Diagnosis Of Acute Respiratory Failure Research Articles

Perioperative and intermediate outcomes of patients with pulmonary embolism undergoing catheter-directed thrombolysis vs percutaneous mechanical thrombectomy

ObjectiveThrombolytic therapy has been a mainstay of treatment for massive or submassive pulmonary embolism (PE), a common and highly morbid pathology. New percutaneous mechanical thrombectomy (PMT) devices have recently become widely available and have been used increasingly for the treatment of acute PE, but evidence demonstrating its efficacy over standard catheter-directed lytic protocol remains limited. MethodsUsing TriNetX Data Network, a global federated database of >250 million patients, we conducted a retrospective cohort study of patients from January 2017 to August 2023 with a diagnosis of PE, treated with either PMT or catheter-directed thrombolysis (CDT). Eligible patients were 1:1 propensity score-matched for preoperative covariates including demographics and comorbidities. We calculated and compared the 30-day outcomes of all-cause mortality, bleeding complications (blood transfusion, gastrointestinal bleed, and intracranial hemorrhage), diagnosis of acute respiratory failure (RF), myocardial infarction (MI), and pulmonary hypertension (PH) using odds ratios (OR) with 95% confidence intervals (CIs). Also, the 5-year outcomes of all-cause mortality, a composite outcome of chronic PH (chronic PE, chronic cor pulmonale, chronic thromboembolic PH), right heart failure (RHF), RF, and emergency department visits, were compared using hazard ratios (HRs) with 95% CIs. ResultsWe identified 2978 patients treated with PMT and 1137 patients treated with CDT. After matching, we compared 1102 patients in each cohort. For 30-day outcomes, all-cause mortality, acute RF, and blood transfusion were similar between the two groups. However, compared with CDT, PMT was associated with a better safety profile, including lower bleeding risk for both ICH (OR, 0.46; 95% CI, 0.24-0.890) and gastrointestinal bleed (OR, 0.42; 95% CI, 0.28-0.63). PMT also demonstrated better immediate functional outcomes, with less PH (OR, 0.53; 95% CI, 0.41-0.68) and MI (OR, 0.54; 95% CI, 0.41-0.76). At 5 years, the all-cause mortality and RF for both procedures were similar, but PMT was associated with lower rates of chronic PH (HR, 0.70; 95% CI, 0.55-0.90), RHF (HR 0.49; 95% CI, 0.37-0.65), and emergency department visits (348 for PMT vs 426 for CDT; P < .01). ConclusionsIn patients undergoing catheter-based therapy for PE, PMT has an improved procedural safety profile vs CDT and results in significantly fewer 30-day postoperative complications, with fewer bleeding events, and is also associated with fewer periprocedural MIs and less acute PH. Perhaps, more important, PMT also demonstrated improved long-term outcomes with significantly fewer chronic PH and RHF diagnoses with fewer emergency department visits.

Opioid Administration Practice Patterns in Patients With Acute Respiratory Failure Who Undergo Invasive Mechanical Ventilation.

The opioid crisis is impacting people across the country and deserves attention to be able to curb the rise in opioid-related deaths. To evaluate practice patterns in opioid infusion administration and dosing for patients with acute respiratory failure receiving invasive mechanical ventilation. Retrospective cohort study. Patients from 21 hospitals in Kaiser Permanente Northern California and 96 hospitals in Philips electronic ICU Research Institute. We assessed whether patients received opioid infusion and the dose of said opioid infusion. We identified patients with a diagnosis of acute respiratory failure who were initiated on invasive mechanical ventilation. From each patient, we determined if opioid infusions were administered and, among those who received an opioid infusion, the median daily dose of fentanyl infusion. We used hierarchical regression models to quantify variation in opioid infusion use and the median daily dose of fentanyl equivalents across hospitals. We included 13,140 patients in the KPNC cohort and 52,033 patients in the eRI cohort. A total of 7,023 (53.4%) and 16,311 (31.1%) patients received an opioid infusion in the first 21 days of mechanical ventilation in the KPNC and eRI cohorts, respectively. After accounting for patient- and hospital-level fixed effects, the hospital that a patient was admitted to explained 7% (95% CI, 3-11%) and 39% (95% CI, 28-49%) of the variation in opioid infusion use in the KPNC and eRI cohorts, respectively. Among patients who received an opioid infusion, the median daily fentanyl equivalent dose was 692 µg (interquartile range [IQR], 129-1341 µg) in the KPNC cohort and 200 µg (IQR, 0-1050 µg) in the eRI cohort. Hospital explained 4% (95% CI, 1-7%) and 20% (95% CI, 15-26%) of the variation in median daily fentanyl equivalent dose in the KPNC and eRI cohorts, respectively. In the context of efforts to limit healthcare-associated opioid exposure, our findings highlight the considerable opioid exposure that accompanies mechanical ventilation and suggest potential under and over-treatment with analgesia. Our results facilitate benchmarking of hospitals' analgesia practices against risk-adjusted averages and can be used to inform usual care control arms of analgesia and sedation clinical trials.

