Hours Of Non-invasive Ventilation Research Articles

Short-term Non-invasive Ventilation for Children with Palliative Care Needs

Objectives: Non-invasive ventilation (NIV), namely continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP), delivers mechanical ventilation without endotracheal intubation. Short-term NIV (planned for <21 days during initiation) can be used for the management of acute respiratory distress (ARD) among paediatric palliative patients with “Do Not Resuscitate or Intubate” (DNI) as the ceiling of care. This study aimed to describe the usage of short-term NIV among paediatric palliative patients in a woman and child hospital with a paediatric palliative subspecialty. Materials and Methods: A retrospective and observational study was conducted on all paediatric palliative patients who received short-term NIV in Tunku Azizah Hospital Kuala Lumpur, Malaysia, from March 2020 to May 2022. Results: During the study period, short-term NIV was offered on 23 occasions for 20 different children. Indications for short-term NIV include 16 (69.6%) occasions of potentially reversible ARD (NIV Category 1) and 7 (30.4%) occasions of comfort care at the end of life (NIV Category 2). The main cause of ARD was pneumonia (90.3%) due to either aspiration or infection. The modality of NIV used was BiPAP only (14 occasions, 60.9%), CPAP only (three occasions, 13%) and both BiPAP and CPAP (six occasions, 26.1%). The median duration of NIV usage was four days (minimum one day and maximum 15 days). NIV was initiated as an escalation from nasal prong, Ventimask or high-flow mask oxygen on 22 occasions and as weaning down post-extubation on one occasion. For the 22 occasions of escalating therapy, there was significant improvement at six hours compared to pre-NIV in the median heart rate (136 to 121, P=0.002), respiratory rate (40 to 31, P=0.002) and oxygen saturation (96% to 99%, P=0.025). All 17 documented parental impressions of the child’s condition post six hours of NIV were that the child had improved. Adverse events during short-term NIV include five episodes (21.7%) of stomach distension, four episodes (17.4%) of skin sores on the face and one episode (4.3%) of excessive drooling. Three patients passed away while on NIV in the hospital. For the other 20 (87%) occasions, patients were able to wean off NIV. Post-weaning off NIV, three patients passed away during the same admission. On 17 occasions, patients were discharged home after weaning off NIV. Conclusion: Usage of short-term NIV in paediatric palliative care, where children have an advanced directive in place indicating DNI, as seen in our study, can be a valuable modality of management for distressing symptoms, in addition to the pharmacological management of breathlessness. This is shown through our study to be of benefit in potentially reversible ARD as well as comfort care at the end of life. Further rigorous studies will need to be conducted for a clearer understanding of short-term NIV that would enable the formulation of guidelines to improve the quality of life and death in children.

Iron Deficiency in Anemic Children Surviving Critical Illness: Post Hoc Analysis of a Single-Center Prospective Cohort in Canada, 2019-2022.

Many children leave the PICU with anemia. The mechanisms of post-PICU anemia are poorly investigated, and treatment of anemia, other than blood, is rarely started during PICU. We aimed to characterize the contributions of iron depletion (ID) and/or inflammation in the development of post-PICU anemia and to explore the utility of hepcidin (a novel iron marker) at detecting ID during inflammation. Post hoc analysis of a single-center prospective study (November 2019 to September 2022). PICU, quaternary center, Canada. Children admitted to PICU with greater than or equal to 48 hours of invasive or greater than or equal to 96 hours of noninvasive ventilation. We excluded patients with preexisting conditions causing anemia or those admitted after cardiac surgery. None. Hematological and iron profiles were performed at PICU discharge on 56 participants of which 37 (37/56) were diagnosed with anemia. Thirty-three children (33/56; 59%) were younger than 2 years. Median Pediatric Logistic Organ Dysfunction score was 11 (interquartile range, 6-16). Twenty-four of the 37 anemic patients had repeat bloodwork 2 months post-PICU. Of those, four (4/24; 16%) remained anemic. Hematologic profiles were categorized as: anemia of inflammation (AI), iron deficiency anemia (IDA), IDA with inflammation, and ID (low iron stores without anemia). Seven (7/47; 15%) had AI at discharge, and one had persistent AI post-PICU. Three patients (3/47; 6%) had IDA at discharge; of which one was lost to follow-up and the other two were no longer anemic but had ID post-PICU. Eleven additional patients developed ID post-PICU. In the exploratory analysis, we identified a diagnostic cutoff value for ID during inflammation from the receiver operating characteristic curve for hepcidin of 31.9 pg/mL. This cutoff would increase the detection of ID at discharge from 6% to 34%. The burden of ID in children post-PICU is high and better management strategies are required. Hepcidin may increase the diagnostic yield of ID in patients with inflammation.

