates of anti-PD-1 antibody in cancer. N Engl J Med 2012 Reference #3: McDermott DF, Atkins MB. PD-1 as a potential target in cancer therapy. Cancer Med 2013 DISCLOSURES: No relevant relationships by Sungryong Noh, source=Web Response

A Comparative Study of Treatment Response of Respiratory Distress Syndrome in Preterm Infants: Early Nasal Intermittent Positive Pressure Ventilation versus Early Nasal Continuous Positive Airway Pressure

Background Infant respiratory distress syndrome (IRDS) is one of the main causes of serious complications and death in preterm infants. Both Nasal Continuous Positive Airway Pressure (NCPAP) and Nasal Intermittent Positive Pressure Ventilation (NIPPV) are known as the most common treatment strategies for IRDS. The present study intended to compare NCPAP and NIPPV in the treatment of preterm infants with respiratory distress syndrome. Materials and Methods To this double blind clinical trial study during a one-year period (2016 to 2017) in Fatemieh Hospital in Hamadan city (Iran), about 60 preterm RDS infants were randomly assigned into two treatment groups; the NIPPV group received the PIP (14–20 cmH2O), RR: 30-50/min, PEEP (5–6 cmH2O), FiO2 up to 60%. The NCPAP group received PEEP (5-6 cmH2o), Flow: 6-7 L/min, and FiO2 up to 60% Results There was not any significant difference in the mean values of gestational age (30.07±1.50 vs. 30.07±2.05; P>0.05), birth weight (1259±263 vs. 1235±285; P>0.05), and 1-minute Apgar score (5.53±1.13 vs. 5.33±1.34; P>0.05) between NIPPV and NCPAP treatment groups. Besides, the rate of recovery, mortality and disease complications was not significantly different between both groups. However, the duration of respiratory support was less in NIPPV than NCPAP (34.9±33.8 vs. 68.4±32 h; P=0.001). Conclusion According to the results, there was not significant advantage between the NIPPV vs. NCPAP methods in the treatment of RDS in preterm infants with very low birth weight.

Chronic lung disease in preterm infants receiving various modes of noninvasive ventilation at ≤30 weeks’ postmenstrual age

Objective: To determine the incidence of chronic lung disease (CLD) in mechanically ventilated infants who were born at <29 weeks’ gestational age (GA), extubated to continuous positive airway pressure (CPAP) or nasal intermittent positive pressure ventilation (NIPPV), and treated with CPAP/NIPPV alone, changed to heated humidified high flow nasal cannula (HHHFNC), or exposed to a combination of CPAP/NIPPV and HHHFNC at ≤30 weeks’ postmenstrual age (PMA).Study design: Retrospective cohort study of infants born at <29 weeks’ GA admitted to tertiary Canadian neonatal intensive care units between 2011 and 2015. Infants were grouped according to the type of noninvasive ventilation they received at ≤30 weeks’ PMA: CPAP/NIPPV alone, HHHFNC alone, or a combination of both.Results: Of the 2378 eligible infants, 1091 (46%) were on CPAP/NIPPV alone, 173 (7.3%) were on HHHFNC alone, and 1114 (47%) were on a combination of CPAP/NIPPV and HHHFNC at ≤30 weeks’ PMA until weaned to room air or low flow nasal cannula. After adjustment for confounders, infants in both the CPAP/NIPPV (odds ratio [95% confidence interval]; 2.37 [1.18, 4.79]) and Combination (3.47 [2.06, 5.86]) groups had higher odds of developing CLD than infants in the HHHFNC group.Conclusions: Our results demonstrate that infants transitioned to HHHFNC ≤30 weeks’ PMA after extubation to CPAP/NIPPV were associated with a lower odds of CLD than infants maintained on CPAP/NIPPV or a combination of CPAP/NIPPV and HHHFNC.