Effectiveness of Lung Ultrasound for Diagnosis of Acute Respiratory Distress Syndrome in Mechanically Ventilated Patients

Background: Acute respiratory distress syndrome (ARDS) requires rapid diagnosis for early intervention and improved outcomes. Lung ultrasound may be a reasonable alternative to chest X-ray for the identification of ARDS but the effectiveness of lung ultrasound in ARDS diagnosis is still uncertain. The objective of the study is to explore the efficacy of lung ultrasound (LUS) for diagnosis of ARDS in mechanically ventilated patients. Methods: A cross sectional study was conducted among 75 patients in Critical Care Centre, Combined Military Hospital, Dhaka from September 2021 to January 2022. The study was approved by the ethical committee in the hospital. In this study, the Bedside Lung Ultrasound in Emergency (BLUE) protocol for the immediate diagnosis of acute respiratory failure was followed. Purposive sampling technique was used. Data were analyzed by using Statistical Package For Social Sciences (SPSS) version 25.0. Results: A total of 75 patients were assessed. Among them male were 42(56%) and female 33(44%). The median age of patients was 48 years (Interquartile range 30-60). Primary diagnoses were pneumonia (22.67%), pulmonary oedema (20%), sepsis (20%) and trauma (17.33%). A total of 34(45.33%) patients fulfilled ‘CXR-based Berlin Definition’ and a total of 36(48%) patients were diagnosed as ARDS by ‘LUS-based Berlin Definition’. Considering the ‘CXR-based Berlin Definition’ as reference standard, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of lung ultrasound were 85.29%, 82.92%, 80.55%, 87.18% and 84% respectively. Conclusion: Lung ultrasound can be an effective tool for the diagnosis &amp; management of ARDS in the intensive care unit. Bangladesh Armed Forces Med J Vol 56 No (2) December 2023, pp 51-57

Mitral Annular Plane Systolic Excursion (MAPSE) as a Predictor of Weaning Failure in Mechanically Ventilated Patients

Weaning failure is multifactorial in nature; it can result from diaphragmatic dysfunction, excess mechanical load, weaning-induced cardiovascular dysfunction, or a reduced ability to clear secretions. To investigate mitral annular plane systolic excursion (MAPSE) by using M-mode echocardiography as a predictor of weaning failure and its relation to length of intensive care unit stay, and to hospital mortality, and correlation of MAPSE with APACHE II and SOFA scores as predictors of outcome. This was a prospective observational cohort study conducted on 50 patients admitted to Critical Care Medicine Department, Cairo University Hospitals (Kasr Al-Aini Hospitals), with a diagnosis of acute respiratory failure who required mechanical ventilation, from January 2019 to December 2020. There was significant relation between weaning from mechanical ventilation and APACHE II score, we found highly significant difference with SOFA score. ROC curve for detection of weaning using MAPSE showed Area Under the Curve of 0.918 with highly statistically significant relation with cut off value is 13.9 with Sensitivity 83.3% and Specificity 92.3%; and thus, MAPSE could be a good indicator for successful weaning. We concluded that; Low Mitral annular plane systolic excursion (MAPSE) could be a good predictor of weaning failure and mortality, The higher MAPSE values are correlated with lower ICU stay duration. We found that RSBI and SOFA score are predictors for successful weaning, also SOFA and APACHE II scores are indicators of mortality.

