Management Of Respiratory Insufficiency Research Articles

Nasopharyngeal Ventilation Compared to Facemask Ventilation: A Prospective, Randomized, Crossover Trial in Two Different Elective Cohorts.

Facemask ventilation is routinely used to preoxygenate patients before endotracheal intubation during anesthesia induction or to secure ventilation in patients with respiratory insufficiency. Occasionally, facemask ventilation cannot be performed adequately. The placement of a regular endotracheal tube through the nose into the hypopharynx may be a valid alternative to improve ventilation and oxygenation before endotracheal intubation (nasopharyngeal ventilation). We tested the hypothesis that nasopharyngeal ventilation is superior in its efficacy compared to traditional facemask ventilation. In this prospective, randomized, crossover trial, we enrolled surgical patients requiring either nasal intubation (cohort #1, n = 20) or patients who met "difficult to mask ventilate" criteria (cohort #2, n = 20). Patients in each cohort were randomly assigned to receive pressure-controlled facemask ventilation followed by nasopharyngeal ventilation or vice versa. The ventilation settings were kept constant. The primary outcome was tidal volume. The secondary outcome was the difficulty of ventilation, measured using the Warters grading scale. Tidal volume was significantly increased by nasopharyngeal ventilation in cohort #1 (597 ± 156 ml vs.462 ± 220 ml, p = 0.019) and cohort #2 (525 ± 157 ml vs.259 ± 151 ml, p < 0.01). Warters grading scale for mask ventilation was 0.6 ± 1.4 in cohort #1, and 2.6 ± 1.5 in cohort #2. Patients at risk for difficult facemask ventilation may benefit from nasopharyngeal ventilation to maintain adequate ventilation and oxygenation before endotracheal intubation. This ventilation mode may offer another option for ventilation at induction of anesthesia and during the management of respiratory insufficiency, especially in the setting of "unexpected" ventilation difficulty.

COVID-19 pneumonia

Die Prognose der pandemisch auftretenden Coronavirus Disease 2019 (COVID-19) wird wesentlich durch das Ausmaß der Infektion der unteren Atemwege mit dem „severe acute respiratory syndrome coronavirus 2“ (SARS-CoV-2) bestimmt. Auch wenn die Mehrzahl der Patienten einen milden Verlauf zeigt, ist die Entwicklung einer Pneumonie mit dem Risiko einer schweren respiratorischen Insuffizienz verbunden. Neben der Virusdiagnostik an Material aus den oberen und/oder unteren Atemwegen hat sich die radiologische Diagnostik mittels hochauflösender Computertomographie (HRCT) als wichtige Methode für die Erkennung und das Verlaufsmonitoring der Erkrankung etabliert. In dem Übersichtsartikel wird neben der Darstellung der klinischen Zeichen und der komplexen und besonderen Pathophysiologie dieser Pneumonie detailliert auf die typischen radiologischen Muster eingegangen, deren Erkennen für die Beurteilung der Erkrankung und der möglichen therapeutischen Ansätze von Bedeutung ist. Bisher ist die Therapie im Wesentlichen symptombezogen und wird vor allem durch die intensivmedizinische Stabilisierung der respiratorischen Insuffizienz bestimmt. Aktuell zeigen sich dabei erste Ansätze einer gezielten medikamentöse Therapie mit antiviralen und antiinflammatorischen Substanzen.

Respiratory physiotherapy with assistance of biphasic cuirass ventilation for patients with neurological disease on tracheostomy positive pressure ventilation

Background: Biphasic Cuirass Ventilation (BCV) is a form of non-invasive ventilation that covers the thorax with a cuirass, stiff plastic shell and provides positive and negative pressure. BCV is useful for assistance during respiratory physiotherapy as well as management of respiratory insufficiency.

The Management of Respiratory Insufficiency in Patients With ALS at or Near the End of Life

Amyotrophic lateral sclerosis (ALS) is a devastating motor neuron disease causing progressive paralysis and eventual death, usually from respiratory failure. Treatment for ALS is focused primarily on optimal symptom management because there is no known cure. Respiratory symptoms that occur are related to the disease process and can be very distressing for patients and their loved ones. Recommendations on the management of respiratory insufficiency are provided to help guide clinicians caring for patients with ALS.

