Initiation Of Respiratory Support Research Articles

To study the efficiency of high-flow nasal cannula in improving the arterial blood gas parameters in children admitted to pediatric intensive care unit with respiratory distress

Abstract Background: In recent times, heated humidified high-flow nasal cannula has become increasingly popular and is now recognized as a standard respiratory support method for pediatric patients experiencing acute respiratory distress. Aims and Objectives: To study the correlation of high-flow nasal cannula (HFNC) with arterial blood gas (ABG) and clinical parameters. Materials and Methods: This prospective observational study included children aged 1 month to 14 years experiencing acute respiratory distress receiving HFNC support. Demographic information, vital signs, and ABG parameters were collected at four-time points: the first ABG at “0” h, indicating admission; the second ABG at “1” h, approximately 1 h after HFNC initiation; the third ABG at “12” h, as a follow-up after the initiation of respiratory support; and the fourth ABG at “24” h, representing daily monitoring for assessing the child’s condition and outcomes. The collected data was subjected to analysis. Results: The study included 133 children, of which 64.66% were male and 35.34% were female, with a mean age of 0.9 years (ranging from 0.3 to 3 years) and a mean weight of 7.8 kg (ranging from 4.7 to 11.8 kg). Over time, there was a statistically significant decrease in heart rate, respiratory rate, and the need for FiO2. Significant reductions in these parameters were observed within the first hour of initiating HFNC therapy, and improvements continued at 12 and 24 h compared to the baseline values (P value < 0.05). The study also revealed a decreasing trend in pCO2 and lactate levels over time. Statistically significant reductions in these parameters were noted at the first hour of HFNC initiation, and improvements persisted at 12 and 24 h compared to the baseline (P value < 0.05). On the other hand, there was an increasing trend in SpO2, pO2, base excess, and HCO3 over time. Significant increases in these parameters were observed at the first hour of HFNC initiation, and the positive trend continued at 12 and 24 h compared to the baseline (P value < 0.05). Conclusion: HFNC can serve as the primary noninvasive respiratory support for children facing respiratory distress. The majority of patients in our study demonstrated good tolerance to the HFNC. Notably, the utilization of HFNC resulted in a significant enhancement of the comfort scale among the participants. Positive changes were observed in vital parameters, comfort scale, and ABG parameters within just 1 h of initiating HFNC.

Investigating Pathways of Ventilation Induced Brain Injury on Cerebral White Matter Inflammation and Injury After 24h in Preterm Lambs.

Initiation of respiratory support in the delivery room increases the risk and severity of brain injury in preterm neonates through two major pathways: an inflammatory pathway and a haemodynamic pathway. The relative contribution of each pathway on preterm brain injury is not known. We aimed to assess the role of the inflammatory and haemodynamic pathway on ventilation-induced brain injury (VIBI) in the preterm lamb. Fetal lambs (125 ± 1 day gestation) were exteriorised, instrumented and ventilated with a high tidal-volume (VT) injurious strategy for 15 min either with placental circulation intact to induce the inflammatory pathway only (INJINF; n = 7) or umbilical cord occluded to induce both the inflammatory and haemodynamic pathways (INJINF+HAE; n = 7). Sham controls were exteriorised but not ventilated (SHAM; n = 5) while unoperated controls (UNOP; n = 7) did not undergo fetal instrumentation. Fetuses were returned in utero following intervention and the ewe allowed to recover. Arterial blood gases and plasma were sampled periodically. Twenty-four hours following intervention, lambs were delivered and maintained on non-injurious ventilation for ∼40 min then brains were collected post-mortem for immunohistochemistry and RT-qPCR to assess inflammation, vascular pathology and cell death within white matter regions. Compared to INJINF lambs, INJINF+HAE lambs achieved a consistently higher VT during injurious ventilation and carotid blood flow was significantly lower than baseline by the end of ventilation. Throughout the 24 h recovery period, systemic arterial IL-6 levels of INJINF+HAE lambs were significantly higher than SHAM while there was no difference between INJINF and SHAM animals. At 24 h, mRNA expression levels of pro-inflammatory cytokines, tight junction proteins, markers of cell death, and histological injury indices of gliosis, blood vessel protein extravasation, oligodendrocyte injury and cell death were not different between groups. Injurious ventilation, irrespective of strategy, did not increase brain inflammation or injury 24 h later when compared to control animals. However, the haemodynamic pathway did influence carotid blood flow adaptations during injurious ventilation and increased systemic arterial IL-6 that may underlie long-term pathology. Future studies are required to further characterise the pathways and their long-term effects on VIBI.