Pulmonary Rehabilitation Utilization in Older Adults with Chronic Obstructive Pulmonary Disease, 2013-2019.

Rationale: Pulmonary rehabilitation (PR) is very effective in patients with chronic obstructive pulmonary disease (COPD) for improving exercise tolerance and functional capacity, alleviating dyspnea, and improving respiratory quality of life. Access to and use of PR remain poor. Objectives: To assess the trends in PR use and factors associated with PR use in adults with COPD. Methods: We retrospectively analyzed the use of PR in adults with COPD using a 20% Medicare beneficiary population from January 1, 2013, to December 31, 2019. Adults with COPD were identified by 1) two or more outpatient visits >30 days apart within 1 year with an encounter diagnosis of COPD or 2) hospitalization with COPD as the primary diagnosis or a primary diagnosis of acute respiratory failure with a secondary discharge diagnosis of COPD. PR use in each calendar year was identified using Current Procedural Terminology and Healthcare Common Procedure Coding System codes. Factors associated with PR use were tested in bivariate and multivariable logistic regression models. Results: There was a gradual but modest increase in the percentage of patients with COPD using PR; the proportion increased from 2.5% in 2013 to 4.0% in 2019. Overall, the percentage of patients using PR remained low. Factors associated with higher odds of using PR included younger age (66-74 yr), White race, higher socioeconomic status, lower comorbidity score, residence in a metropolitan urban area, and sole or comanagement by a pulmonologist. Conclusions: The use of PR by Medicare beneficiaries with COPD has not changed meaningfully in the past decade and remains low.

Acute respiratory failure in achalasia with megaesophagus

Introduction: Achalasia is one of the most common causes of dysphagia. Typical symptoms include difficulty in swallowing, regurgitation, weight loss, and chest pain. Megaesophagus is a complication of advanced achalasia. This condition rarely causes tracheal compression with acute dyspnea. Case Presentation : A 51 years old man came to the emergency room and had complaints of intermittent shortness of breath accompanied by a cough for 1 week, chest pain that came and went, nausea (+), vomiting (+), difficulty in swallowing food, and fever (-). The medical history showed that the patient went to gastroenterology polyclinic to examine his dysphagia and esophageal sphincter dilatation 2 months ago. The patient received treatment in the ward, but the complaints he suffered was getting worse, so he was transferred to the ICU with a diagnosis of acute respiratory failure. Conclusion: The patient was then intubated and decompressed for the megaoesophagus he suffered with the aim to reduce the compression of the trachea and lungs by the esophagus. The patient was getting better and could be extubated on the 3rd day of treatment.

Clinical Outcomes according to Timing to Non Invasive Ventilation Initiation in COPD Patients with Acute Respiratory Failure: A Retrospective Cohort Study.

Nighttime and non-working days are characterized by a shortage of dedicated staff and available resources. Previous studies have highlighted that patients admitted during the weekend had higher mortality than patients admitted on weekdays ("weekend effect"). However, most studies have focused on specific conditions and controversial results were reported. We conducted an observational, monocentric, retrospective cohort study, based on data collected prospectively to evaluate the impact of the timing of NIV initiation on clinical outcomes in COPD patients with acute respiratory failure (ARF). A total of 266 patients requiring NIV with a time gap between diagnosis of ARF and NIV initiation <48 h were included. Interestingly, 39% of patients were not acidotic (pH = 7.38 ± 0.09 vs. 7.26 ± 0.05, p = 0.003) at the time of NIV initiation. The rate of NIV failure (need for intubation and/or all-cause in-hospital death) was similar among three different scenarios: "daytime" vs. "nighttime", "working" vs. "non-working days", "nighttime or non-working days" vs. "working days at daytime". Patients starting NIV during nighttime had a longer gap to NIV initiation compared to daytime (219 vs. 115 min respectively, p = 0.01), but this did not influence the NIV outcome. These results suggested that in a training center for NIV management, the failure rate did not increase during the "silent" hours.

