Episode Of Acute Respiratory Failure Research Articles

Upper airway manifestations of anti-IgLON5 disease: Otorhinolaryngological point of view

IntroductionAnti-IgLON5 disease is a recently described neurological disorder with multisystemic features. The disease is characterized by the presence of IgLON5 antibodies in serum and cerebrospinal fluid. Our objective is to describe in detail the otorhinolaryngological manifestations of this disease, which are frequent and may include dysphagia, dysarthria, vocal cord paralysis and laryngospasm. MethodsIn this study, we present a series of 9 patients with anti-IgLON5 disease and otolaryngological manifestations. Patients were evaluated between July 2012 and March 2022 by video-polysomnography, fiber-optic laryngoscopy, and functional endoscopic evaluation of swallowing. ResultsThe median age was 71 years, and 5 (56%) were female. Video-polysomnography showed a NREM/REM parasomnia in 6 patients (67%), obstructive sleep apnea in 8 (88%), stridor during sleep in 7 (78%) and central apneas in 1 (11%). Six out of the 9 patients (67%) presented episodes of acute respiratory failure that required mechanical ventilation, 6 had vocal fold palsy with 4 of them requiring tracheostomy (3 had to be performed on an emergency basis). Dysphagia occurred in 8 patients (89%). Prominent upper airway secretion and sialorrhea was also present in 3 cases. ConclusionThe anti-IgLON5 disease exhibits extensive otolaryngological symptoms, mainly affecting the upper airway. These symptoms affect the quality of life and can be life-threatening. Prompt acute management is essential for stridor, dyspnea, and dysphagia. Given the potential severity of the symptoms and rarity of the disease, it is important for otolaryngologists to be familiar with anti-IgLON5 disease. Level of evidenceLevel 4.

Spinal Muscular Atrophy (SMA) Mortality Despite Novel Medications: Case Reports.

Despite new effective medications, patients with SMA types 1-3 can continue to have inadequate cough flows to prevent episodes of acute respiratory failure. Ventilator unweanable intubated patients are thought to require tracheostomy tubes. As a result, potentially beneficial medications may be discontinued and patients die despite receiving these medications. Three cases are presented of medically treated, physically strengthening children, with SMA type 1. All three subsequently died or underwent tracheotomy. However, there is no evidence of extubation attempts to noninvasive ventilatory support settings or optimal mechanical insufflation-exsufflation despite this option being described to be over 98% successful for extubating unweanable medically untreated children with SMA1.

A Focused Review of the Initial Management of Patients with Acute Respiratory Distress Syndrome.

At present, the management of patients with acute respiratory distress syndrome (ARDS) largely focuses on ventilator settings to limit intrathoracic pressures by using low tidal volumes and on FiO2/PEEP relationships to maintain optimal gas exchange. Acute respiratory distress syndrome is a complex medical disorder that can develop in several primary acute disorders, has a rapid time course, and has several classifications that can reflect either the degree of hypoxemia, the extent of radiographic involvement, or the underlying pathogenesis. The identification of subtypes of patients with ARDS would potentially make precision medicine possible in these patients. This is a very difficult challenge given the heterogeneity in the clinical presentation, pathogenesis, and treatment responses in these patients. The analysis of large databases of patients with acute respiratory failure using statistical methods such as cluster analysis could identify phenotypes that have different outcomes or treatment strategies. However, clinical information available on presentation is unlikely to separate patients into groups that allow for secure treatment decisions or outcome predictions. In some patients, non-invasive positive pressure ventilation provides adequate support through episodes of acute respiratory failure, and the development of specialized units to manage patients with this support might lead to the better use of hospital resources. Patients with ARDS have capillary leak, which results in interstitial and alveolar edema. Early attention to fluid balance in these patients might improve gas exchange and alter the pathophysiology underlying the development of severe ARDS. Finally, more attention to the interaction of patients with ventilators through complex monitoring systems has the potential to identify ventilator dyssynchrony, leading to ventilator adjustments and potentially better outcomes. Recent studies with COVID-19 patients provide tentative answers to some of these questions. In addition, expert clinical investigators have analyzed the promise and difficulties associated with the development of precision medicine in patients with ARDS.