Comparison of continuous positive airway pressure and non-invasive positive pressure ventilation as modes of non-invasive respiratory support for neonates in a Level III neonatal intensive care unit

Objectives: To compare the effectiveness of continuous positive airway pressure (CPAP) and non-invasive positive pressure ventilation (NIPPV) in neonates with mild to moderate respiratory distress. Method: A single centre randomized controlled trial was conducted at the Sri Jayawardenepura General Hospital, Sri Lanka from January to December 2015. The trial was registered with The Clinical Trials Registry ‘Clinical Trials.gov’ retrospectively. Eighty neonates admitted to the neonatal intensive care unit (NICU) were randomly allocated to NIPPV and CPAP. Outcomes of respiratory support were observed and information on risk factors were obtained by going through the bed head tickets of the study cohort. Data analysis was done using SPSS 20 software. Results: Infants treated with NIPPV and CPAP had comparable demographic data and clinical status at the time of enrolment into the study. Infants treated initially with NIPPV needed less endotracheal ventilation than infants treated with CPAP (35% vs 40%, p = 0.644) but this difference is not statistically significant. Conclusions: The risks for respiratory failure and the need for ventilation were not statistically significantly different whether using NIPPV or CPAP. Sri Lanka Journal of Child Health, 2018; 4 7 : 242-248

Early diastolic dysfunction and respiratory morbidity in premature infants: an observational study.

To test if diastolic dysfunction measured on day one of age is associated with the need for invasive ventilation in preterm infants. We conducted a retrospective observational tissue Doppler echocardiographic study over the first 12 h of age for infants born <32 weeks who were invasively ventilated, and infants on continuous positive pressure ventilation (CPAP). One hundred and eighty-three infants were included (27 ± 2 weeks and 999 ± 296 g). Invasively ventilated infants [(n = 96 (53%)] had lower left ventricular (LV) e' (3.4 ± 1.0 vs. 4.1 ± 1.5 cm/s, p < 0.01) and lower LV ea' ratio (0.8 ± 0.2 vs. 1.0 ± 0.4, p < 0.01), even after adjusting for common neonatal confounders (LV e' adjusted OR 0.62, 95% CI 0.45 - 0.87, p < 0.01; LV ea' adjusted OR 0.14, 95% CI 0.03-0.68, p = 0.01). LV diastolic dysfunction is independently associated with a higher risk for invasive ventilation on day one of age.

Provision of respiratory support compared to no respiratory support before cord clamping for preterm infants.

Placental transfusion (by means of delayed cord clamping (DCC), cord milking, or cord stripping) confers benefits for preterm infants. It is not known if providing respiratory support to preterm infants before cord clamping improves outcomes. To assess the efficacy and safety of respiratory support provided during DCC compared with no respiratory support during placental transfusion (in the form of DCC, milking, or stripping) in preterm infants immediately after delivery. We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL, 2017, Issue 5), MEDLINE via PubMed (1966 to 19 June 2017), Embase (1980 to 19 June 2017), and CINAHL (1982 to 19 June 2017). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials. Randomized, cluster randomized, or quasi-randomized controlled trials enrolling preterm infants undergoing DCC, where one of the groups received respiratory support before cord clamping and the control group received no respiratory support before cord clamping. All review authors assisted with data collection, assessment, and extraction. Two review authors assessed the quality of evidence using the GRADE approach. We contacted study authors to request missing information. One study fulfilled the review criteria. In this study, 150 preterm infants of less than 32 weeks' gestation undergoing 60 second DCC were randomized to a group who received respiratory support in the form of continuous positive airway pressure (CPAP) or positive pressure ventilation during DCC and a group that did not receive respiratory support during the procedure. Mortality during hospital admission was not significantly different between groups with wide confidence intervals (CI) for magnitude of effect (risk ratio (RR) 1.67, 95% CI 0.41 to 6.73). The study did not report neurodevelopmental disability and death or disability at two to three years of age. There were no significant differences between groups in condition at birth (Apgar scores or intubation in the delivery room), use of inotropic agents (RR 1.25, CI 0.63 to 2.49), and receipt of blood transfusion (RR 1.03, 95% CI 0.70 to 1.54). In addition, there were no significant differences in the incidences of any intraventricular haemorrhage (RR 1.50, 95% CI 0.65 to 3.46) and severe intraventricular haemorrhage (RR 1.33, 95% CI 0.31 to 5.75). Several continuous variables were reported in subgroups depending on method of delivery. Unpublished data for each group as a whole was made available and showed peak haematocrit in the first 24 hours and duration of phototherapy did not differ significantly. Overall, the quality of evidence for several key neonatal outcomes (e.g. mortality and intraventricular haemorrhage) was low because of lack of precision with wide CIs. The results from one study with wide CIs for magnitude of effect do not provide evidence either for or against the use of respiratory support before clamping the umbilical cord. A greater body of evidence is required as many of the outcomes of interest to the review occurred infrequently. Similarly, the one included study cannot answer the question of whether the intervention is or is not harmful.