The hypoxic patient in the intensive cardiac care unit: from nasal cannulas to oro-tracheal intubation

Acute respiratory failure is a frequent complication of patients admitted to the intensive cardiac care unit and it is associated with a poor short- and long-term outcome. Acute respiratory failure can be managed with traditional oxygen therapy, with high-flow nasal cannula, continuous positive airway pressure, non-invasive ventilation or invasive ventilation according to clinical and blood gas condition. The use of advanced respiratory therapies is associated with both respiratory and hemodynamic effects, therefore the intensivist cardiologist should know deeply these respiratory devices. The intensivist cardiologist should perform an early diagnosis of acute respiratory failure, an appropriate selection of the respiratory device, and accurate monitoring and management to obtain clinical improvement and to avoid mechanical invasive ventilation.

Pro: Does Every Anesthesiologist Need to Learn Point-of-Care Ultrasound?

THE APPLICATIONS OF ULTRASOUND for the anesthesiologist are diverse and expanding rapidly. Although national society guidelines governing the appropriate use of ultrasound in anesthesiology have been available only for transesophageal echocardiography (TEE) and vascular access imaging, clinical guidance has more recently been published describing the use of focused cardiac ultrasound in multiple clinical contexts. 1 Troianos CA Hartman GS Glas KE et al. Guidelines for performing ultrasound guided vascular cannulation: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 2011; 24: 1291-1318 Abstract Full Text Full Text PDF PubMed Scopus (257) Google Scholar , 2 American Society of Anesthesiologists and Society of Cardiovascular Anesthesiologists Task Force on Transesophageal EchocardiographyPractice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology. 2010; 112: 1084-1096 Crossref PubMed Scopus (391) Google Scholar , 3 Spencer KT Kimura BJ Korcarz CE et al. Focused cardiac ultrasound: Recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2013; 26: 567-581 Abstract Full Text Full Text PDF PubMed Scopus (398) Google Scholar , 4 Via G Hussain A Wells M et al. International evidence-based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr. 2014; 27 (683.e1-683.e33) Abstract Full Text Full Text PDF PubMed Scopus (368) Google Scholar Additionally, numerous point-of-care ultrasound (POCUS) protocols now exist to guide the examination of nearly every organ system and area, including cardiac, pulmonary and/or pleural, abdominal, genitourinary, ocular, and airway. 4 Via G Hussain A Wells M et al. International evidence-based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr. 2014; 27 (683.e1-683.e33) Abstract Full Text Full Text PDF PubMed Scopus (368) Google Scholar , 5 Haskins SC Bronshteyn Y Perlas A et al. American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians-part I: Clinical indications. Reg Anesth Pain Med. 2021; 46: 1031-1047 Crossref PubMed Scopus (15) Google Scholar , 6 Haskins SC Bronshteyn Y Perlas A et al. American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians-part II: Recommendations. Reg Anesth Pain Med. 2021; 46: 1048-1060 Crossref PubMed Scopus (14) Google Scholar , 7 Holm JH Frederiksen CA Johl-Olsen P et al. Perioperative use of focus assessed transthoracic echocardiography (FATE). Anesth Analg. 2012; 115: 1029-1032 Crossref PubMed Scopus (71) Google Scholar , 8 Lichtenstein DA Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: The BLUE protocol. Chest. 2008; 134: 117-125 Abstract Full Text Full Text PDF PubMed Scopus (1146) Google Scholar , 9 Volpicelli G Elbarbary M Blaivas M et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012; 38: 577-591 Crossref PubMed Scopus (1758) Google Scholar , 10 Scalea TM Rodriguez A Chiu WC et al. Focused Assessment with Sonography for Trauma (FAST): Results from an international consensus conference. J Trauma. 1999; 46: 466-472 Crossref PubMed Google Scholar , 11 Perlas A Van de Putte P Van Houwe P et al. I-AIM framework for point-of-care gastric ultrasound. Br J Anaesth. 2016; 116: 7-11 Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar

Feasibility and Safety of Transbronchial Lung Cryobiopsy for Diagnosis of Acute Respiratory Failure with Mechanical Ventilation in Intensive Care Unit.