Effect of very early use of caffeine citrate in preterm neonates needing respiratory support

Abstract Background Caffeine citrate is one of the most widely used medications in neonatal intensive care units. It is a respiratory stimulant which has well established therapeutic effects in apnea and extubation. Little is known about the very early use of caffeine citrate in preterm neonates. We aim to explore the effectiveness of its very early use in reducing the duration of the respiratory support used and not just extubation. Objectives to study the effect of the very early use of caffeine citrate in preterm neonates on morbidity and short-term neonatal outcomes. Subjects and Methods A prospective phase 3 clinical trial was carried out on 54 preterm neonates less than 34 weeks of gestation who require respiratory support and were given caffeine citrate in two different settings, over a period of one year. Patients were randomly allocated to one of two groups, the first group was given caffeine citrate at initiation of respiratory support(CPAP, NIPPV and IPPV). The second group received caffeine citrate 6 hours before weaning of the respiratory support used. Caffeine citrate was stopped after complete removal of the respiratory support used. Both groups were compared as regard the duration of each respiratory support used separately and the total duration of respiratory support needed for each patient. Results The duration of IPPV used in patients was significantly lower in the patients that received early caffeine citrate. Total duration of the respiratory support needed for each patient was significantly lower in the early group. There was no significant difference in the development of complications related to the drug use between both groups. The total duration of NICU stay was significantly lower in the early group than the other group. Conclusion The Early initiation of caffeine citrate has effectively and safely decreased duration of respiratory support used and NICU stay without the development of any complications. Key words early caffeine citrate, preterm neonates, respiratory support. *CPAP: Continuous positive airway pressure NIPPV: Non invasive positive pressure ventilation IPPV: Intermittent positive pressure ventilation NICU: Neonatal Intensive care unit

External validation and update of prediction models for unfavorable outcomes in hospitalized patients with COVID-19 in Japan

IntroductionMost of the currently used prognostic models for COVID-19 are based on Western cohorts, but it is unknown whether any are applicable to patients with COVID-19 in Japan. MethodsThis retrospective cohort study included 160 patients with COVID-19 who were admitted to the National Center for Global Health and Medicine between January 26, 2020 and July 25, 2020. We searched PubMed for prognostic models for COVID-19. The predicted outcome was initiation of respiratory support or death. Performance of the candidate models was evaluated according to discrimination and calibration. We recalibrated the intercept of each model with our data. We also updated each model by adding β2-microglobulin (β2MG) to the model and recalculating the intercept and the coefficient of β2MG. ResultsMean patient age was 49.8 years, 68% were male, 88.7% were Japanese. The study outcomes occurred in 15 patients, including two deaths. Two-hundred sixty-nine papers were screened, and four candidate prognostic models were assessed. The model of Bartoletti et al. had the highest area under receiver operating characteristic curve (AUC) (0.88; 95% confidence interval 0.81–0.96). All four models overestimated the probability of occurrence of the outcome. None of the four models showed statistically significant improvement in AUCs by adding β2MG. ConclusionsOur results suggest that the existing prediction models for COVID-19 overestimate the probability of occurrence of unfavorable outcomes in a Japanese cohort. When applying a prediction model to a different cohort, it is desirable to evaluate its performance according to the prevalent health situation in that region.