The Management of Respiratory Insufficiency in Patients With ALS at or Near the End of Life

The Management of Respiratory Insufficiency in Patients With ALS at or Near the End of Life

Pathophysiology and Therapy of Cardiac Dysfunction in Duchenne Muscular Dystrophy

Cardiac dysfunction is a frequent manifestation of Duchenne muscular dystrophy (DMD) and a common cause of death for individuals with this condition. Early diastolic dysfunction and focal fibrosis proceed to dilated cardiomyopathy (DCM), complicated by heart failure and arrhythmia in most patients. Improvements in the management of respiratory insufficiency in DMD have improved lifespan and overall prognosis, but heart failure and sudden death continue to impact survival and quality of life for people with DMD. Since the specific mechanisms resulting in heart failure for people with DMD are poorly understood, current treatments are not targeted, but rely on approaches that are considered standard for DCM. These approaches include angiotensin-converting enzyme (ACE) inhibitors and β-adrenoceptor antagonists. Data from one trial in DMD support the use of ACE inhibitors before the onset of left ventricular dysfunction. Angiotensin receptor blockers have shown similar efficacy to ACE inhibitors in numerous studies of dilated cardiomyopathy, and are a good choice for patients who cannot tolerate ACE inhibition. The pathogenesis of DMD-associated cardiomyopathy may be similar to other genetic disorders of the cytoskeletal complex of ventricular myocytes, though unique features offer targeted opportunities to impact treatment. Novel areas of investigation are focused on the regulatory role of dystrophin in relation to neuronal nitric oxide synthase (nNOS) and transient receptor potential canonical channels (TRPC). Inhibition of phosphodiesterase-5 (PDE5) addresses several aspects of regulatory dysfunction induced by dystrophin deficiency, and studies with PDE5-inhibitors have shown benefits in murine models of DMD. PDE5-inhibitors are currently under investigation in at least one study in humans. This article focuses on mechanisms of cardiac dysfunction, as well as potential targets for pharmacologic manipulation to prevent or improve cardiomyopathy in DMD.

Non-Invasive Ventilation: New Challenges For Hospice Nurses

Specialist palliative care units such as hospices are increasingly providing care for patients with non-malignant conditions. However, that means that palliative care nurses require education and training in the care of people with a variety of conditions, not just cancer. Also, palliative care nurses need to understand that they cannot be expected to know how to manage all conditions and therefore need to liaise with other specialist services. This article uses a case-scenario approach to describe the problems that arose during the nursing management of respiratory insufficiency, using non-invasive ventilation, in a patient with advanced motor neurone disease. Possible educational/training responses by which such problems might have been avoided are suggested. Since writing this article, Sheila, the patient upon whom the article is based, has died. To maintain confidentiality, Sheila is a pseudonym and other identifying details have been changed to preserve patient anonymity ([Nursing and Midwifery Council, 2008][1]). The author gained permission from her line manager to use this case as the basis of this article. Conflicts of interest: none [1]: #ref-29

IN51-WE-01 Management of respiratory insufficiency and sialorrhea in amyotrophic lateral sclerosis

IN51-WE-01 Management of respiratory insufficiency and sialorrhea in amyotrophic lateral sclerosis

Pathogenesis and management of respiratory insufficiency following pulmonary resection

The underlying principle of the surgical treatment of non-small-cell lung cancer (NSCLC) is complete removal of the local/regional disease within the thorax. Pulmonary resection should be as conservative as possible without compromising the adequacy of tumor removal. A multitude of factors influence the incidence and severity of complications following pulmonary resection including the pre-operative physical and psychological status of the patient, the pathologic process requiring resection, the physiologic impact of the procedure, and the addition of pre-operative or postoperative adjuvant therapy. The insidious onset of interstitial changes on chest X-ray (CXR) 1 to 2 days after pulmonary resection forewarns of respiratory distress; however, the pathophysiology of adult respiratory distress syndrome (ARDS) with progression to respiratory failure requiring mechanical ventilation and advanced critical care often unfolds. Management of patients with severe respiratory failure remains primarily supportive. “Good critical care” is the mainstay of therapy: this includes gentle mechanical ventilation to avoid ventilator-induced barotrauma and over-extension of remaining functional alveoli, diuresis, infection identification and management, and nutritional support. New therapeutic strategies that may impact on outcomes in the adult population include pressure-limited ventilation (permissive hypercapnia), inverse ratio ventilation, high-frequency jet ventilation, high-frequency oscillatory ventilation, intratracheal pulmonary ventilation, and prone position ventilation. In addition, alternative therapies such as partial liquid ventilation, inhaled nitric oxide, and extracorporeal techniques including extracorporeal membrane oxygenation (ECMO), extracorporeal carbon dioxide removal (ECCO2R), intravascular oxygenation (IVOX), and arteriovenous carbon dioxide removal (AVCO2R), provide additional modalities. A component of some or all of these strategies is finding a role in clinical practice. Semin. Surg. Oncol. 18:183–196, 2000. © 2000 Wiley-Liss, Inc.