COPD Exacerbation: Why It Is Important to Avoid ICU Admission.

Chronic obstructive pulmonary disease (COPD) is one of the major causes of morbidity and mortality worldwide. Hospitalization due to acute exacerbations of COPD (AECOPD) is a relevant health problem both for its impact on disease outcomes and on health system resources. Severe AECOPD causing acute respiratory failure (ARF) often requires admission to an intensive care unit (ICU) with endotracheal intubation and invasive mechanical ventilation. AECOPD also acts as comorbidity in critically ill patients; this condition is associated with poorer prognoses. The prevalence reported in the literature on ICU admission rates ranges from 2 to 19% for AECOPD requiring hospitalization, with an in-hospital mortality rate of 20-40% and a re-hospitalization rate for a new severe event being 18% of the AECOPD cases admitted to ICUs. The prevalence of AECOPD in ICUs is not properly known due to an underestimation of COPD diagnoses and COPD misclassifications in administrative data. Non-invasive ventilation in acute and chronic respiratory failure may prevent AECOPD, reducing ICU admissions and disease mortality, especially when associated with a life-threating episode of hypercapnic ARF. In this review, we report on up to date evidence from the literature, showing how improving the knowledge and management of AECOPD is still a current research issue and clinical need.

486 A blue man standing

An 85-year-old was admitted in Internal Medic Ward for recurrent episodes of acute respiratory failure. His electrocardiogram showed a new onset of atrial flutter with spontaneous reversal to sinus rhythm (narrow QRS complex and normal atrioventricular conduction). The dyspnoea was worse with the patient sitting and was better when lying supine. Also, he report back pain associated to his major kyphoscoliosis. Results of chest radiography and blood test were normal. The arterial blood gas test revealed a hypocapnic hypoxemic respiratory failure, therefore the patient oxygen supplementation with noninvasive ventilation (NIV) was started, but peripheral oxygen saturation was persistently below 88% despite the high flow oxygenation. The patient underwent nasopharyngeal (NP) swab (ruling out SARS-CoV-2), high-resolution computed tomography (which was not pathologic), and computed tomography angiography (excluding pulmonary embolism). A transthoracic echocardiography was performed showing concentric hypertrophy, left atriomegaly and severe aortic ectasia of the root and of his ascending part, normal pulmonary pression and an aneurism of the interatrial septum with the presence of right-to-left shunt after using agitate saline contrast with Valsalva maneuver. Transesophageal echocardiography (TTE) confirmed the presence of severe structural interatrial septal abnormality with wide left convex aneurysm and an atrial septum defect (ASD) as ostium secundum, causing severe bidirectional shunt. Therefore, the patient underwent a successful transcatheter closure of secundum ASD with device Amplatzer Septal Occluder 018, while monitored with cardiac catheterization and transesophageal echocardiography. After few days, the patient was discharged at home without oxygen therapy. At the 3-month follow-up visit he reported no respiratory symptoms. Platypnea-orthodeoxia syndrome (POS) is an uncommon disorder characterized by dyspnoea and hypoxemia that occurs when the patient is sitting or standing and disappear quickly when recumbent. POS is characterized by both an anatomic and a functional component. The anatomic element is typically an interatrial communication such as ASD or Patent Foramen Ovale, which cause blood shunt left-to-right due to a higher pressure in left atrium and a greater compliance of the right ventricle, in the presence of normal pulmonary artery pressure. The syndrome occurs when a functional element, such as an increased atrial pressure or a decreased compliance of the right ventricle, reverses the flow. The shunts are often small and could remain asymptomatic: the high left atrial pressure let the defect close until there is a reverse pression which stretched atrial septum in particular in the upright position. In fact, when the patient is standing, the inferior vena cava comes in line with the defect increasing the right-to-left flow, sparking the respiratory symptoms. This could be linked to a cardiac or an extracardiac condition; in this case the presence of kyphoscoliosis and severe aortic ectasia of the root and of his ascending part, played an important role. The diagnosis is mainly made by echocardiography and cardiac catheterization to verify the mismatch in oxygen saturation between the pulmonary vein and the aorta. The diagnosis of POS is challenging, often considered only after other possible diagnosis is excluded. When POS is triggered by an interatrial defect in the absence of severe pulmonary hypertension, the usual treatment is a percutaneous or surgical closure.