Acute hypoxemic respiratory failure is common in intensive care units (ICUs). Lung biopsies may be required to make a definitive diagnosis in patients with unknown etiologies. The feasibility of transbronchial lung cryobiopsy is undetermined in patients with respiratory failure in the ICU. Patients who underwent bronchoscopy examinations with transbronchial lung cryobiopsy (TBLC) between July 2018 and December 2019 were retrospectively analyzed through medical chart review. The procedures were performed by well-experienced interventional pulmonologists. Ten patients underwent bronchoscopy examinations with TBLC in the ICU at Chang Gung Memorial Hospital during the study period. In all patients, the diagnosis was made via pathological analysis. One patient developed pneumothorax and required chest tube placement after the procedure. None of the patients had bleeding requiring blood transfusion, and no deaths were directly related to the procedure. TBLC is a feasible technique to obtain lung pathology in patients with acute respiratory diseases of unknown etiologies. While the complication rate may be acceptable, the procedure should be performed by experienced interventional pulmonologists. However, airway blockers and fluoroscopy are highly recommended when used according to the current guideline. We do not encourage TBLC to be performed without having airway blockers available at the bedside.

CLINICAL AND ECONOMIC IMPACT OF DELIRIUM ON HOSPITALIZATION OUTCOMES OF ACUTE RESPIRATORY FAILURE: A RETROSPECTIVE NATIONAL COHORT

CLINICAL AND ECONOMIC IMPACT OF DELIRIUM ON HOSPITALIZATION OUTCOMES OF ACUTE RESPIRATORY FAILURE: A RETROSPECTIVE NATIONAL COHORT

Noninvasive Ventilation Exposure Prior to Intubation in Pediatric Hematopoietic Cell Transplant Recipients.

Noninvasive ventilation (NIV) has become more studied in immunocompromised patients. However, it has not been studied in hematopoietic cell transplantation (HCT) recipients, who have higher mortality and higher pulmonary complication rates than other immunocompromised patients. This population may be prone to negative effects from this treatment modality. The aim of this study was to determine whether NIV use is associated with worse outcomes in this vulnerable patient population. A secondary analysis of a retrospective multi-center database was performed. Twelve pediatric ICUs across the United States enrolled HCT subjects from 2009-2014 that were admitted to the pediatric ICU (PICU) with the diagnosis of acute respiratory failure. Subjects exposed to NIV prior to intubation were compared against those not exposed to NIV. Our primary outcome was all-cause mortality at 90 d; secondary outcomes included ventilator-free days (VFD) at 28 d and development of pediatric ARDS. Multivariable logistic and linear regression models were constructed using variables significant on univariable analysis. Two-hundred eleven subjects were included. Of these, 82 (39%) received NIV prior to intubation. Those that received NIV prior to intubation were older (13 vs 6 y, P < .001) and more commonly diagnosed with respiratory distress (90% vs 74%, P = .004). On multivariable analysis, NIV use prior to intubation was associated with a higher PICU mortality (hazard ratio 1.51 [95% CI 1.18-2.28], P = .02) and fewer VFD at 28 d (β -3.50 [95% CI -6.09 to 0.91], P = .008). Those with NIV exposure prior to intubation also had higher rates of development of pediatric ARDS (95% vs 78%, P = .001). In this cohort of children post-HCT, NIV use prior to intubation was associated with worse outcomes. The benefits and risks of NIV in this patient population should be carefully evaluated prior to its use, and careful patient selection is crucial for its optimal utilization.

Sartans and ACE Inhibitors: Mortality in Patients Hospitalized with COVID-19. Retrospective Study in Patients on Long-Term Treatment Who Died in the Italian Hospitals of Area Vasta n.5-Marche Region.

