Negative Inspiratory Force Research Articles

Morphological and Functional Alterations of Respiratory Muscle Performance and Spirometry Parameters in Patients with Congestive Heart Failure

The purpose of the study. To identify structural changes and functional modifications in respiratory muscle performance in patients with congestive heart failure.Materials and methods. We conducted prospective observational study at the V. A. Almazov National Medical Research Center involving 118 subjects: 49 patients with congestive heart failure (CHF-group) and 69 healthy people (control group). NYHA functional classes of II to IV were taken as inclusion criteria in the CHF group, and respiratory diseases, abdominal pathology, morbid obesity, and anemia — as exclusion criteria. Ultrasound imaging was used to assess the structural (thickness) and functional (thickening and excursion indices) diaphragmatic impairments during quiet (resting) and deep breathing. Facemask spirometry was used to assess pulmonary function. Results. Patients with CHF were on average older than 59.0 years (53.0; 70.0) vs. 25.0 years (24.0; 26.0) in the control group, P=0.000001, had excessive body weight — 82.0 (73.0; 95.0) vs. 68.5 (55.0; 84.0) kg, P=0.000005 and higher body mass index — 28.4 (24.3; 31.3) vs 21.8 (19.9; 24.0) kg/m2, P=0.000001, but did not differ in height 173.0 (166.0; 179.0) vs. 170.0 (165.0; 183.0) cm, 0.97.Lower maximum inspiratory volume (MIV): 3000.0 (2300.0; 4000.0) vs. 3684.1 (3392.5; 4310.8) ml, P=0.0006, and negative inspiratory force (NIF) measured as max negative pressure generated by the respiratory muscles: 43.1 (–56.7; –33.0) vs. 53.5 (–58.8; –50.9) mBar, P=0.000082, respectively were found in patients with CHF. The diaphragm was significantly thicker (mm) in patients with CHF during quiet (eupnea) and deep breathing compared to healthy subjects. The thickness at the end of quiet inspiration was 3.0 (2.2; 3.6)/1.9 (1.5; 2.2) in the right hemi-diaphragm, P<0.001; and 3.0 (2.4; 3.5)/1.7 (1.4; 2.0) — in the left, P=0.000001; thickness at the end of quite expiration — 2.2 (1.8; 2.9)/1.5 (1.2; 1.7) in the right dome, P=0.000001; and 2.0 (1.7; 2.5)/1.4 (1.2; 1.5) — in the left, P=0.000001. Thickness at the end of deep inspiration was 5.1 (4.4; 6.1)/4.4 (3.6; 5.1) in the right dome, P=0.0005, and 4.9 (4.2; 6.2)/ 3.7 (3.1; 4.8) — in the left, P=0.000007.The diaphragm thickening index during deep breathing was lower in the CHF group than in the control group: 131.1 (82.5; 181.8) vs. 190.9 (150.0; 240.0) in the right dome, P=0.000004; and 148.8 (112.5; 190.3) vs. 175.2 (130.7; 227.7) — in the left, P=0.03, respectively.Diaphragmatic excursions during quiet breathing were larger in patients with CHF than in healthy controls: 2.3 (1.6; 2.8)/1.7 (1.5; 1.9), P=0.0001 and 1.8 (1.5; 2.2)/1.5 (1.3; 1.9), P=0.03 of the right and left domes, respectively.Conclusion. Congestive heart failure contributes to the development of structural and functional impairments of the diaphragm.