Non-invasive ventilation and surfactant treatment as the primary mode of respiratory support in surfactant-deficient newborn piglets.

BackgroundNasal continuous positive airway pressure (NCPAP) and nasal intermittent positive pressure ventilation (NIPPV), forms of non-invasive ventilation (NIV) for respiratory support, are increasingly being chosen as the initial treatment for neonates with surfactant (SF) deficiency. Our objective was to compare NCPAP with NIPPV with or without SF administration as a primary mode of ventilation.MethodsTwenty-four newborn piglets with SF-deficient lung injury produced by repetitive bronchoalveolar lavages were randomly assigned to NCPAP or NIPPV, with or without SF administration (InSurE method). We evaluated pulmonary, systemic (hemodynamic and oxygen metabolism), and cerebral effects.ResultsSF-deficient piglets developed respiratory distress (FiO2:1, pH<7.2, PaCO2>70 mm Hg, PaO2<70 mm Hg, and Cdyn<0.5 ml/cmH2O/kg). Gradual improvements in pulmonary status were observed in both NIV groups, with NIPPV achieving lower lung inflammation markers and injury scores. Both SF-treated groups obtained significantly better respiratory outcomes than groups not treated with SF before NIV. All NIV-treated groups showed low brain injury scores.ConclusionIn spontaneously breathing SF-deficient newborn piglets, NIPPV is a suitable NIV strategy. SF administration in combination with NCPAP or NIPPV improves pulmonary status providing extra protection against pulmonary injury. No injury to the developing brain was observed to be associated with these NIV strategies, with or without SF therapy.

Enteral Nutrition Practices in Critically Ill Children Requiring Noninvasive Positive Pressure Ventilation.

Evaluate the practice of providing enteral nutrition in critically ill children requiring noninvasive positive pressure ventilation. Retrospective cohort study. PICU within a quaternary care children's hospital. PICU patients older than 30 days requiring noninvasive positive pressure ventilation for greater than or equal to 24 hours from August 2014 to June 2015. Invasive mechanical ventilation prior to noninvasive positive pressure ventilation and inability to receive enteral nutrition at baseline were additional exclusionary criteria. None. The primary outcome was enteral nutrition initiation within 24 hours of admission. Secondary outcomes included time to goal enteral nutrition rate, adequacy of nutrition, adverse events (pneumonia not present at admission, intubation after enteral nutrition initiation, feeding tube misplacement), and lengths of noninvasive positive pressure ventilation and PICU stay. Among those included (n = 562), the median age was 2 years (interquartile range, 39 d to 6.8 yr), 54% had at least one chronic condition, and 43% had malnutrition at baseline. The most common primary diagnosis was bronchiolitis/viral pneumonia. The median length of time on noninvasive positive pressure ventilation was 2 days (interquartile range, 2.0-4.0). Most (83%) required continuous positive airway pressure or bi-level support during their PICU course. Sixty-four percent started enteral nutrition within 24 hours, with 72% achieving goal enteral nutrition rate within 72 hours. Forty-nine percent and 44% received an adequate cumulative calorie and protein intake, respectively, during their PICU admission. Oral feeding was the most common delivery method. On multivariable analysis, use of bi-level noninvasive positive pressure ventilation (odds ratio, 0.40; 95% CI, 0.25-0.63) and continuous dexmedetomidine (odds ratio, 0.59; 95% CI, 0.35-0.97) were independently associated with decreased likelihood of early enteral nutrition. Twelve percent of patients had at least one adverse event. A majority of patients requiring noninvasive positive pressure ventilation received enteral nutrition within 24 hours. However, less than half achieved caloric and protein goals during their PICU admission. Further investigation is warranted to determine the safety and effectiveness of early enteral nutrition in this population.

Mechanical ventilation. Part II: Basic principles and function of ventilators.