Introduction: During the 2019 Coronavirus pandemic (COVID-19), a concern emerged regarding a possible correlation between the severe form of SARS-CoV-2 infection and administration of ACE-Inhibitors (ACE-I) and Sartans (ARB), since long-term use of these drugs may potentially result in an adaptive response with up-regulation of the ACE 2 receptor. Given the crucial role of ACE2, being the main target for virus entry into the cell, the potential consequences of ACE2 up-regulation have been a source of debate. The aim of this retrospective cohort study on COVID-19-positive patients who died is to investigate whether previous long-term exposure to ACE-I and/or ARB was associated with higher mortality due to COVID-19 infection, compared to all other types of drug treatment. Methods: We analysed the clinical and demographic data of 615 patients hospitalized for COVID-19 at the two hospitals of the Vasta Area n.5, between March 2020 and April 2021. Among them, 86 patients, treated with ACE-Is and/0 ARBs for about 12 months, died during hospitalization following a diagnosis of acute respiratory failure. Several quantitative and qualitative variables were recorded for all patients by reading their medical records. Results: The logistic model showed that the variables that increase mortality are age and comorbid diseases. There were no demonstrable mortality effects with ACE-I and ARB intake. Conclusions: The apparent increase in morbidity in patients with COVID-19 who received long-term treatment with ACE-I or ARB is not due to the drugs themselves, but to the conditions associated with their use.

Risk Factors for Severe COVID-19 Outcomes Among Persons Aged ≥18 Years Who Completed a Primary COVID-19 Vaccination Series - 465 Health Care Facilities, United States, December 2020-October 2021.

Vaccination against SARS-CoV-2, the virus that causes COVID-19, is highly effective at preventing COVID-19-associated hospitalization and death; however, some vaccinated persons might develop COVID-19 with severe outcomes† (1,2). Using data from 465 facilities in a large U.S. health care database, this study assessed the frequency of and risk factors for developing a severe COVID-19 outcome after completing a primary COVID-19 vaccination series (primary vaccination), defined as receipt of 2 doses of an mRNA vaccine (BNT162b2 [Pfizer-BioNTech] or mRNA-1273 [Moderna]) or a single dose of JNJ-78436735 [Janssen (Johnson & Johnson)] ≥14 days before illness onset. Severe COVID-19 outcomes were defined as hospitalization with a diagnosis of acute respiratory failure, need for noninvasive ventilation (NIV), admission to an intensive care unit (ICU) including all persons requiring invasive mechanical ventilation, or death (including discharge to hospice). Among 1,228,664 persons who completed primary vaccination during December 2020-October 2021, a total of 2,246 (18.0 per 10,000 vaccinated persons) developed COVID-19 and 189 (1.5 per 10,000) had a severe outcome, including 36 who died (0.3 deaths per 10,000). Risk for severe outcomes was higher among persons who were aged ≥65 years, were immunosuppressed, or had at least one of six other underlying conditions. All persons with severe outcomes had at least one of these risk factors, and 77.8% of those who died had four or more risk factors. Severe COVID-19 outcomes after primary vaccination are rare; however, vaccinated persons who are aged ≥65 years, are immunosuppressed, or have other underlying conditions might be at increased risk. These persons should receive targeted interventions including chronic disease management, precautions to reduce exposure, additional primary and booster vaccine doses, and effective pharmaceutical therapy as indicated to reduce risk for severe COVID-19 outcomes. Increasing COVID-19 vaccination coverage is a public health priority.

Rationale and limitations of the SpO2/FiO2 as a possible substitute for PaO2/FiO2 in different preclinical and clinical scenarios.

Although the PaO 2/FiO 2 derived from arterial blood gas analysis remains the gold standard for the diagnosis of acute respiratory failure, the SpO2/FiO2 has been investigated as a potential substitute. The current narrative review presents the state of the preclinical and clinical literature on the SpO2/FiO2 as a possible substitute for PaO2/FiO2 and for use as a diagnostic and prognostic marker; provides an overview of pulse oximetry and its limitations, and assesses the utility of SpO2/ FiO2 as a surrogate for PaO2/FiO2 in COVID-19 patients. Overall, 49 studies comparing SpO2/FiO2 and PaO2/FiO2 were found according to a minimal search strategy. Most were conducted on neonates, some were conducted on adults with acute respiratory distress syndrome, and a few were conducted in other clinical scenarios (including a very few on COVID-19 patients). There is some evidence that the SpO2/ FiO2 criteria can be a surrogate for PaO2/FiO2 in different clinical scenarios. This is reinforced by the fact that unnecessary invasive procedures should be avoided in patients with acute respiratory failure. It is undeniable that pulse oximeters are becoming increasingly widespread and can provide costless monitoring. Hence, replacing PaO2/FiO2 with SpO2/FiO2may allow resourcelimited facilities to objectively diagnose acute respiratory failure.