57 Undifferentiated heart sarcoma in young adult: from differential diagnosis to management

Abstract A 34-year-old patient arrived in Emergency Department (ED) with a history of haemoptysis, fever, and night sweats. Echocardiographic examination revealed a large isoechoic thickening that totally encompassed posterior mitral leaflet and which extended contiguously, both inferiorly with subvalvular apparatus with chordal fusion, and superiorly up to left atrial wall. This alteration caused a moderate mitral stenosis with an estimated average gradient of 10–15 mmHg (with possible overestimation due to temporary state of hyperdynamic circulation secondary to anaemization). There also was an anteriorly directed, eccentric jet of mitral regurgitation (2 +/4 + grade).Differential diagnosis of the aforementioned mitral formation included infectious etiology (endocarditic vegetation), pure phlogistic (inflammatory/rheumatic valvulitis), aseptic vegetation, and thrombosis. Transesophageal echocardiographic evaluation showed the extension of the mass into posterior leaflet, the latter completely englobed from commissure to commissure, and cranially adhered to posterior wall of left atrium with estimated dimensions of 1.9 × 12 mm; inferiorly, contiguity with diffusely thickened subvalvular apparatus and chordal fusion, was appreciated. Resulting stenosis was about 13–14 mmHg. Planimetric mitral valve area was estimated to be about 1 cm with associated mild-moderate regurgitation. Global systolic function was preserved with normal segmental kinesis and without significant anomalies affecting other valves. On cardiac magnetic resonance (CMR) with contrast medium, known sleeve thickening of left atrium (maximum thickness 12 mm in lateral area and 7.5 mm at the level of atrial septum) was extended caudocranially for 2.5 cm in lateral area and for 3.2 cm in the side of the atrial septum and with subocclusion of left inferior pulmonary vein. An esophagogastroduodenoscopy (EGDS) was performed with biopsy examination and subsequent histological typing. It concluded for ‘undifferentiated pleomorphic sarcoma’ according to the WHO classification of thoracic tumours. In the stomach there was a diffuse infiltration of lamina propria by atypical, pleomorphic, and large cellular elements. Following cancer evaluation, first-line chemotherapy with ifosfamide and doxorubicin was undertaken. Two days later, due to finding of hyperpyrexia, with a feverish peak of up to 39°, infusion of chemotherapy was interrupted and empiric antibiotic therapy (piperacillin tazobactam) was started. Blood and urine cultures were carried out with search for antigens of legionella and pneumococcus, (MRSA), fungi, and respiratory viruses but all of them were negative for active infection. The following day, an episode of acute respiratory failure occurred, so we performed an urgent chest CT with finding of pneumonia with bilateral pleural effusion and linezolid was started. Because of sudden worsening of clinical conditions, patient was transferred to ICCU (Intensive Cardiac Care Unit) with gradual resolution of desaturation. Cardiac ultrasound imaging, from the very first performed in ED, has been fundamental in documenting the presence of a mass in mitral valve. The timeliness in identifying first and then characterizing it certainly had a positive impact on cancer management, especially in such an aggressive neoplasm in a young patient. Furthermore diagnostic process, corroborated by instrumental data provided by ecocardiography, CT, MRI, PET, and scintigraphy, allowed a better staging of the disease and highlighted other organ involvement in order to manage optimal therapeutic approach.

Pulmonary Complications in Children Following Hematopoietic Cell Transplantation: A Case Report and Review of the Diagnostic Approach.