Mechanical ventilation is the process of supporting respiration by manual or mechanical means. When normal breathing is inefficient or has stopped, mechanical ventilation is life-saving and should be applied at once. The ventilator increases the patient's ventilation by inflating the lungs with oxygen or a mixture of air and oxygen. Ventilators play an important role in the anaesthetic management of patients, as well as in the treatment of patients in the ICU. However, there are differences between the anaesthetic ventilators and the ventilators in ICU. The main indication for mechanical ventilation is difficulty in ventilation and/or oxygenation of the patient because of any respiratory or other disease. The aims of mechanical ventilation are to supply adequate oxygen to patients with a limited vital capacity, to treat ventilatory failure, to reduce dyspnoea and to facilitate rest of fatigued breathing muscles. Depression of the central nervous system function is a pre-requirement for mechanical ventilation. Some times, opioids or muscle relaxants can be used in order to depress patient's breathing. Mechanical ventilation can be applied using many different modes: assisted ventilation, controlled ventilation, continuous positive pressure ventilation, intermittent positive pressure ventilation and jet ventilation. Furthermore, there are different types of automatic ventilators built to provide positive pressure ventilation in anaesthetized or heavily sedated or comatose patients: manual ventilators (Ambu-bag), volumecontrolled ventilators with pressure cycling, volume-controlled ventilators with time cycling and pressure-controlled ventilators. In veterinary practice, the ventilator should be portable, compact and easy to operate. The controls on most anaesthetic ventilators include settings for tidal volume, inspiratory time, inspiratory pressure, respiratory rate and inspiration: expiration (I:E) ratio. The initial settings should be between 10-20 ml/kg for tidal volume, 12-30 cmH2 0 for the inspiratory pressure and 8-15 breaths/min for the respiratory rate. Mechanical ventilation is a very important part of treatment in the ICU, but many problems may arise during application of mechanical ventilation in critically ill patients. All connections should be checked in advance and periodically for mechanical problems like leaks. Moreover, complications like lung injury, pneumonia, pneumothorax, myopathy and respiratory failure can occur during the course of mechanical ventilation causing difficulty in weaning.

Systematic review of efficacy of continuous positive airway pressure in treatment of epilepsy with obstructive sleep apnea syndrome

Objective To evaluate the efficacy of continuous positive airway pressure (CPAP) ventilation treatment for epilepsy with obstructive sleep apnea syndrome (OSAS). Methods The data were collected from the following words: sleep apnoea, obstructive sleep apnoea, OSA, obstructive sleep apnoea syndrome, OSAS, sleep apnoea syndromes, sleep-related breathing disorder, epilepsy, continuous positive airway pressure, CPAP. PubMed, EMBASE/SCOPUS and Cochrane Library retrieval on randomized controlled clinical trials, clinical guidelines, systematic review (including Meta-analysis), case controlled studies and retrospective cohort studies of CPAP ventilation treatment of epilepsy with OSAS from January 1, 1980 to February 28, 2017. Jadad Scale, Cochrane System Evaluation Handbook and RevMan 5.3 software were used for quality assessment and Meta-analysis. Results A total of 1197 English literatures were obtained, and 17 English articles were included in the study, including one clinical guideline, one systematic review, one Meta-analysis, one randomized controlled clinical trial, 10 case controlled studies and 3 retrospective cohort studies. The results showed that: 1) CPAP ventilation treatment can decrease the seizure frequency or even emarge seizure free in epilepsy with OSAS. 2) CPAP ventilation treatment can reduce the seizure frequency of refractory epilepsy with OSAS. 3) CPAP ventilation treatment can reduce the seizure frequency of elderly epilepsy patients with OSAS. 4) Meta-analysis on three clinical studies (153 epilepsy and OSAS patients) with Jadad ≥ 4 scores showed cases with reduction seizure frequency > 50% in CPAP group were more than those in unused CPAP group ( RR = 3.170, 95%CI: 1.650-6.090; P = 0.001). Conclusions CPAP ventilation treatment can reduce the seizure frequency of patients with epilepsy and OSAS. The effect of treatment depends on patients compliance. Sudden drug-withdrawl or pressure insuffiency may increase seizure frequency. This conclusion remains to be confirmed. DOI: 10.3969/j.issn.1672-6731.2017.10.005