National Early Warning Score 2 (NEWS2) to identify inpatient COVID-19 deterioration: a retrospective analysis

We sought to provide the first report of the use of NEWS2 monitoring to pre-emptively identify clinical deterioration within hospitalised COVID-19 patients. Consecutive adult admissions with PCR-confirmed COVID-19 were included in this single-centre retrospective UK cohort study. We analysed all electronic clinical observations recorded within 28 days of admission until discharge or occurrence of a serious event, defined as any of the following: initiation of respiratory support, admission to intensive care, initiation of end of life care, or in-hospital death. 133/296 (44.9%) patients experienced at least one serious event. NEWS2 ≥ 5 heralded the first occurrence of a serious event with sensitivity 0.98 (95% CI 0.96-1.00), specificity 0.28 (0.21-0.35), positive predictive value (PPV) 0.53 (0.47-0.59), and negative predictive value (NPV) 0.96 (0.90-1.00). The NPV (but not PPV) of NEWS2 monitoring exceeded that of other early warning scores including the Modified Early Warning Score (MEWS) (0.59 [0.52-0.66], p<0.001) and quick Sepsis Related Organ Failure Assessment (qSOFA) score (0.58 [0.51-0.65], p<0.001). Our results support the use of NEWS2 monitoring as a sensitive method to identify deterioration of hospitalised COVID-19 patients, albeit at the expense of a relatively high false-trigger rate.

Acute Delivery Room Resuscitation of Neonates Exposed to Selective Serotonin Reuptake Inhibitors

To determine whether full-term neonates with in utero exposure to selective serotonin reuptake inhibitors (SSRI) require respiratory support in the delivery room, as indicated by the standardized Neonatal Resuscitation Program algorithm, significantly more often than nonexposed neonates. In this retrospective cohort study, we extracted data from medical records of full-term neonates with and without in utero SSRI exposure, defined as documentation of third trimester maternal SSRI treatment. A hospital-based sample was identified at Northwestern Medical Hospital in Chicago, Illinois. Full-term singleton newborns identified in a 6-month period (n=4933) were selected for study. Neonates with a major congenital anomaly were excluded. The primary outcome was initiation of respiratory support in the delivery room, as indicated by the Neonatal Resuscitation Program algorithm. Of the 4933 full-term singleton neonates, 3.3% were exposed to SSRI in utero. Respiratory support was initiated significantly more often in SSRI exposed (12.9%) than unexposed (4.2%) neonates (covariate-adjusted OR, 4.04; 95% CI, 2.40-6.49). In utero SSRI exposure also was associated with a higher rate of neonatal intensive careunit admission (covariate-adjusted OR, 2.19; 95% CI, 1.30-3.50) and 1-minute Apgar score of ≤5 (covariate-adjusted OR, 3.51; 95% CI, 2.07-5.67). In this cohort, in utero SSRI exposure was associated with a significantly greater odds of resuscitation in the delivery room as well as neonatal intensive care unit admission. Although the mechanism underlying these associations have not been determined and causality cannot be assumed, these findings supporta recommendation that third trimester SSRI exposure be considered a risk factor for needing resuscitation.

Clinical Characteristics and Emergent Therapeutic Interventions in Patients Evaluated through the In-hospital Stroke Alert Protocol