Rationale and limitations of the SpO2/FiO2 as a possible substitute for PaO2/FiO2 in different preclinical and clinical scenarios

Although the PaO2/FiO2 derived from arterial blood gas analysis remains the gold standard for the diagnosis of acute respiratory failure, the SpO2/FiO2 has been investigated as a potential substitute. The current narrative review presents the state of the preclinical and clinical literature on the SpO2/FiO2 as a possible substitute for PaO2/FiO2 and for use as a diagnostic and prognostic marker; provides an overview of pulse oximetry and its limitations, and assesses the utility of SpO2/FiO2 as a surrogate for PaO2/FiO2 in COVID-19 patients. Overall, 49 studies comparing SpO2/FiO2 and PaO2/FiO2 were found according to a minimal search strategy. Most were conducted on neonates, some were conducted on adults with acute respiratory distress syndrome, and a few were conducted in other clinical scenarios (including a very few on COVID-19 patients). There is some evidence that the SpO2/FiO2 criteria can be a surrogate for PaO2/FiO2 in different clinical scenarios. This is reinforced by the fact that unnecessary invasive procedures should be avoided in patients with acute respiratory failure. It is undeniable that pulse oximeters are becoming increasingly widespread and can provide costless monitoring. Hence, replacing PaO2/FiO2 with SpO2/FiO2may allow resourcelimited facilities to objectively diagnose acute respiratory failure.

Trends in Clinical Severity of Hospitalized Patients With Coronavirus Disease 2019-Premier Hospital Dataset, April 2020-April 2021.

BackgroundClinical severity of coronavirus disease 2019 (COVID-19) may vary over time; trends in clinical severity at admission during the pandemic among hospitalized patients in the United States have been incompletely described, so a historical record of severity over time is lacking.MethodsWe classified 466677 hospital admissions for COVID-19 from April 2020 to April 2021 into 4 mutually exclusive severity grades based on indicators present on admission (from most to least severe): Grade 4 included intensive care unit (ICU) admission and invasive mechanical ventilation (IMV); grade 3 included non-IMV ICU and/or noninvasive positive pressure ventilation; grade 2 included diagnosis of acute respiratory failure; and grade 1 included none of the above indicators. Trends were stratified by sex, age, race/ethnicity, and comorbid conditions. We also examined severity in states with high vs low Alpha (B.1.1.7) variant burden.ResultsSeverity tended to be lower among women, younger adults, and those with fewer comorbidities compared to their counterparts. The proportion of admissions classified as grade 1 or 2 fluctuated over time, but these less-severe grades comprised a majority (75%–85%) of admissions every month. Grades 3 and 4 consistently made up a minority of admissions (15%–25%), and grade 4 showed consistent decreases in all subgroups, including states with high Alpha variant burden.ConclusionsClinical severity among hospitalized patients with COVID-19 has varied over time but has not consistently or markedly worsened over time. The proportion of admissions classified as grade 4 decreased in all subgroups. There was no consistent evidence of worsening severity in states with higher vs lower Alpha prevalence.