The metabolic cost of inspiratory muscle training in mechanically ventilated patients in critical care

BackgroundDiaphragmatic dysfunction is well documented in patients receiving mechanical ventilation. Inspiratory muscle training (IMT) has been used to facilitate weaning by strengthening the inspiratory muscles, yet the optimal approach remains uncertain. Whilst some data on the metabolic response to whole body exercise in critical care exist, the metabolic response to IMT in critical care is yet to be investigated. This study aimed to quantify the metabolic response to IMT in critical care and its relationship to physiological variables.MethodsWe conducted a prospective observational study on mechanically ventilated patients ventilated for ≥ 72 h and able to participate in IMT in a medical, surgical, and cardiothoracic intensive care unit. 76 measurements were taken on 26 patients performing IMT using an inspiratory threshold loading device at 4 cmH2O, and at 30, 50 and 80% of their negative inspiratory force (NIF). Oxygen consumption (VO2) was measured continuously using indirect calorimetry.ResultsFirst session mean (SD) VO2 was 276 (86) ml/min at baseline, significantly increasing to 321 (93) ml/min, 333 (92) ml/min, 351(101) ml/min and 388 (98) ml/min after IMT at 4 cmH2O and 30, 50 and 80% NIF, respectively (p = 0.003). Post hoc comparisons revealed significant differences in VO2 between baseline and 50% NIF and baseline and 80% NIF (p = 0.048 and p = 0.001, respectively). VO2 increased by 9.3 ml/min for every 1 cmH2O increase in inspiratory load from IMT. Every increase in P/F ratio of 1 decreased the intercept VO2 by 0.41 ml/min (CI − 0.58 to − 0.24 p < 0.001). NIF had a significant effect on the intercept and slope, with every 1 cmH2O increase in NIF increasing intercept VO2 by 3.28 ml/min (CI 1.98–4.59 p < 0.001) and decreasing the dose–response slope by 0.15 ml/min/cmH2O (CI − 0.24 to − 0.05 p = 0.002).ConclusionsIMT causes a significant load-dependent increase in VO2. P/F ratio and NIF impact baseline VO2. The dose–response relationship of the applied respiratory load during IMT is modulated by respiratory strength. These data may offer a novel approach to prescription of IMT.Take home messageThe optimal approach to IMT in ICU is uncertain; we measured VO2 at different applied respiratory loads to assess whether VO2 increased proportionally with load and found VO2 increased by 9.3 ml/min for every 1 cmH2O increase in inspiratory load from IMT. Baseline NIF has a significant effect on the intercept and slope, participants with a higher baseline NIF have a higher resting VO2 but a less pronounced increase in VO2 as the inspiratory load increases; this may offer a novel approach to IMT prescription.Trial registration ClinicalTrials.gov, registration number: NCT05101850. Registered on 28 September 2021, https://clinicaltrials.gov/ct2/show/NCT05101850

0995 Sleep-related Hypoventilation in a 62-Year-Old Female with a Rare Genetic Neuromuscular Disorder

Abstract Introduction Central Core Myopathy (CCM) is a rare genetic neuromuscular disorder involving a mutation in the ‘Ryanodine Receptor’ (RyR1) gene, also known as the gatekeeper of calcium within the muscle cells. CCM typically manifests as slowly progressive proximal muscle weakness Currently, there is limited data regarding the management of nocturnal hypoventilation in adults with neuromuscular disorders. Report of case(s) We present a 62-year-old woman with CCM, as identified via RyR1 mutation (c14818G&amp;gt;A) on genetic testing, as well as muscle biopsy. This genotype is associated with &amp;lt; 10% respiratory muscle involvement. She presented to the sleep clinic with complaints of morning headaches, non-restorative sleep, and daytime sleepiness. Her polysomnogram (PSG) showed an overall Apnea-Hypopnea-Index in the normal range. However, there was a progressive increase in transcutaneous carbon dioxide levels (PtcCO2), reaching a peak of 53 mmHg during rapid eye movement (REM) sleep from 38 mmHg during wakefulness, consistent with sleep-related neuromuscular hypoventilation. On further evaluation, this patient had no evidence of neuromuscular restrictive lung physiology or overt diaphragmatic dysfunction, as suggested by &amp;lt; 20% variation in the supine forced vital capacity. Moreover, her negative inspiratory force (NIF) value was not less than negative 40. However, in the setting of her sleep-related symptoms and evidence of nocturnal hypoventilation, our team decided to trial non-invasive positive pressure ventilation (NIPPV). Since we had concerns about respiratory alkalosis in NREM sleep in the setting of normal body mass index, normal pulmonary function tests, and hypoventilation limited to REM sleep, the patient was sent for in-lab titration of pressures with measurement of PtcCO2 to appropriately recommend NIPPV settings. The study demonstrated bi-level positive airway pressure settings of IPAP 7 cmH20, EPAP 5 cmH20, and a backup rate of 12/min resulting in sustained eucarbia and steady PtcCO2 levels during both REM and NREM sleep. Conclusion This case highlights the importance of evaluation for nocturnal hypoventilation in symptomatic patients with rare neuromuscular disorders and the potential for symptomatic improvement with treatment with NIPPV. Moreover, the case demonstrates the importance of in-lab titration of pressure settings for NIPPV when hypoventilation is limited to REM sleep, due to concern for iatrogenic hyperventilation and respiratory alkalosis. Support (if any)