P/F Ratio is a Better Predictor for Non-Invasive Ventilation Failure and Length of Stay in Patients with Community-Acquired Pneumonia

Introduction: Community-acquired pneumonia (CAP) can deteriorate into respiratory failure requiring immediate ventilatory intervention. This study compared the performance of the PaO2/FiO2 (P/F) ratio, the ratio of oxygen saturation (ROX) index, and the heart rate, acidosis, consciousness, oxygenation, and respiratory rate (HACOR) score in predicting non-invasive ventilation (NIV) failure and length of hospital stay in patients diagnosed with CAP. Methods: This study was conducted at Universitas Sebelas Maret Hospital, Surakarta, from March to September 2023. All patients diagnosed with CAP who were eligible for NIV were recruited. Each patient’s age, sex, comorbidities, vital signs, pneumonia severity index (PSI), blood urea, bilirubin, hematocrit, blood sodium, P/F ratio, ROX index, and HACOR score were measured within the first 24 hours of NIV. Subsequently, the correlations between these variables and NIV failure (intubation or mortality) and length of hospital stay were assessed. Results: The P/F ratio, ROX index, and HACOR score were not correlated with intubation or length of stay. The P/F ratio was correlated with mortality (p = 0.040), whereas the other scores were not. Higher body temperature was correlated with intubation (p = 0.032). PSI was correlated with both mortality (p = 0.033) and length of hospital stay (p = 0.009). Conclusion: The P/F ratio is superior to the ROX index and HACOR score in predicting mortality in patients with pneumonia-related respiratory failure treated with NIV. Since it is simple and accessible, measuring the P/F ratio within the first 24 hours of NIV is recommended to identify a patient’s risk of NIV failure and apply appropriate monitoring.

Evaluating diaphragmatic dysfunction and predicting non-invasive ventilation failure in acute exacerbation of chronic obstructive pulmonary disease in India.

Baseline diaphragmatic dysfunction (DD) at the initiation of non-invasive ventilation (NIV) correlates positively with subsequent intubation. We investigated the utility of DD detected 2 hours after NIV initiation in estimating NIV failure in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients. In a prospective-cohort design, we enrolled 60 consecutive patients with AECOPD initiated on NIV at intensive care unit admission, and NIV failure events were noted. The DD was assessed at baseline (T1 timepoint) and 2 hours after initiating NIV (T2 timepoint). We defined DD as ultrasound-assessed change in diaphragmatic thickness (ΔTDI) <20% (predefined criteria [PC]) or its cut-off that predicts NIV failure (calculated criteria [CC]) at both timepoints. A predictive-regression analysis was reported. In total, 32 patients developed NIV failure, nine within 2 hours of NIV and remaining in next 6 days. The ∆TDI cut-off that predicted NIV failure (DD-CC) at T1 was ≤19.04% (area under the curve [AUC], 0.73; sensitivity, 50%; specificity, 85.71%; accuracy; 66.67%), while that at T2 was ≤35.3% (AUC, 0.75; sensitivity, 95.65%; specificity, 57.14%; accuracy, 74.51%; hazard ratio, 19.55). The NIV failure rate was 35.1% in those with normal diaphragmatic function by PC (T2) versus 5.9% by CC (T2). The odds ratio for NIV failure with DD criteria ≤35.3 and <20 at T2 was 29.33 and 4.61, while that for ≤19.04 and <20 at T1 was 6, respectively. The DD criterion of ≤35.3 (T2) had a better diagnostic profile compared to baseline and PC in prediction of NIV failure.