Background and Purpose: Emergent evaluation of inpatients with suspected acute ischemic stroke faces difficulty of symptoms recognition, false alarms, and high rate of contraindications to reperfusion therapies. We aim to assess the clinical characteristics and therapeutic interventions implemented in patients evaluated though the in-hospital Stroke Alert Protocol. Methods: We analyzed 4 years-worth of Stroke Alert cases at a university hospital. Demographics, clinical presentation, final diagnosis, and acute interventions were compared between inpatients and those presenting to the emergency department. Findings: A total of 1965 Stroke Alert cases were included: 959 (48.8%) were acute cerebrovascular events and 1006 (51.2%) were noncerebrovascular. Hospitalized patients accounted for 489 (24.9%) of Stroke Alerts and patients in the emergency department for 1476 (75.1%). Inpatients were more likely to present with nonfocal neurological deficits (46.2% versus 32.4%, P < .0001) and be diagnosed with noncerebrovascular disorders (62.4% versus 47.5%, P < .0001). Acute interventions other than thrombolysis were delivered in 77.1% of in-hospital cases. Compared to the emergency department, inpatients were more commonly managed with rectification of metabolic abnormalities (21.5% versus 13.7%, P < .001), suspension or pharmacological reversal of drugs (11% versus 3.7%, P < .001), and initiation of respiratory support (13.5% versus 9.3%, P = .01). Inpatients with acute ischemic stroke received intravenous thrombolysis less frequently (4.9% versus 23.9%, P < .001), but the endovascular treatment rate was comparable (9.8% versus 10.3%) to the emergency department. Conclusion: Nonfocal neurological deficits and noncerebrovascular disorders are commonly encountered during in-hospital Stroke Alerts. In the inpatient setting, intravenous thrombolysis is rarely delivered while other time-sensitive therapeutic interventions are frequently implemented.

Abstract TP304: Emergent Therapeutic Interventions Beyond Thrombolysis in Patients Evaluated Through the In-Hospital Stroke Alert Protocol

Background: In-Hospital Stroke Alert Protocols (IHSAPs) are designed to evaluate acute thrombolysis candidacy in patients who develop acute ischemic stroke (AIS) while hospitalized for other causes. However, co-existing medical illnesses may result in difficulty in symptom recognition, false positive alerts, and a high number of contraindications to reperfusion therapies. Methods: We analyzed data of all Stroke Alert Protocol cases evaluated by the vascular neurology team in an academic university hospital over 4 consecutive years. Patient demographics and location at the moment of activation were recorded. Clinical presentation, final diagnosis, and acute interventions were compared between inpatients and those presenting to the emergency department (ED). Results: Of 1,965 included cases, 489 (24.9%) Stroke Alerts were activated in already hospitalized patients and 1,476 (75.1%) in the emergency department. IHSAPs cases were more likely to present with non-localizing neurological deficits (46.2 % vs. 32.4%, p&lt;0.0001) and diagnosed with non-cerebrovascular disorders (62.4% vs. 47.5%, p&lt;0.0001). Critical acute therapeutic interventions other than thrombolysis were delivered in 377 (77.1%) cases evaluated through the IHSAP. When compared to the ED, inpatients were more commonly managed with correction of metabolic abnormalities (21.5% vs. 13.7%, p&lt;0.0001), suspension or pharmacological reversal of drugs (11% vs. 3.7%, p&lt;0.0001), and initiation of respiratory support (13.5% vs. 9.3%, p=0.01). Inpatients diagnosed with AIS received intravenous thrombolysis less frequently (4.9% vs. 23.9%, p&lt;0.0001), but the proportion of endovascular treatments was similar to those presenting to the ED (9.8% vs. 10.3%). Conclusion: Patients who developed in-hospital ischemic stroke rarely received intravenous thrombolysis, however, the rate of endovascular treatment was similar to those presenting from the community to the ED. The vascular neurology team commonly implemented emergent time-sensitive therapeutic interventions other than thrombolysis during the evaluation of inpatients with stroke-like symptoms.

62 Techniques and Devices for Neonatal Resuscitation

Establishing breathing and oxygenation after birth is vital for survival and long-term health of premature infants. However, approximately 10% of premature infants require breathing support at birth. An international consensus...