Pulmonary complications are common in children following hematopoietic cell transplantation (HCT) and contribute to their morbidity and mortality. Early diagnosis is essential for management and prevention of progression of lung injury and damage. In many cases, diagnosis can be challenging and may require diagnostic imaging and more invasive testing such as bronchoscopy and lung biopsy. We report the case of a 12-year-old girl who developed recurrent episodes of acute respiratory failure requiring intensive care unit admission in the post-HCT phase and describe the diagnostic and multidisciplinary approach for her management. In addition, we review the diagnostic approach of pulmonary complications post-HCT and highlight the utility and risks of bronchoscopy and lung biopsy in these children.

English

BACKGROUND Community-Acquired Pneumonia (CAP) is defined as “an acute infection of the pulmonary parenchyma. The most important complication of CAP is Acute Respiratory Failure (ARF) and some of them may require Invasive Mechanical Ventilation (IMV) to manage hypoxia and hypoventilation along with appropriate antibiotic therapy. A number of studies, however, indicate that IMV is associated with high rates of serious complications and mortality in patients with ARF. For this reason Non-Invasive Ventilation (NIV) has been used for ARF of diverse aetiologies.The most important rationale for using NIV in early stages of respiratory failure is to decrease the workload on respiratory muscles and improve ventilation by applying positive airway pressure. This may help to overcome an episode of severe ARF without the need for MV. In this study we evaluated the efficacy of NIV in patients with ARF and compare the outcome of using NIV in CAP with ARF patients with and without comorbidities. METHODS This prospective observational study was done on 150 CAP patients in acute respiratory failure who received NIV. It was conducted in the Department of Respiratory Medicine in Gandhi Hospital, Secunderabad, for a period of one year and six months. A comparative analysis of the outcome of using NIV in CAP with ARF patients with and without co-morbidities was carried out. RESULTS In the current study 150 CAP patients with ARF who needed NIV, were treated initially with NIV, antibiotic therapy and other supportive measures as per the American Thoracic Society (ATS) guidelines 32. 95 (63.3 %) of 150 patients were continuously treated with NIV. Apart from these, 55 (36.7 %) patients required MV. In patients with continued NIV, 93 (98 %) recovered, remaining 2 died with sudden cardiac arrest. In patients who were gone for MV, 12 (22 %) survived. CONCLUSIONS Early intervention by NIV in CAP patients suffering from acute respiratory failure secondary to community acquired pneumonia was found to be successful in avoiding mechanical ventilation and its attendant morbidity and mortality31. Early intervention with NIV, identifying risk factors for NIV failure, addressing associated co-morbid conditions will go in a long way in effectively managing these patients by significantly minimizing the ICU and hospital stay. Patients with co-morbidities have more chances of NIV failures. Patients with co morbidities on NIV stayed significantly more number of days in the hospital than patients without co-morbidities. The current study suggests that co morbid patients require more monitoring as compared to patients without co morbidities on NIV. KEY WORDS Community-Acquired Pneumonia (CAP), Non-Invasive Ventilation (NIV), Mechanical Ventilation (MV), Acute Respiratory Failure (ARF), Arterial Blood Gas Analysis (ABG), Intensive Care Unit (ICU), Intubation

P0437 / #2122: OUTCOMES OF NON-INVASIVE BI-LEVEL POSITIVE AIRWAY PRESSURE VENTILATION AS INITIAL MANAGEMENT OF ACUTE RESPIRATORY FAILURE IN PEDIATRIC CRITICAL CARE