Inspiratory Effort and Respiratory Mechanics in Patients with Acute Exacerbation of Idiopathic Pulmonary fibrosis: A Preliminary Matched Control Study

BackgroundPatients with acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) may experience severe acute respiratory failure, even requiring ventilatory assistance. Physiological data on lung mechanics during these events are lacking. MethodsPatients with AE-IPF admitted to Respiratory Intensive Care Unit to receive non-invasive ventilation (NIV) were retrospectively analyzed. Esophageal pressure swing (ΔPes) and respiratory mechanics before and after 2 hours of NIV were collected as primary outcome. The correlation between positive end-expiratory pressure (PEEP) levels and changes of in dynamic compliance (dynCRS) and PaO2/FiO2 ratio was assessed. Further, an exploratory comparison with a historical cohort of ARDS patients matched 1:1 by age, sequential organ failure assessment score, body mass index and PaO2/FiO2 level was performed. ResultsAt baseline, AE-IPF patients presented a high respiratory drive activation with ΔPes = 27 (21–34) cmH2O, respiratory rate (RR) = 34 (30–39) bpm and minute ventilation (VE) = 21 (20–26) L/min. Two hours after NIV application, ΔPes, RR and VE values showed a significant reduction (16 [14–24] cmH2O, p<0.0001, 27 [25–30] bpm, p=0.001, and 18 [17–20] L/min, p=0.003, respectively) while no significant change was found in dynamic transpulmonary pressure, expiratory tidal volume (Vte), dynCRS and dynamic mechanical power. PEEP levels negatively correlated with PaO2/FiO2 ratio and dynCRS (r=–0.67, p=0.03 and r=–0.27, p=0.4, respectively). When compared to AE-IPF, ARDS patients presented lower baseline ΔPes, RR, VE and dynamic mechanical power. Differently from AE-IPF, in ARDS both Vte and dynCRS increased significantly following NIV (p=0.01 and p=0.004 respectively) with PEEP levels directly associated with PaO2/FiO2 ratio and dynCRS (r=0.24, p=0.5 and r=0.65, p=0.04, respectively). ConclusionsIn this study, patients with AE-IPF showed a high inspiratory effort, whose intensity was reduced by NIV application without a significant improvement in respiratory mechanics. In an exploratory analysis, AE-IPF patients showed a different mechanical behavior under spontaneous unassisted and assisted breathing compared with ARDS patients of similar severity.

Why Reduced Inspiratory Pressure Could Determine Success of Non-Invasive Ventilation in Acute Hypoxic Respiratory Failure.

The magnitude of inspiratory effort relief within the first 2 hours of non-invasive ventilation for hypoxic respiratory failure was shown in a recent exploratory clinical study to be an early and accurate predictor of outcome at 24 hours. We simulated the application of non-invasive ventilation to three patients whose physiological and clinical characteristics match the data in that study. Reductions in inspiratory effort corresponding to reductions of esophageal pressure swing greater than 10 cmH2O more than halved the values of total lung stress, driving pressure, power and transpulmonary pressure swing. In the absence of significant reductions in inspiratory pressure, multiple indicators of lung injury increased after application of non-invasive ventilation. Clinical Relevance- We show using computer simulation that reduced inspiratory pressure after application of noninvasive ventilation translates directly into large reductions in multiple well-established indicators of lung injury, providing a potential physiological explanation for recent clinical findings.

Study of use of non-invasive ventilation in patients of acute exacerbation of chronic obstructive pulmonary disease

Background: Chronic obstructive pulmonary disease (COPD) is one of the common causes of morbidity as well as mortality particularly in developing countries including India. Acute exacerbations of COPD remain one of the common causes of intensive care unit admissions worldwide and respiratory failure remains one of the common life-threatening complications of such an acute exacerbation. In patients with respiratory failure invasive as well as non-invasive ventilation (NIV) may be used. Many studies have shown that NIV is effective in managing these patients with an advantage over invasive ventilation which may associated with complications associated with endotracheal intubation. Aims and Objectives: (i) To assess the effectiveness of NIV in patients coming with type 2 respiratory failure. (ii) To find out the duration of NIV required for clinical improvement with the end point being normalization of arterial pH. Materials and Methods: This was an observational and retrospective study conducted in the Department of Pulmonary Medicine Seth GS Medical College and KEM Hospital, Mumbai. The duration of study was 2 years. Forty-four patients of acute exacerbation of chronic obstructive airway disease were included in this study on the basis of a predefined inclusion and exclusion criteria. The computerized record of all the patients who had been given NIV for acute exacerbations of chronic airway disease was analyzed. The data analysis included comparing the arterial blood gas pH and the use of NIV. The improvement in the pH value was correlated with the use of NIV. Other comorbidities were included in the data and correlated with the pH values. Results: In our study, the most of the patients belonged to the age group of 51–60 years (31.8%) followed by 41–50 years (29.5%) and 61–70 years (20.5%). Improvement in pH was observed in 42 out of 43 studied cases. It was observed that the average number of hours of NIV per patient was 10–15 h (20.5%) followed by 16–20 h (15.9%) of the study population. Conclusion: NIV is safe and effective form of managing patients of acute exacerbation of chronic obstructive airway disease.