Use of Peripheral Venous Blood Gas Analysis and Oximetry to Assess Respiratory Failure in the Emergency Department

Purpose: The diagnosis of acute respiratory failure (ARF) is based on arterial blood gas analysis (ABGA), which is associated with patient discomfort and requires an additional vascular puncture. Our aim was to compare ABGA with peripheral venous blood gas analysis (PVBGA) and pulse oximetry in adult patients with dyspnea and/or suspected ARF.Methods: We included 102 patients (56 males) in a prospective study performed in a medical emergency department from March–May 2019. Patients with overt signs of circulatory shock or severe respiratory failure were not included.Results: We showed significant positive correlations between ABGA and PVBGA results (for pH, ρ=0.590; for HCO3, ρ=0.901; and for pCO2, ρ=0.740), and insignificant differences between oxygen saturation based on ABGA and pulse oximetry (95% vs. 94%; p=0.49). When we subtracted 1 kPa from the venous pCO2 and added 4 kPa to the venous pO2 , there were no statistically significant differences between peripheral venous and arterial pCO2 and pO2 (4.8 vs. 4.7 kPa, p=0.26 and 9.5 vs. 8.9 kPa, p=0.21, respectively).Conclusion: The combination of PVBGA and pulse oximetry provided sufficient data to make clinical decisions in a select group of patients with dyspnea and/or ARF.

Diagnostic Accuracy of Bedside Lung Ultrasound in Emergency Protocol for the Diagnosis of Acute Respiratory Failure.

Background:The multifactorial etiology of acute respiratory failure (ARF) often complicates diagnosis at an early stage of clinical presentation. Despite being a common life-threatening disorder, accurate and timely diagnosis is hindered by bad quality of bedside radiographs and nonavailability of immediate computed tomography imaging. This study was an attempt to evaluate the diagnostic accuracy of ultrasound in diagnosing ARF.Methods:This hospital-based cross-sectional study investigated the underlying etiological factor in 130 patients presenting with ARF and admitted to the intensive care unit. Lung ultrasound was performed according to the Bedside Lung Ultrasound in Emergency (BLUE) protocol. The diagnostic accuracy of lung ultrasound by emergency protocol was measured against each final diagnosis.Results:The mean age observed was 49.28 ± 14.9 years among the cohort. Of the 130 patients, pneumonia was the most common cause of ARF, seen in 42 patients. Breathlessness (56.15%) and fever accompanied by cough (25.38%) were the chief complaints. Diagnostic accuracy of ultrasound lung emergency protocol was 95.38% in the diagnosis of pulmonary edema, 100% for pneumothorax, 93.85% for pneumonia, 96.92% for chronic obstructive pulmonary disease, 99.23% for pulmonary thromboembolism, and 95.38% for acute respiratory distress syndrome.Conclusion:Lung ultrasound is a reliable modality that provided accurate and timely diagnosis of ARF in this study. Therefore, BLUE protocol is feasible, easily implementable in the intensive care unit, and must be scaled up in respiratory health-care settings.

Diaphragm thickening fraction predicts noninvasive ventilation outcome: a preliminary physiological study

BackgroundA correlation between unsuccessful noninvasive ventilation (NIV) and poor outcome has been suggested in de-novo Acute Respiratory Failure (ARF) patients. Consequently, it is of paramount importance to identify accurate predictors of NIV outcome. The aim of our preliminary study is to evaluate the Diaphragmatic Thickening Fraction (DTF) and the respiratory rate/DTF ratio as predictors of NIV outcome in de-novo ARF patients.MethodsOver 36 months, we studied patients admitted to the emergency department with a diagnosis of de-novo ARF and requiring NIV treatment. DTF and respiratory rate/DTF ratio were measured by 2 trained operators at baseline, at 1, 4, 12, 24, 48, 72 and 96 h of NIV treatment and/or until NIV discontinuation or intubation. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the ability of DTF and respiratory rate/DTF ratio to distinguish between patients who were successfully weaned and those who failed.ResultsEighteen patients were included. We found overall good repeatability of DTF assessment, with Intra-class Correlation Coefficient (ICC) of 0.82 (95% confidence interval 0.72–0.88). The cut-off values of DTF for prediction of NIV failure were < 36.3% and < 37.1% for the operator 1 and 2 (p < 0.0001), respectively. The cut-off value of respiratory rate/DTF ratio for prediction of NIV failure was > 0.6 for both operators (p < 0.0001).ConclusionDTF and respiratory rate/DTF ratio may both represent valid, feasible and noninvasive tools to predict NIV outcome in patients with de-novo ARF.Trial registration ClinicalTrials.gov Identifier: NCT02976233, registered 26 November 2016.