Aims & Objectives: To assess the outcomes of non-invasive bi-level positive airway pressure (BLPAP) ventilation as first-line therapy in children with acute respiratory failure (ARF). Methods: Design: A retrospective observational study. Setting: Pediatric Intensive Care Unit (PICU) of a university hospital. Patients: Eighty-seven patients subjected to non-invasive ventilation (NIV) as the initial management in a total of 92 ARF episodes were included, from July-2017 to June-2020. Each episode was treated as an independent event. Main Outcome Measures: We evaluated changes of heart rate, respiratory rate and SpO2/FiO2 ratio (S/F) at 3, 6, 12, and 24 hours after NIV onset, and compared patients using BLAP vs CPAP as first-line therapy. Results: BLPAP was started in 63 episodes (68.5%). Ten of 29 episodes (34.5%) that started CPAP were escalated to BLPAP. Baseline characteristics, initial physiologic parameters and severity score did not differ between groups. The S/F ratio increase at 6 hours was significantly greater in the BLPAP group (mean 48; CI95% 29-66) compared to the CPAP group (mean 21; CI95% -17-59; p=0,011). The trend continued over time, S/F ratio increase was greater in the BLPAP group at 24 hours. No difference was found in the intubation rate (BLPAP 4.4% vs CPAP 3.2%). The mean length of stay in the PICU was 1 day longer in the CPAP group, although it was not a significant difference. Conclusions: In children with ARF, the initial use of BLPAP rapidly improves the S/F ratio compared to CPAP. BLPAP as first-line therapy could be the best option for the management of patients with ARF.

Obstetric implications of acute respiratory failure during the peripartum period

Pregnant women are at risk for episodes of acute respiratory failure due to anatomical changes brought on by the gestational period, as well as the characteristic immunohumoral status. Due to these changes, women are more prone to develop severe forms of respiratory pathologies and frequent complications. For this reason, pregnant women should be carefully monitored, thus avoiding dramatic situations that require mechanical ventilation, cardiorespiratory support or resuscitation maneuvers. The symptomatology and values of paraclinical parameters are often altered in pregnancy and thus they are not very helpful in diagnosis. However, early diagnosis of underlying disease is critical in these cases and the treatment should be started promptly. In addition to the idea of a careful follow-up, the presence of the fetus warrants extreme care, using some of the diagnostic and treatment techniques for maternal acute respiratory failure, as it may rapidly suffer irreversible effects due to hypoxia.

Updated Evaluation of the Safety, Efficacy and Tolerability of Pirfenidone in the Treatment of Idiopathic Pulmonary Fibrosis.

Idiopathic Pulmonary Fibrosis (IPF) is a chronic fibrotic disease characterized by a progressive decline in lung function with a median survival of 3–5 years after diagnosis. The course of disease is highly variable and unpredictable, often punctuated by episodes of acute respiratory failure, known as acute exacerbations. The incidence of IPF is on the rise due to the aging population, as age is the most important risk factor for this disease. Pirfenidone and nintedanib are the two anti-fibrotic drugs approved for IPF which have shown reduction in lung function decline. This review will discuss the efficacy, safety and tolerability profile of pirfenidone from clinical trials and the real-world clinical experience. Pirfenidone reduces the decline in lung function and improves progression-free survival in patients with IPF. It is generally well tolerated with the most common side effects being gastrointestinal and phototoxicity.

The application of non-invasive and invasive mechanical ventilation in the first episode of acute respiratory failure.

Acute respiratory failure (RF) is a life-threatening syndrome. This study investigated the application of two major clinical strategies, non-invasive mechanical ventilation (NIV) and invasive mechanical ventilation (IMV), in the first episode of acute RF. Data from the longitudinal health insurance database, which included 1,000,000 insured citizens, were used. The NIV group consisted of 1201 patients and the IMV group consisted of 16,072 patients. Chi-square test and t test were applied to determine the differences in categorical and continuous variables. Further analysis was performed by using univariate and multivariable logistic regression and Poisson regression. There was a significant increase of 733% in the number of NIV users from 2000 to 2012. NIV use was frequently observed in old-age persons (aOR 3.99, 95% CI 3.06–5.21 for those aged ≥ 80 years), women (aOR 1.33, 95% CI 1.18–1.50), patients admitted to a high-level hospital (aOR 1.95, 95% CI 1.63−2.34 for those admitted to a medical center), and patients with a higher Charlson comorbidity index (CCI, aOR 1.38−1.66 for those CCI ≥ 2). In addition, patients with chronic pulmonary disease, cancer, and congestive heart failure were predominant in NIV users and were significantly associated with NIV use. Overall, the use of NIV has markedly increased over the past few years. Persons of advanced age, women, patients admitted to a high-level hospital, and patients with multiple comorbidities were associated with more frequent NIV use. Chronic pulmonary disease, cancer, and congestive heart failure were most important comorbidities for NIV use.Electronic supplementary materialThe online version of this article (10.1007/s11739-020-02315-1) contains supplementary material, which is available to authorized users.