Is hypocapnia a risk factor for non-invasive ventilation failure in cardiogenic acute pulmonary edema?

The impact of hypocapnia in the prognosis of cardiogenic acute pulmonary edema (CAPE) has not been sufficiently studied. The aim of this study was to analyse whether hypocapnia is a risk factor for non-invasive ventilation (NIV) failure and hospital mortality, in CAPE patients CAPE. Retrospective observational study of all patients with CAPE treated with NIV. Patients were classified in three groups according to PaCO2 level (hypocapnic, eucapnic and hypercapnic). NIV failure was defined as the need for endotracheal intubation and/or death. 1138 patients were analysed, 390 (34.3%) of which had hypocapnia, 186 (16.3%) had normocapnia and 562 (49.4%) had hypercapnia. NIV failure was more frequent in hypocapnic (60 patients, 15.4%) than in eucapnic (16 pacientes, 8.6%) and hypercapnic group (562 pacientes, 10.7%), with statistical significance (p = 0.027), as well as hospital mortality, 73 (18.7%), 19(10.2%) and 83 (14.8%) respectively (p = 0.026). The predicted factors for NIV failure were the presence of do-not-intubate order, complications related to NIV, a lower left ventricular ejection fraction, higher SAPS II and SOFA score and a higher HACOR score at one hour of NIV initiation. Hypocapnia in patients with CAPE is associated with NIV failure and a greater in-hospital mortality.

The effect of non-invasive ventilation on intra-abdominal pressure.

Non-invasive ventilation is a well-established treatment modality in patients with respiratory failure of different aetiologies. A previous case report described how non-invasive ventilation caused gastric distension and intra-abdominal hypertension with subsequent cardio-respiratory arrest and clinical recovery following resuscitative efforts including gastric decompression with a nasogastric tube. The aim of this prospective multicentre observational study was to assess the effect of non-invasive ventilation on intra-abdominal pressure. Following informed consent, intra-abdominal pressure and PaCO2 were measured before and after the application of non-invasive ventilation for up to three days in critically ill patients requiring non-invasive ventilation. Thirty-five patients were enrolled; mean (±SD) age of 67.8 (±12.5) years, median (interquartile range) body mass index of 27.9 (24.5-30.0) kg m-2, Acute Physiology and Chronic Health Evaluation II score of 15.8 (±6.4). On admission and after 24 hours of non-invasive ventilation, intra-abdominal pressure was 11.0 (7.5-15.0) mm Hg and 11.0 (8.5-14.5) mm Hg (P = 0.82) and PaCO2 was 44.4 (±11.4) mm Hg and 51.3 (±14.3) mm Hg (P = 0.19), respectively. The application of non-invasive ventilation was not associated with an increase in intra-abdominal pressure over 72 hours in this small observational study. Thus, it appears that intra-abdominal pressure does not frequently increase when applying non-invasive ventilation in critically ill patients with respiratory failure.

Association between ARDS Etiology and Risk of Noninvasive Ventilation Failure.