Pathogenesis and management of respiratory insufficiency following pulmonary resection.

The underlying principle of the surgical treatment of non-small-cell lung cancer (NSCLC) is complete removal of the local/regional disease within the thorax. Pulmonary resection should be as conservative as possible without compromising the adequacy of tumor removal. A multitude of factors influence the incidence and severity of complications following pulmonary resection including the pre-operative physical and psychological status of the patient, the pathologic process requiring resection, the physiologic impact of the procedure, and the addition of pre-operative or postoperative adjuvant therapy. The insidious onset of interstitial changes on chest X-ray (CXR) 1 to 2 days after pulmonary resection forewarns of respiratory distress; however, the pathophysiology of adult respiratory distress syndrome (ARDS) with progression to respiratory failure requiring mechanical ventilation and advanced critical care often unfolds. Management of patients with severe respiratory failure remains primarily supportive. "Good critical care" is the mainstay of therapy: this includes gentle mechanical ventilation to avoid ventilator-induced barotrauma and over-extension of remaining functional alveoli, diuresis, infection identification and management, and nutritional support. New therapeutic strategies that may impact on outcomes in the adult population include pressure-limited ventilation (permissive hypercapnia), inverse ratio ventilation, high-frequency jet ventilation, high-frequency oscillatory ventilation, intratracheal pulmonary ventilation, and prone position ventilation. In addition, alternative therapies such as partial liquid ventilation, inhaled nitric oxide, and extracorporeal techniques including extracorporeal membrane oxygenation (ECMO), extracorporeal carbon dioxide removal (ECCO(2)R), intravascular oxygenation (IVOX), and arteriovenous carbon dioxide removal (AVCO(2)R), provide additional modalities. A component of some or all of these strategies is finding a role in clinical practice.

Impact of sleep in respiratory failure

Sleep has a physiological influence on respiration, which can have major adverse effects on gas exchange in patients with respiratory insufficiency. These effects relate largely to a reduction in various stimulant inputs to the brainstem respiratory centre. Conditions that may be associated with sleep-related respiratory insufficiency range from pulmonary disorders (such as chronic obstructive pulmonary disease (COPD)), to central respiratory insufficiency (such as central alveolar hypoventilation), neurological and neuromuscular disorders (such as polio and muscular dystrophy), and thoracic cage disorders (such as kyphoscoliosis). All these conditions have in common the finding of hypoxaemia and hypercapnia, which become more pronounced during sleep. The relative hypoventilation, which is common to each condition, is due to varying combinations of an inadequate respiratory drive and an increase in the work of breathing. Management of respiratory insufficiency during sleep should be directed first at optimizing the underlying disorder, then at correcting hypoxaemia with controlled low-flow supplemental oxygen. Pharmacological therapy may be effective in some instances, but the choice of agent varies with the underlying disorder. Assisted ventilation is an important part of the management of advanced cases, and the recent development of intermittent positive pressure ventilation by nasal mask (NIPPV) has been an important advance in this area. Use of NIPPV during the night is associated with beneficial effects during the day, particularly improved awake gas exchange and respiratory muscle strength, in addition to less dyspnoea and improved quality of life. Electrophrenic pacing of the diaphragm is helpful in highly selected cases, particularly patients with central respiratory insufficiency and high quadriplegia, but is frequently complicated by the development of obstructive sleep apnoea.

Rehabilitation ideology and respiratory support technology

This paper examines the impact changing ventilation technology and the ideologies of rehabilitation medicine on the long term adaptations of people with post-polio respiratory disability. Multiple in-depth interviews with 10 respirator-dependent people indicates that cultural ideologies learned during rehabilitation continue to effect the adoption of technology and daily management of respiratory insufficiency. Adaptive strategies through which benefits of technology are maximized and the social costs minimized, have transformed rehabilitation ideologies and moderated the late, aging-related effects of poliomyelitis.

The breath of life: medical technology and the careers of people with post‐respiratory poliomyelitis

Abstract This paper examines the impact of medical technology on the careers of people with post‐polio respiratory disability. The data have been taken from multiple in‐depth interviews with ten people who contracted polio during the epidemics of the early 1950s, all of whom used or had used a variety of methods of mechanical respiratory support. It focuses on ideologies of disability and the adoption of technology, the management of respiratory insufficiency and strategies of‘trading off whereby the benefits of technology are maximized and the costs minimized. While technology made an enormous contribution to the quality of life of these people, the problems it created transformed both their experience of the illness and the character of their everyday existence.