Atrial arrhythmias in chronic lung disease-associated pulmonary hypertension.

Atrial arrhythmias are common during episodes of acute respiratory failure in patients with chronic lung disease-associated pulmonary hypertension. Expert opinion suggests that management of atrial arrhythmias in patients with pulmonary hypertension should aim to restore sinus rhythm. This is clinically challenging in pulmonary hypertension patients with coexisting chronic lung disease, as there is controversy on the use of rhythm control agents; generally, in regard to either their pulmonary toxicity profile or the lack of evidence supporting their use. Rate control methods are largely focused on the use of beta blockers and calcium channel blockers. Concerns regarding their use involve their negative inotropic properties in cor pulmonale, the risk of bronchospasm associated with beta blockers, and the potential for ventilation/perfusion mismatching associated with calcium channel blockers. While digoxin has been associated with promising outcomes during acute right ventricular failure, there is limited evidence to suggest its routine use. Electrical cardioversion is associated with a high failure rate and it frequently requires multiple attempts. Radiofrequency catheter ablation is a more definitive approach, but concerns surrounding mechanical ventilation and sedation limit its applicability in decompensated pulmonary hypertension. Individual approaches are needed to address atrial arrhythmia management during acute episodes of respiratory failure.

Prevalence and development of chronic critical illness in acute patients admitted to a respiratory intensive care setting

IntroductionChronic Critical Illness (chronic CI) is a condition associated to patients surviving an episode of acute respiratory failure (ARF). The prevalence and the factors associated with the development of chronic CI in the population admitted to a Respiratory Intensive Care Unit (RICU) have not yet been clarified. MethodsAn observational prospective cohort study was undertaken at the RICU of the University Hospital of Modena (Italy). Patients mechanically ventilated with ARF in RICU were enrolled. Demographics, severity scores (APACHEII, SOFA, SAPSII), and clinical condition (septic shock, pneumonia, ARDS) were recorded on admission. Respiratory mechanics and inflammatory-metabolic blood parameters were measured both on admission and over the first week of stay. All variables were tested as predictors of chronic CI through univariate and multivariate analysis. ResultsChronic CI occurred in 33 out of 100 patients observed. Higher APACHEII, the presence of septic shock, diaphragmatic dysfunction (DD) at sonography, multidrug-resistant (MDR) bacterial infection, the occurrence of a second infection during stay, and a C-reactive protein (CRP) serum level inceasing 7 days over admission were associated with chronic CI. Septic shock was the strongest predictor of chronic CI (AUC = 0.92 p < 0.0001). ConclusionsChronic CI is frequent in patients admitted to RICU and mechanically ventilated due to ARF. Infection-related factors seem to play a major role as predictors of this syndrome.

Fully closed-loop insulin delivery in inpatients receiving nutritional support: a two-centre, open-label, randomised controlled trial