Rationale: The etiology of acute respiratory distress syndrome (ARDS) may play an important role in the failure of noninvasive ventilation (NIV). Objectives: To explore the association between ARDS etiology and risk of NIV failure. Methods: A multicenter prospective observational study was performed in 17 intensive care units in China from September 2017 to December 2019. Patients with ARDS who used NIV as a first-line therapy were enrolled. The etiology of ARDS was recorded at study entry. Results: A total of 306 patients were enrolled. Of the patients, 146 were classified as having pulmonary ARDS (ARDSp) and 160 were classified as having extrapulmonary ARDS (ARDSexp). From initiation to 24 hours of NIV, the respiratory rate, heart rate, arterial oxygen pressure (PaO2)/fraction of inspired oxygen (FiO2), and arterial carbon dioxide pressure improved slower in patients with ARDSp than those with ARDSexp. Patients with ARDSp experienced more NIV failure (55% vs. 28%; P < 0.01) and higher 28-day mortality (47% vs. 14%; P < 0.01). The adjusted odds ratios of NIV failure and 28-day mortality were 5.47 (95% confidence interval [CI], 3.04-9.86) and 10.13 (95% CI, 5.01-20.46), respectively. In addition, we combined the presence of ARDSp, presence of septic shock, age, nonpulmonary sequential organ failure assessment score, respiratory rate at 1-2 hours of NIV, and PaO2/FiO2 at 1-2 h of NIV to develop a risk score of NIV failure. With the increase of the risk score, the rate of NIV failure increased. The area under the curve of the receiver operating characteristic was 0.84 (95% CI, 0.79-0.89) and 0.81 (0.69-0.92) in the training and validation cohorts, respectively. Using 5.5 as cutoff value to predict NIV failure, the sensitivity and specificity was good. Conclusions: Among patients with ARDS who used NIV as a first-line therapy, ARDSp was associated with slower improvement, more NIV failure, and higher 28-day mortality than ARDSexp. The risk score combined presence of ARDSp, presence of septic shock, age, nonpulmonary sequential organ failure assessment score, respiratory rate at 1-2 hours of NIV, and PaO2/FiO2 at 1-2 hours of NIV has high accuracy to predict NIV failure among ARDS population.

Dynamic prediction of late noninvasive ventilation failure in intensive care unit using a time adaptive machine model

Background: Noninvasive ventilation (NIV) failure is strongly associated with poor prognosis. Nowadays, plenty of mature studies have been proposed to predict early NIV failure (within 48 hours of NIV), however, the prediction for late NIV failure (after 48 hours of NIV) lacks sufficient research. Late NIV failure delays intubation resulting in the increasing mortality of the patients. Therefore, it is of great significance to expeditiously predict the late NIV failure. In order to dynamically predict late NIV failure, we proposed a Time Updated Light Gradient Boosting Machine (TULightGBM) model.Material and Methods: In this work, 5653 patients undergoing NIV over 48 hours were extracted from the database of Medical Information Mart for Intensive Care Ⅲ (MIMIC-Ⅲ) for model construction. The TULightGBM model consists of a series of sub-models which learn clinical information from updating data within 48 hours of NIV and integrates the outputs of the sub-models by the dynamic attention mechanism to predict late NIV failure. The performance of the proposed TULightGBM model was assessed by comparison with common models of logistic regression (LR), random forest (RF), LightGBM, eXtreme gradient boosting (XGBoost), artificial neural network (ANN), and long short-term memory (LSTM).Results: The TULightGBM model yielded prediction results at 8, 16, 24, 36, and 48 hours after the start of the NIV with dynamic AUC values of 0.8323, 0.8435, 0.8576, 0.8886, and 0.9123, respectively. Furthermore, the sensitivity, specificity, and accuracy of the TULightGBM model were 0.8207, 0.8164, and 0.8184, respectively. The proposed model achieved superior performance over other tested models.Conclusions: The TULightGBM model is able to dynamically predict the late NIV failure with high accuracy and offer potential decision support for clinical practice.

Predictors of Failure of Noninvasive Ventilation in Critically Ill Children.

Noninvasive ventilation (NIV) is a common modality employed to treat acute respiratory failure. Most data guiding its use is extrapolated from adult studies. We sought to identify clinical predictors associated with failure of NIV, defined as requiring intubation. This single-center retrospective observational study included children admitted to pediatric intensive care unit (PICU) between July 2014 and June 2016 treated with NIV, excluding postextubation. A total of 148 patients was included. Twenty-seven (18%) failed NIV. There was no difference between the two groups with regard to age, gender, comorbidities, or etiology of acute respiratory failure. Those that failed had higher admission pediatric risk of mortality ( p = 0.01) and pediatric logistic organ dysfunction ( p = 0.002) scores and higher fraction of inspired oxygen (FiO 2 ; p = 0.009) at NIV initiation. Failure was associated with lack of improvement in tachypnea. At 6 hours of NIV, the failure group had worsening tachypnea with a median increase in respiratory rate of 8%, while the success group had a median reduction of 18% ( p = 0.06). Multivariable Cox's proportional hazard models revealed FiO 2 at initiation and worsening respiratory rate at 1- and 6-hour significant risks for failure of NIV. Failure was associated with a significantly longer PICU length of stay (success [2.8 days interquartile range (IQR): 1.7, 5.5] vs. failure [10.6 days IQR: 5.6, 13.2], p < 0.001). NIV can be successfully employed to treat acute respiratory failure in pediatric patients. There should be heightened concern for NIV failure in hypoxemic patients whose tachypnea is unresponsive to NIV. A trend toward improvement should be closely monitored.