Effect comparison of different aerosol inhalation methods of continuous non-invasive positive pressure ventilation in patients with AECOPD combined withII type respiratory failure

Objective To compare the application effects of different aerosol inhalation methods of continuous non-invasive positive pressure ventilation (NIPPV) in the treatment of the patients with AECOPD combined withⅡ type respiratory failure and offer reference for the appropriate choice of patients' aerosol inhalation methods. Methods With the convenience sampling method, totals of 150 continuous NIPPV patients with AECOPD combined withⅡ type respiratory failure were divided into the observation group and the control group according to the hospitalization time (75 patients in each group) . The patients in the control group used NIPPV and the standard oral spray driven by the atomizing pump. In the observation group the aerosol inhalation device was connected between the nasal face mask/nasal mask and the pipeline of the breathing machine. The patients in the observation group used NIPPV combined with the inhalation of atomizing drugs. Patients' oxygen saturation, heart rate, respiratory rate, dyspnea, dry mouth and sore throat, expectoration difficulties and comfort level in the two groups were compared between before and after the aerosol inhalation. Results After the aerosol inhalation, the heart rate and the respiratory rate in the observation group were (98.32±3.39) times/min and (23.16±1.30) times/min respectively, which were significantly lower compared with the control group [heart rate: (100.18±3.16) times/min, t=3.476, P<0.05; respiration rate: (25.67±1.21) times/min, t=12.240, P<0.05].The scores of dry mouth and sore throat, expectoration difficulties, and the comfort level in the observation group were (17.53±2.73) , (20.49±3.71) and (17.81±4.47) , which were significantly higher compared with the control group [dry mouth and sore throat: (16.48±3.07) , t=2.213, P<0.05; expectoration difficulties: (14.43±2.18) , t=12.196, P<0.05; comfort level: (16.37±3.74) , t=2.140, P<0.05]. Conclusions In the process of the continuous NIPPV, the aerosol inhalation device and nasal face mask are connected in the pipeline of the non-invasive breathing machine for the aerosol inhalation treatment, which can improve the therapy effect and the comfort level for patients and decrease the adverse effect level due to the use of the breathing machine. Key words: Pulmonary disease, chronic obstructive; Aerosol inhalation; Non-invasive positive pressure ventilation

Clinical And Economic Benefit Of Upper Airway Stimulation For Obstructive Sleep Apnea In The German Setting

Upper airway stimulation (UAS) is a treatment approach intended for patients with medium-to-severe obstructive sleep apnea who have failed or cannot tolerate continuous positive airway pressure therapy. Our objective was to evaluate the clinical and economic benefit of UAS in the German healthcare system. A five-state Markov model projected the probabilities of hypertension, major adverse cardiovascular or cerebrovascular events (myocardial infarction [MI], stroke), and motor vehicle collisions (MVC) to estimate cardiovascular and all-cause mortality, quality-adjusted life years (QALYs), and total direct costs for UAS versus no treatment from the German statutory health insurance perspective. Baseline characteristics and treatment efficacy were obtained from a recent prospective observational study and derived from literature via multivariate regression. Ten-year relative event risks (RR) and undiscounted lifetime survival benefit were computed as well as well as incremental cost-effectiveness ratios in Euros per QALY, discounted at 3% for costs and effects. Based on a real-world study from Germany, the patients’ mean age at baseline was 57 years, their BMI was 29 kg/m2, and their apnea-hypopnea index was reduced from 31.2 to 13.8 events per hour by UAS compared to no treatment. UAS reduced all types of events projected (ten-year relative risks for stroke, MI, cardiovascular death, and MVC: 0.76, 0.64, 0.65, and 0.34, respectively) and increased survival by 1.27 life years. While the UAS strategy incurred an additional 1.02 QALYs, there were also additional mean costs of 54,578 Euros over the patient’s lifetime, resulting in an incremental cost-effectiveness ratio of €53,698 per QALY gained. Upper airway stimulation adds meaningful benefit to endpoints relevant to obstructive sleep apnea patients and is a cost-effective therapy for patients ineligible to continuous positive pressure ventilation in the German healthcare setting.