SummaryBackgroundGlucose management is challenging in patients who require nutritional support in hospital. We aimed to assess whether fully closed-loop insulin delivery would improve glycaemic control compared with conventional subcutaneous insulin therapy in inpatients receiving enteral or parenteral nutrition or both.MethodsWe did a two-centre (UK and Switzerland), open-label, randomised controlled trial in adult inpatients receiving enteral or parenteral nutrition (or both) who required subcutaneous insulin therapy. Patients recruited from non-critical care surgical and medical wards were randomly assigned (1:1) using a computer-generated minimisation schedule (stratified by type of nutritional support [parenteral nutrition on or off] and pre-study total daily insulin dose [<50 or ≥50 units]) to receive fully closed-loop insulin delivery with faster-acting insulin aspart (closed-loop group) or conventional subcutaneous insulin therapy (control group) given in accordance with local clinical practice. Continuous glucose monitoring in the control group was masked to patients, ward staff, and investigators. Patients were followed up for a maximum of 15 days or until hospital discharge. The primary endpoint was the proportion of time that sensor glucose concentration was in target range (5·6–10·0 mmol/L), assessed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT01774565.FindingsBetween Feb 8, 2018, and Sept 21, 2018, 90 patients were assessed for eligibility, of whom 43 were enrolled and randomly assigned to the closed-loop group (n=21) or the control group (n=22). The proportion of time that sensor glucose was in the target range was 68·4% [SD 15·5] in the closed-loop group and 36·4% [26·6] in the control group (difference 32·0 percentage points [95% CI 18·5–45·5; p<0·0001]). One serious adverse event occurred in each group (one cardiac arrest in the control group and one episode of acute respiratory failure in the closed-loop group), both of which were unrelated to study interventions. There were no adverse events related to study interventions in either group. No episodes of severe hypoglycaemia or hyperglycaemia with ketonaemia occurred in either study group.InterpretationClosed-loop insulin delivery is an effective treatment option to improve glycaemic control in patients receiving nutritional support in hospital.FundingDiabetes UK, Swiss National Science Foundation, National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome Trust, and European Foundation for the Study of Diabetes.

Combined noninvasive ventilation and mechanical insufflator-exsufflator for acute respiratory failure in patients with neuromuscular disease: effectiveness and outcome predictors.

Background:To determine the effectiveness of combined noninvasive ventilation (NIV) and mechanical insufflator-exsufflator (MI-E) for acute respiratory failure (ARF) in patients with neuromuscular disease (NMD), and outcome predictors.Methods:A prospectively observational study of patients with ARF was conducted in a pediatric intensive care unit (PICU). All received combined NIV/MI-E during PICU stays between 2007 and 2017. Pertinent clinical variables of heart rate (HR), respiratory rate (RR), pH, PaCO2, and PaO2/FiO2 ratio were collected at baseline and at 2 h, 4-8 h, and 12-24 h after initiating use of NIV/MI-E. Treatment success was defined as avoiding intubation.Results:A total of 62 ARF episodes in 56 patients with NMD (median age, 13 years) were enrolled. The most frequent underlying NMD was spinal muscular atrophy (32/62, 52%). ARF was primarily due to pneumonia (65%). The treatment success rate was 86%. PICU stay and hospitalization were shorter in the success group (9.4 ± 6.1 vs. 21.9 ± 13.9 days and 16.3 ± 7.8 vs. 33.6 ± 17.9 days, respectively; both p < 0.05). HR, RR, pH, and PaCO2 showed a progressive improvement, particularly after 4 h following successful NIV/MI-E treatment. RR decrease at 4 h, and pH increase and PaCO2 decrease at 4-8 h might predict success of NIV/MI-E treatment. The multivariate analysis identified PaCO2 at 4-8 h of 58.0 mmHg as an outcome predictor of NIV/MI-E treatment.Conclusions:Applying combined NIV/MI-E in the acute care setting is an efficient means of averting intubation in NMD patients with ARF. Clinical features within 8 h of the institution may predict treatment outcome. The reviews of this paper are available via the supplemental material section.