Risk of COVID-19 Infection in Healthcare Workers Exposed During Use of Non-invasive Ventilation in a Tertiary Care Hospital in OmanRisk of COVID-19 Infection in Healthcare Workers Exposed During Use of Non-invasive Ventilation in a Tertiary Care Hospital in Oman

ObjectivesHealthcare workers (HCWs), especially those working on the front line, are considered to be at high risk of nosocomial acquisition of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19). Little is known about the effectiveness of the recommended protective methods as few reports have described spread of the disease in hospital settings among this high-risk population. We describe the hospital-based transmission of SARS-CoV-2 related to non-invasive ventilation (NIV) in one of the main tertiary care hospitals in Oman.MethodsAll exposed patients and HCWs from Royal Hospital were screened, quarantined, and underwent telephone interviews to stratify their risk factors, clinical symptoms, and exposure risk assessment.ResultsA total of 46 HCWs and patients tested positive for SARS-CoV-2 after exposure to an index case who received 48 hours of NIV before diagnosing COVID-19 infection. Over half of the exposed (56.5%; n = 26) were nurses, 26.1% (n = 12) were patients, and 15.2% (n = 7) were doctors. None of the HCWs required hospitalization. Sore throat, fever, and myalgia were the most common symptoms.ConclusionsNIV poses a significant risk for SARS-CoV-2 transmission within hospital settings if appropriate infection control measures are not taken.

Noninvasive Ventilation in a Pediatric Trauma Center: A Cohort Study.

To determine whether non-invasive ventilation (NIV) can avoid the need for tracheal intubation and/or reduce the duration of invasive ventilation (IMV) in previously intubated patients admitted to the pediatric intensive care unit (PICU) and developing acute hypoxemic respiratory failure (AHRF) after major traumatic injury. A single center observational cohort study. Pediatric ICU in a University Hospital (tertiary referral Pediatric Trauma Centre). During the 48-month study period, 276 patients (median age 6.4 years) with trauma were admitted to PICU; among 86 of them, who suffered from AHRF and received ventilation (IMV and/or NIV) for more than 12 hrs, 32 patients (median age 8.5 years) were treated with NIV. Inclusion criteria: at least 12 hours of NIV; exclusion criteria: patients with facial trauma or congenital malformations; patients receiving IMV <12 hours or perioperative ventilation. Among NIV patients, 27 (84,3%) were previously on IMV, while 5 (15,6%) could be managed exclusively with NIV. In patients with post-extubation respiratory distress, NIV was successful in 88.4% of cases. Before starting NIV, P/F ratio was 242.7 ± 71. After 8 hours of NIV treatment, a significant oxygenation improvement (PaO2/FiO2 = 354.3 ± 81; p = 0.0002) was found, with no significant changes in carbon dioxide levels. A trend toward increasing ventilation-free time has been evidenced; NIV resulted feasible and generally well tolerated. AHRF in trauma patients is multifactorial and may be due to many reasons, such as lung contusion, aspiration of blood or gastric contents. Systemic inflammatory response and transfusions may also contribute to hypoxia. Our pilot study strongly suggests that NIV can be applied in post-traumatic AHRF: it may successfully reduce the time of both invasive ventilation and deep sedation. Further data from controlled studies are needed to assess the advantage of NIV in pediatric trauma.

Management of critically ill patients with COVID-19: suggestions and instructions from the coordination of intensive care units of Lombardy.

With 63,098 confirmed cases on 17 April 2020 and 11,384 deaths, Lombardy has been the most affected region in Italy by coronavirus disease 2019 (COVID-19). To cope with this emergency, the COVID-19 Lombardy intensive care units (ICU) network was created. The network identified the need of defining a list of clinical recommendations to standardize treatment of patients with COVID-19 admitted to Intensive Care Unit (ICU). Three core topics were identified: 1) rational use of intensive care resources; 2) ventilation strategies; 3) non-ventilatory interventions. Identification of patients who may benefit from ICU treatment is challenging. Clinicians should consider baseline performance and frailty status and they should adopt disease-specific staging tools. Continuous positive airway pressure, mainly delivered through a helmet as elective method, should be considered as initial treatment for all patients with respiratory failure associated with COVID-19. In case of persisting dyspnea and/or desaturation despite 4-6 hours of noninvasive ventilation, endotracheal intubation and invasive mechanical ventilation should be considered. In the early phase, muscle relaxant use and volume-controlled ventilation is recommended. Prone position should be performed in patients with PaO<inf>2</inf>/FiO<inf>2</inf>≤100 mmHg. For patients admitted to ICU with COVID-19 interstitial pneumonia, we do not recommend empiric antibiotic therapy for community-acquired pneumonia. Consultation of an infectious disease specialist is suggested before start of any antiviral therapy. In conclusion, the COVID-19 Lombardy ICU Network identified a list of best practice statements supported by the available evidence and clinical experience or identified as panel members expert opinions for the management of critically ill patients with COVID-19.