Effects of Patent Foramen Ovale Closure on Obstructive Sleep Apnea Syndrome: PCOSA Study

BackgroundPrevious studies have shown a higher prevalence of patent foramen ovale (PFO) in patients with obstructive sleep apnea syndrome (OSAS). Right to left shunting through a PFO may be encouraged by the respiratory physiology of OSAS, contributing to the disease pathophysiology. We assessed whether PFO closure would improve respiratory polygraphy parameters compared with baseline measurements in patients with OSAS. MethodsTwenty-six patients with newly diagnosed OSAS and a moderate-large PFO (prevalence, 18% of 143 patients screened) were referred for PFO closure. The oxygen desaturation index (ODI), apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS), 6-minute walk test (6MWT), and Sleep Apnea Quality of Life Index (SAQLI) results were compared in these patients at baseline (before continuous positive pressure ventilation [CPAP]) and at 6-month follow-up (after interrupting CPAP for 1 week). ResultsAll PFOs were safely sealed at 6 months, as confirmed by repeated transthoracic echocardiography. The ODI (44.8 [interquartile range (IQR), 31.2-63.5) vs 42.3 [IQR, 34.0-60.8]; P = 0.89) and AHI (47.9 [IQR, 31.5-65.2] vs 42.3 [IQR, 32.1-63]; P = 0.99) did not change after PFO closure nor did the 6MWT, although the ESS (13.0 [IQR, 12.0-16.8] vs 6.0 [IQR, 4.0-8.8]; P < 0.001) and the SAQLI (3.4 [IQR, 2.8-4.3] vs 4.4 [IQR, 3.9-5.3]; P < 0.001) did improve. ConclusionsThe prevalence of PFO in OSAS appears to be no higher than that in the general population. Although PFO closure is safe and effective, it did not improve respiratory polygraphy measures of OSAS severity. The improvement in the ESS and SAQLI likely reflect residual benefits from CPAP.

Use of the Totaltrack® Video Laryngeal Mask Airway for tracheal intubation: A feasibility study

BackgroundAccording to both national and international difficult airway guidelines, supraglottic airway devices (SGADs) can be used as either ventilatory devices or as intubation conduits, if tracheal intubation is desired. The Totaltrack® VLM was recently developed as a second-generation SGAD that allows continuous visualization, uninterrupted oxygenation, and positive pressure ventilation during both intubation and extubation. AimTo evaluate the functionality and ease of use of the Totaltrack® VLM regarding the adequacy of oxygenation during tracheal intubation under continuous visualization and ventilation. MethodsFollowing IRB approval, thirty adult (>18 yo) patients, with Mallampati classifications I-III and mouth openings > 2 cm, scheduled for elective surgery requiring general anesthesia and tracheal intubation were included in this study. In order to assess the feasibility and performance of the Totaltrack® VLM, various measurements were collected, including lowest oxygen saturation (SpO2) during the intubation procedure, number of attempts required to intubate, time taken until CO2 detection and intubation, and a subjective assessment describing the level of difficulty of the intubation process (1 Very Easy - 5 Not Possible). ResultsThe Totaltrack® VLM was successfully placed and facilitated tracheal intubation in 25 patients (83.3%, 95% confidence interval: 65.3%–94.4%) during the first intubation attempt. The minimum SpO2 was 98.5% ± 4.3% (mean ± SD) during Totaltrack® VLM intubation. The median time required for initial ventilation, for all 30 patients, was 16.1s. The median time required for the entire intubation procedure and a successful intubation was 34.3s and 13.9s, respectively. The median ease-of-use score for laryngoscopy, intubation, and overall use, was Easy (2), as measured by a numeric rating scale (NRS) with an interquartile range of 1–3, based on the total 30 patients. The Totaltrack® VLM provided an overall intubation success rate of 93.3% (95% CI: 77.9%-99.2), with an overall ventilation success rate of 100%. ConclusionThis study demonstrated that the Totaltrack® VLM provided satisfactory functionality as a ventilatory device and intubation conduit, while adequately oxygenating patients during tracheal intubation. However, considering the novelty of this particular study, further research is warranted, to determine its usefulness in patients with known or predicted difficult airways.

Ventilation of Preterm Infants during Delayed Cord Clamping (VentFirst): A Pilot Study of Feasibility and Safety.