Respiratory Failure, Noninvasive Ventilation, and Symptom Burden: An Observational Study

BackgroundNoninvasive ventilation (NIV) is commonly used to manage acute respiratory failure due to decompensated cardiorespiratory disease. We describe symptom burden in this population. MeasuresFifty consecutive, consenting, English-speaking, cognitively intact patients, admitted to wards other than the intensive care unit in a tertiary teaching hospital and treated with NIV for hypercapnic respiratory failure, were recruited. The 14-item Condensed Memorial Symptom Assessment Scale was used to assess physical and psychological symptoms within 36 hours of commencing NIV. Breathlessness (using Borg score), pain location and intensity using a numerical rating scale, and four symptoms potentially prevalent in patients undergoing NIV (cough, sputum, gastric bloating, and dry eyes) were also assessed. OutcomesPatients reported a median of 10 symptoms (IQR 9–13). A median of five symptoms (IQR 3–7) were rated as severe. Breathlessness was the most prevalent and most distressing symptom, with participants reporting a mean maximum Borg score of 7.55 over the 24 hours before admission. Dry mouth, lack of energy, cough, sputum, difficulty sleeping, and psychological symptoms were prevalent. Pain, when reported, was of moderate intensity and contributed to distress. Conclusions/Lessons learnedThis study describes the patient-reported symptoms occurring during an episode of acute respiratory failure. Understanding the symptom profile of patients in this setting may allow clinicians to target symptom relief while simultaneously managing respiratory failure, enhancing care.

How should we monitor patients with acute respiratory failure treated with noninvasive ventilation?

Noninvasive ventilation (NIV) is currently one of the most commonly used support methods in hypoxaemic and hypercapnic acute respiratory failure (ARF). With advancing technology and increasing experience, not only are indications for NIV getting broader, but more severe patients are treated with NIV. Depending on disease type and clinical status, NIV can be applied both in the general ward and in high-dependency/intensive care unit settings with different environmental opportunities. However, it is important to remember that patients with ARF are always very fragile with possible high mortality risk. The delay in recognition of unresponsiveness to NIV, progression of respiratory failure or new-onset complications may result in devastating and fatal outcomes. Therefore, it is crucial to understand that timely action taken according to monitoring variables is one of the key elements for NIV success. The purpose of this review is to outline basic and advanced monitoring techniques for NIV during an ARF episode.

High-flow nasal oxygen therapy versus noninvasive ventilation in chronic interstitial lung disease patients with acute respiratory failure

Background High-flow nasal oxygen therapy (HFNOT) may be a suitable alternative for noninvasive ventilation (NIV) in chronic interstitial lung disease (ILD) during an episode of acute respiratory failure (ARF). Patients and methods Consecutive ILD patients who had ARF and a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) of 300 mmHg or less were randomly assigned to NIV or HFNOT. The primary outcome was the need for intubation. Secondary outcomes were in-hospital mortality and ventilator-free days. Results A total of 70 patients with ILD were included. The rate of intubation was 20.6% (seven of 34 patients) in the HFNOT group and 22.2% (eight of 36) in the NIV group (P=0.87). The ventilator-free days at day 28 was higher in the HFNOT group (20±5 vs. 16±7 days in the NIV group; P=0.008). The rate of in-hospital mortality was 26.5% in the HFNOT group versus 30.6% in the NIV group (P=0.71). Conclusion HFNOT improved patient comfort and the ventilator-free days in patients with ILD and ARF, despite no difference in the rate of intubation when compared with NIV.

Decision-making for tracheostomy in amyotrophic lateral sclerosis (ALS): a retrospective study

Background: ALS patients should discuss the issue of tracheostomy before the onset of terminal respiratory failure. While the process of shared decision-making is desirable, there are few data on the practical application of this real-life situation.Aim of the study: To determine how a decision-making process is actually carried out, we analysed the episodes of acute respiratory failure preceding tracheostomy.Methods: We studied the charts of a group of ALS patients after tracheostomy. An interview focusing on the existence of anticipated directives was carried out. Tracheostomies were classified as planned or unplanned according to the presence of a decision plan.Results: A total of 209 ALS patients were cared for during a three-year period. Of these patients, 34 (16%) were tracheotomised. In 38% of cases, tracheostomy was planned, 41% were unplanned, and 21% remained undiagnosed.Conclusions: A minority of ALS patients make a voluntary decision for tracheostomy before the procedure is conducted. The advising process of care still presents limits that have been thus far poorly addressed. In the future, we will need to develop guidelines for the timing and content of the shared-decision making process.