Intermittent Positive Pressure Ventilation via Nasal Access in the Management of Respiratory Insufficiency

These are preliminary observations of the introduction of a new technique of noninvasive positive pressure respiratory support for patients with subacute or chronic respiratory failure. Clinical situations where intubation or tracheostomy may have been performed were managed by intermittent positive pressure ventilation via nasal access (NIPPV) with a CPAP mask, or a custom constructed Vel-Foam nose piece. Four patients were managed at home with the use of portable volume ventilators. One patient employed the technique while hospitalized with subacute respiratory failure. Two patients, otherwise dependent on mouth intermittent positive pressure ventilation (MIPPV) 24 hours a day, received necessary dental care with NIPPV support. In a large population with a decade or more follow-up, MIPPV was shown to be an effective noninvasive technique to support respiration in patients with the most severe paralytic respiratory failure. Preliminary observations suggest that NIPPV may compare favorably with MIPPV and deserves more widespread study and application.

The effect of positive end-expiratory pressure on regional ventilation and perfusion in the normal and injured primate lung

Although positive end-expiratory pressure (PEEP) is being employed in the management of respiratory insufficiency, many of its physiological effects remain undetermined. The cardiopulmonary effects of PEEP as well as its effect on regional ventilation and perfusion were studied in 10 baboons before and after pulmonary injury with oleic acid. In the normal lung, there was significant improvement in oxygenation at a PEEP of 5 cm. of water secondary to improved ventilation and perfusion in all PEEP greater than 5 cm. of water produced increasing mismatch of ventilation and perfusion in all zones. After oleic acid was injected, hypoxemia was evident with a reversal of the normal ventilation-perfusion (V/Q) relationship between upper and lower lung zones. This mismatch of ventilation and perfusion was corrected at a PEEP of 15 cm. of water. It was reasonable to conclude that the use of PEEP in the injured lung exerts it beneficial effect by balancing regional ventilation and perfusion in addition to increasing functional residual capacity.

Management of respiratory insufficiency in infants with congenital heart disease.

Management of respiratory insufficiency in infants with congenital heart disease.

MANAGEMENT OF THE PATIENT WITH MYASTHENIA GRAVIS FOR THYMECTOMY.

A method of management of myasthenia gravis patients for thymectomy has been presented Preoperative preparation, conduct of anaesthesia, and care in the postoperative period is discussed Emphasis has been placed on assessment and management of respiratory insufficiency and avoidance of anticholinesterase treatment in the immediate and early postoperative recovery period This has eliminated the all too common hazard of “cholinergic crisis” The results, suggesting a reduction m operative mortality and morbidity, have been discussed

The role of the anaesthetist in the postanaesthetic period.

The anaesthetist’s responsibility and interests are broadening. The role of the anaesthetist in the postanaesthetic period and his rdle in the management of special care patients in the postanaesthetic recovery room at Vancouver General Hospital is reviewed. The most common recovery room calls that may be associated with any surgical patient in the postanaesthetic period are for acute respiratory difficulty, hypotension, pain, nausea, and vomiting. There are special problems associated with the surgical patient after cardiac arrest and open-heart procedures. Problems of respiratory insufficiency may arise in the postanaesthetic period with patients having pre-existing chronic respiratory pathology associated with post-poliomyelitis, advanced emphysetna, myasthenia gravis, and tetanus. In addition, intensive care by the anaesthetist may be required in the management of respiratory insufficiency in patients with a crushed chest, chronic asthmatics with acute exacerbations, and in advanced pulmonary emphysema.

The rapid-rocking bed: its effect on the ventilation of poliomyelitis patients with respiratory paralysis.

RECENT improvements in the management of respiratory insufficiency in patients with acute poliomyelitis have considerably reduced mortality in this stage of the disease. As a result, increasing numbers of patients have required artificial respiration for long periods after the acute febrile stage of poliomyelitis has passed. Although tank-type "iron-lung" respirators are life-saving for acutely ill patients, their continued use over periods of many weeks or months is associated with certain disadvantages. These include fixation and fibrosis of the diaphragm, restriction of motion of the extremities and difficulty in inducing patients to rely on their own recovering ventilatory mechanisms. A device . . .