Background Establishing lung inflation prior to umbilical cord clamping may improve the cardiovascular transition and reduce the risk of intraventricular hemorrhage in preterm infants. We developed a pilot feasibility and safety study in which infants < 33 weeks' gestation received assisted ventilation during delayed cord clamping (DCC). Methods Infants born between 24 0/7 and 32 6/7 weeks' gestation whose mothers consented were enrolled. All infants received continuous positive airway pressure or positive pressure ventilation during 90 seconds of DCC. Outcomes included feasibility (ability to complete protocol and maintain a sterile field during cesarean deliveries) and safety variables (Apgar scores, umbilical cord pH and base deficit, admission temperature, and postcesarean infection). Results A total of 29 infants were enrolled, including one set of twins (median gestation: 30 weeks; 72% cesarean births). In all cases, the protocol was completed. Heart rate at 60 seconds was more than 100 beats per minute in all infants. Apgar scores, cord blood gas values, and admission temperature were comparable to other preterm deliveries at our institution. Conclusion Assisting ventilation of very preterm infants during 90 seconds of DCC is challenging but feasible and appears to be safe in this small pilot study. A randomized clinical trial is warranted to determine clinical benefit.

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FigureFigureFigureA 4-year-old boy with a history of asthma is brought to the ED by his mother with cough, fever, and increasing lethargy over the past three days. He was given albuterol for his cough without improvement, and had posttussive emesis on one occasion. His mother denied stool changes. He attends daycare but has no sick contacts or pets at home. His vital signs are notable for a temperature of 38.3°C, tachypnea to 45, and a heart rate of 160 bpm. He is normotensive, and you hear decreased breath sounds on the left. His abdominal exam is benign, but he has trace edema of his ankles bilaterally and fine petechiae where a tourniquet was placed. His portable chest radiograph is shown and demonstrates a left multilobar pneumonia with a large, loculated pleural effusion. His laboratory results are significant for a white blood count of 11.7, platelets of 12, hemoglobin of 5.7, a BUN of 49, and a creatinine of 1.2. A peripheral smear shows helmet cells. The patient is started on broad-spectrum antibiotics and placed on bi-level positive pressure ventilation. What should you do next? Does the patient warrant blood products at this time? Find the diagnosis and case discussion on the next page. Diagnosis: Atypical Hemolytic-Uremic Syndrome Hemolytic-uremic syndrome (HUS) is characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. It primarily affects children under 5, with an annual incidence of 6.1 cases per 100,000 children. (New Engl J Med 2009;361[17]:1676.) HUS has classically been divided into diarrhea-positive (typical HUS) and diarrhea-negative (atypical HUS) subtypes. Typical HUS is associated with Shiga toxin-producing Escherichia coli (STEC) diarrhea, and accounts for 90 percent of all HUS cases in children. Atypical HUS — the diagnosis in this case — can be triggered by Streptococcus pneumoniae, complement dysregulation, medications, or a variety of viral infections. Atypical HUS has a mortality up to 25 percent, and nearly half will progress to end-stage renal disease. (J Am Soc Nephrol 2005;16[4]:1035.) Treatment is focused on supportive care. Adequate intravenous fluids are crucial. Packed red blood cells should be transfused for symptomatic anemia, but platelets should be withheld unless major bleeding is present. Dialysis is warranted for symptomatic uremia, volume overload, and electrolyte derangements. Other therapies can be tailored to the cause of HUS. Antibiotics are traditionally not given for STEC-related HUS because of concerns of bacterial lysis causing worsening toxin release, but appropriate antibiotics should be started for streptococcal-associated atypical HUS. Therapies such as steroids, plasmapheresis, and intravenous immunoglobulin have failed to demonstrate consistent benefit for HUS. (Eur J Pediatr 2010;169[1]:7.) There is mounting evidence for the use of an anti-C5 monoclonal antibody — eculizumab — for atypical HUS triggered by inherited or acquired complement dysregulation. (Pediatr Nephrol 2016;31[1]:15.) The patient was admitted to the pediatric intensive care unit (PICU) and had chest tube drainage of the empyema, which was sent for S. pneumoniae antigen confirmation. He was placed on a renal diet with sufficient intravenous rehydration and with nephrology following closely to initiate dialysis if needed. His glomerular filtration rate hit a nadir of 22 and then returned to baseline without the need for renal replacement therapy. He required one packed red blood cell transfusion for symptomatic anemia but did not receive any platelets. His pneumonia steadily improved on antibiotics. He was discharged home on room air without restrictions after a week in the PICU. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website or in our free iPad app, both available at www.EM-News.com. Comments? Write to us at [email protected].