Frequency of respiratory deterioration after immunisation in preterm infants

To determine the relationship between the initiation of respiratory support and the first routine immunisation of neonates at 2 months of age during primary hospitalisation. An historical cohort study design was used to study the neonatal factors associated with the initiation of respiratory support within 7 days of immunisation in a cohort of 7629 preterm and term infants admitted to the Neonatal Unit of the Royal Women's Hospital between 2001 and 2008. The 411 infants who received their first immunisations in hospital were both very preterm and of extremely low birth weight (ELBW, below 1000 g). Twenty-two infants experienced post-immunisation apnoea of sufficient severity to warrant the initiation of either intermittent positive pressure ventilation (two cases) or continuous positive airway pressure (20 cases). Infants exhibiting a respiratory deterioration following immunisation had a higher incidence of previous septicaemia (Odds ratio 2.5, 95% confidence interval 1.0, 6.1; P = 0.04) and received CPAP for a longer period prior to vaccination (P = 0.03). Apnoea following immunisation may be an aetiological factor in the requirement of respiratory support in a small number of preterm, ELBW infants particularly those with significant lung disease and those who have previously experienced septicaemia.

Survival rate of patients with amyotrophic lateral sclerosis in Wakayama Prefecture, Japan, 1966 to 2005

To investigate longitudinal changes in the survival rate of patients with amyotrophic lateral sclerosis in Wakayama Prefecture, Japan, we made a retrospective hospital-based study of 454 patients diagnosed with motor neuron disease (MND) at Wakayama Medical University (WMU) Hospital between 1966 and 2005. Of the 454 patients, 240 who were born and who lived in Wakayama Prefecture were diagnosed with definite or probable ALS during this period, according to the El Escorial criteria. The clinical data of the 240 patients, including sex, birth date, birthplace, address, age at onset, initial symptoms, date when respiratory support was applied (tracheostomy, noninvasive positive pressure ventilation, or mandatory artificial ventilation), and date of death were reviewed retrospectively. The age at onset of patients who developed initial symptoms before 1990 was 53.4+/-10.6 (mean+/-S.D.) and that in 1990 or thereafter was 64.8+/-10.3, respectively, showing a significant difference (p<0.0001). Clinical duration was determined from onset to either date of death or initiation of respiratory support in this study. Survival rate was compared using the Kaplan-Meier method according to age at onset, sex, initial symptoms and year of onset. Mean age at onset shifted towards older age according to a later year of onset, due to the overwhelming senility rate in Wakayama Prefecture. Older onset patients had a significantly poorer survival rate than younger onset patients when it was compared based on 10-year age groups (log rank, p<0.0001). Male patients had a poorer survival rate than female patients (p<0.0001). ALS patients with bulbar palsy onset showed shorter clinical durations than those with lower leg onset (p<0.0071, Breslow-Gehan-Wilcoxon test). Patients over 70 years old more frequently showed bulbar palsy onset compared to those younger than 69 (p=0.003). In a comparison of year of onset before and after 1990, ALS patients after 1990 had characteristics of older age onset and shorter clinical duration, and more frequently showed bulbar palsy onset compared with those before 1990. These findings indicated that younger onset patients with ALS decreased after 1990 in Wakayama Prefecture and this might partly explain the recent decline of ALS incidence in Wakayama Prefecture. The shift of the mean age at onset to older age might be due to exogenous factors, including changes in lifestyle, food, and drinking water in this area. Bulbar palsy onset and age at onset were expected as predictors of the survival rate.

PNEUMONIA IN PREGNANCY

Although the advent of broad-spectrum antibiotics has markedly improved the maternal outcomes of pneumonia complicating pregnancy, pneumonia remains a significant condition that may complicate pregnancy. This article has reviewed the inherent physiologic respiratory changes that accompany pregnancy and the common causes of pneumonia in the pregnant woman. The clinical course of bacterial pneumonia seems to be minimally altered by pregnancy, whereas viral pneumonia carries a significantly worse prognosis when encountered during gestation. Prompt diagnosis, the initiation of respiratory support, and appropriate antimicrobial/antiviral therapy are key components of therapy for women in whom pregnancy is complicated by pneumonia. Because preterm labor frequently accompanies pneumonia, women should be monitored closely for the occult onset of preterm labor and appropriate interventions initiated if indicated. Perhaps even more important than interventions to treat acute pneumonia are efforts directed at active immunization or prophylactic therapy to prevent the development of pneumonia in select patient populations. The combination of these efforts is essential to optimize medical care for pregnant women.