The use of non-invasive ventilation to treat acute respiratory failure in long term care setting: clinical experience in elderly patient

Background. Nowadays older patients with acute respiratory failure (ARF) leading to a severe respiratory acidosis are frequently ventilated using a non-invasive approach in intensive care unit (ICU). Current guidelines suggest that patients with more severe acidosis should be managed in a higher dependency area. However, the use of non-invasive ventilation (NIV) is effective and safe in treating ARF in general wards in elderly. Case report. a 82 years old male patient was admitted to a long term care facility due to a severe chronic obstructive pulmonary disease (COPD). Three days after the admission, he suffered of severe acute exacerbation of COPD leading to hypercapnic coma. NIV in Bi-PAP mode and standard medical therapy was started, taking into consideration the do-not-intubate order of the patient. His state of consciousness improved after 48 hours of NIV with decreasing of PaCO2 values and the patient was progressively weaned from the ventilator. Conclusions. NIV should be considered a successful approach even in unusual setting of long term facility. The choice of use NIV should be taken by multidisciplinary medical staff in a setting where nurses and medical team are trained in NIV protocol, in order to reduce ICU admission, intubation rates and mortality.

Respiratory Needs in Patients with Type 1 Spinal Muscular Atrophy Treated with Nusinersen

To evaluate the effects of nusinersen on respiratory function of patients with type 1 spinal muscular atrophy. Observational, longitudinal cohort study. We collected respiratory data from 118 children with type 1 spinal muscular atrophy and differing pulmonary requirements and conducted a semistructured qualitative interview among a subsample of caregivers at baseline, 6months, and 10months after the first nusinersen treatment. Patients were stratified according to ventilation modalities and age at study entry. Most patients in our cohort remained stable (84/109=77%). More than 80% of the children treated before age 2years survived, in contrast to the lower survival reported in natural history studies, and did so without tracheostomy or noninvasive ventilation (NIV) ≥16hours. In those less than 2years old, only 3 patients shifted from NIV ≤10hours to NIV >10hours, and the other 3 reduced the hours of NIV required. Most of the older patients remained stable; this included not only those on tracheostomy or NIV >10hours but also 75% of those on NIV ≤10hours. Our results suggest that nusinersen may produce some improvement in the progression of respiratory impairment, both in terms of survival and need for respiratory support ≥16hours, especially before the age of 2years.

A Study of Indications and Outcome of Non-Invasive Ventilation in Respiratory Care Unit of a Tertiary Care Hospital in Eastern India