Intubation-Surfactant: Extubation on Continuous Positive Pressure Ventilation. Who Are the Best Candidates?

Respiratory distress syndrome (RDS) continues to be the leading cause of illness and death in preterm infants. Studies indicate that INSURE strategy (INtubate-SURfactant administration and Extubate to nasal continuous positive airway pressure [nCPAP]) is better than mechanical ventilation (MV) with rescue surfactant, for the management of respiratory distress syndrome (RDS) in very low birth weight (VLBW) neonates, as it has a synergistic effect on alveolar stability. To identify the factors associated with INSURE strategy failure in preterm infants with gestational age (GA) ≤ 32 weeks. This was a retrospective cohort study, based on data collected in the Romanian National Registry for RDS patients by three regional (level III) centers between 01.01.2010 and 31.12.2011. All preterm infants of ≤ 32 weeks GA were included. Prenatal and neonatal information were compared between (Group 1), the preterm infants successfully treated using INtubation-SURfactant-Extubation on nasal CPAP (INSURE) strategy and (Group 2 ), those who needed mechanical ventilation within seventy two hours after INSURE. A total of 637 preterm infants with GA ≤ 32 weeks were included in the study. INSURE strategy was performed in fifty seven cases (8.9%) [ Group 1] and was successful in thirty one patients (54.4%). No differences were found as regards the studied prenatal and intranatal characteristics between (Group 1) and Group 2 who needed mechanical ventilation. Group 2 preterm infants who needed mechanical ventilation within 72 hours after INSURE had significantly lower mean Apgar scores at 1 and 5 minutes and lower peripheral oxygen saturation (SpO2) during resuscitation at birth (p<0.05). Successful INSURE strategy was associated with greater GA, birth weight (BW), fraction of inspired oxygen (FiO2) during resuscitation, and an increased mean dose of surfactant but these associations were not statistically significant (p>0.5). In preterm infants ≤ 32 weeks gestation, increased INSURE failure rates are associated with complicated pregnancies, significantly lower Apgar scores at 1 and 5 minutes, and lower peripheral oxygen saturation during resuscitation.

The transition to extra‐uterine life by extremely preterm infants – handle with care

The transition to extra‐uterine life by extremely preterm infants – handle with care

Oxygenation failure after cardiac surgery: early re-intubation versus treatment by nasal continuous positive airway pressure (NCPAP) or non-invasive positive pressure ventilation (NPPV)

Due to an increasing incidence of respiratory failure after cardiac surgery we wanted to study whether nasal continuous positive airway pressure (NCPAP) may improve pulmonary oxygen transfer and may avoid reintubation after coronary operations. Additionally, we compared this protocol to non-invasive positive pressure ventilation (NPPV). For a period of 2 years we analyzed all patients that were extubated within 12 hours after coronary surgery, and in whom oxygen transfer (PaO2/FIO2) deteriorated without hypercapnia so that all these patients met predefined criteria for reintubation: group A=immediate reintubation (n=88), group B=NCPAP-treatment (n=173), group C=NPPV (n=18). 25.4% of group B- and 22.2% of group C-patients were also intubated after a period of NCPAP or NPPV. All other patients of groups B and C could be weaned from these devices (B = 34.3 +/- 5.9 hours; C = 26.4 +/- 4.4 h; p < 0.05) and were well oxygenated by face mask at ambient pressure (Ratio PaO2/FIO2: B, 138 +/- 13; C, 140 +/- 13). In group A we found a higher mortality (7.95%) compared to group B (4.04%) and group C (5.55%). NCPAP-patients suffered more frequently from an impaired sternal wound healing (A = 4.5%, B = 8.6%; p < 0.05). We conclude that reintubation after cardiac operations should be avoided since NCPAP and NPPV are safe and effective to improve arterial oxygenation in most patients with non hypercapnic respiratory failure.