Introduction: Patients with Acute Respiratory Failure (ARF) can be ventilated noninvasively through Bi-Level Positive Pressure Ventilation (Bi-PAP). The proper timing, indications and outcome of Non-invasive Ventilation (NIV) have been evaluated worldwide by many investigators. Optimum selection of patients leads to better outcome reducing need for invasive ventilation; while the reverse can cause inappropriate delay in intubation leading to clinical deterioration, increased morbidity and mortality. Aim: To evaluate the indications and outcome, with relevant factors in all patients requiring NIV in Respiratory Care Unit (RCU) of a teaching hospital. Materials and Methods: This was a hospital-based observational study conducted from April 2016 to March 2017. After ethical approval, all patients who were put on NIV in RCU of the institution during the period of one year were enlisted. Evaluation by history, detailed clinical examination and necessary investigations including blood count, biochemistry, Arterial Blood Gas (ABG) analysis, oxymetry, microbiological investigations, imaging of thorax etc., was done. Examination and investigations were periodically repeated as necessary. Pre-fixed NIV protocol and end point definitions were followed. Descriptive statistics done using Mean and Standard Deviation (SD). Mann-Whitney U test was done for comparing quantitative data. Chi-square test or Fisher’s-exact test was used to compare categorical data. Results: Most common age group for Respiratory Failure (RF) was 41 to 60 years, (mean 56.5±11.6), with a male predominance (M:F=1.4:1). The most common underlying disease leading to RF and requiring NIV support was Acute Exacerbation of Chronic Obstructive Pulmonary Disorder (COPD) (n=31) in Type 2 and pneumonia (n=11) in Type 1 RF. Hypertension (25%) and diabetes mellitus (20%) were common co-morbidities. Favourable outcome was seen in 68.33% patients an average hospital stay of 15 days. The baseline APACHE-II (Acute Physiology and Chronic Health Evaluation) score (p≤0.0001) and Partial Pressure of Oxygen(PaO2)/ Fraction of Inspired Oxygen (FiO2) at 1st hour of NIV (p=0.0054) have significant predictive value the outcome. Reasons for shifting to IMV were: non-improvement of ABG (37.93%), worsening of dyspnoea (24.14%) and haemodynamic instability (20.7%). Average time gap from initiation of NIV to mechanical ventilation in failure cases was 8.03 hours in Type 2 RF and 5.78 hours in Type 1 RF. Fatality rate in Type 2 RF (23.68%) was much less than in Type 1 RF (45.45%). Conclusion: This study strengthens the fact that efficient utilisation of NIV therapy in properly selected patients of acute RF can lead to reduced need for IMV, thus reducing the cost and complications. Disease severity at admission (APACHE-II score), non-improvement of ABG parameters in 1st and 4th hour of NIV initiation, PaO2/FiO2 ratio, development of haemodynamic instability and deteriorating level of consciousness, all play pivotal roles in the outcome assessment.

Post-extubation non-invasive ventilation in the pediatric intensive care unit: a multicenter study.

Extubation failure is a complication that increases morbidity and mortality. Noninvasive ventilation (NIV) has demonstrated to be effective as ventilatory support therapy. To determine the rate of postextubation NIV success and the factors associated with procedural failure or success. Design: observational, retrospective, analytical, and multicenter study. All patients who required post-extubation NIV during 2014 and 2015 were included. Rescue NIV was defined as the implementation of NIV for acute respiratory failure; elective NIV was described as its implementation for prophylaxis. NIV failure was defined as the need for orotracheal intubation within the first 48 hours. The characteristics of failure and success and the types of NIV were compared, and the equipment used was assessed. Rescue NIV was required in 112 children; elective NIV, in 143. The rates of success were 68.8% and 72.7%, respectively. Mortality was higher among patients in whom rescue NIV failed compared to those with successful NIV. A longer length of stay and more days of invasive mechanical ventilation prior to extubation were observed in the elective NIV group. The most common diagnosis was acute lower respiratory tract infection in previously healthy children. The use of post-extubation NIV may be a useful tool to prevent reintubation with invasive mechanical ventilation. Immunocompromised patients and those with neurological history had a higher rate of failure. Patients with failure tolerated less hours of NIV and had a longer length of stay in the pediatric intensive care unit.

Short-term effects of non-invasive ventilation on cerebral blood flow and cognitive function in COPD

ObjectivesInvestigate the acute effects of non-invasive ventilation (NIV) on cerebral blood flow (CBF) and on cognitive functions in COPD. MethodsNine non-hypercapnic stable COPD and twelve healthy controls were enrolled. CBF (transcranial Doppler), cognitive tests and cardiorespiratory response were performed at baseline, during one hour of NIV and after 30 min. ResultsBoth groups had an increase in tidal volume and reduction in respiratory rate during NIV, but only controls showed PaCO2 reductions (41.2 ± 4.6 to 36.5 ± 7.3 in controls vs. 40.9 ± 4.5 to 42.9 ± 5.9 in COPD). During NIV CBF was significantly reduced in healthy controls and COPD, although this effect was less pronounced in the latter. At the same time, healthy controls demonstrated an improvement in cognitive executive function compared to COPD in the Trail Making Test part B (90.5 vs. 180s; respectively). ConclusionNIV application for one hour reversibly reduced CBF in healthy controls and non-hypercapnic stable COPD patients, despite no significant reductions of the PaCO2 in the latter group. It was associated with minor cognitive improvements in the executive function in healthy volunteers, but not in COPD.