Reversing Neuromuscular Blockade without Nerve Stimulator Guidance in a Postsurgical ICU-An Observational Study.

We aimed to determine if not using residual neuromuscular blockade (RNB) analysis to guide neuromuscular blockade reversal administration in the postsurgical ICU resulted in consequences related to residual weakness. This single-center, prospective study evaluated 104 patients arriving in a postcardiac surgical ICU. After demonstrating spontaneous movement and T > 35.5 °C, all patients underwent RNB evaluation, and neostigmine/glycopyrrolate was then administered. When patients later demonstrated an adequate Rapid Shallow Breathing Index, negative inspiratory force generation, and arterial blood gas values with minimal mechanical ventilatory support, RNB evaluation was repeated in 94 of the 104 patients, and all patients were extubated. Though RNB evaluation was performed, patients were extubated without considering these results. Eleven of one hundred four patients had not achieved a Train-of-Four (TOF) count of four prior to receiving neostigmine. Twenty of ninety-four patients demonstrated a TOF ratio ≤ 90% prior to extubation. Three patients received unplanned postextubation adjunct respiratory support-one for obvious respiratory weakness, one for pain-related splinting compounding baseline disordered breathing but without obvious benefit from BiPAP, and one for a new issue requiring surgery. Residual neuromuscular weakness may have been unrecognized before extubation in 1 of 104 patients administered neostigmine without RNB analysis. ICU-level care may mitigate consequences in such cases.

Monitorización del destete ventilatorio en el paciente crítico

The weaning process can be classified as simple, difficult, or prolonged. The incidence of difficult or prolonged weaning varies from 15% to 25%, according to the series. In critically ill patients it accounts for up to 50% of the total time that they are connected to the ventilator. It is very important to monitor weaning to detect the patients in whom it will be prolonged, and to help us in their management and decision making. Firstly, gas exchange and ventilatory mechanics must be monitored, fundamental in all patients on mechanical ventilation (MV). In addition, monitoring specific parameters that provide information on the patient's respiratory effort is strategic in the weaning process. These parameters include occlusion pressure (P0.1), oesophageal pressure (Poes), Negative Inspiratory Force (NIF), also known as Maximum Inspiratory Pressure (MIP), diaphragmatic electric activity (Edi), total work of breathing (WOB), and its components, elastic WOB (eWOB), and resistive WOB (rWOB). Monitoring weaning from mechanical ventilation means we can establish when the conditions have been met to start the weaning process, propose a weaning protocol adapted to the conditions of the patient, and define our post-extubation respiratory care protocol to prevent weaning failure.

Monitoring Respiratory Effort and Lung-distending Pressure Noninvasively during Mechanical Ventilation: Ready for Prime Time.

Monitoring Respiratory Effort and Lung-distending Pressure Noninvasively during Mechanical Ventilation: Ready for Prime Time.

Measuring Success of Patient Safety Initiatives: The 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade

Measuring Success of Patient Safety Initiatives: The 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade

Efficacy and Safety of Sugammadex to Shorten Time-to-Extubation Following Cardiac Surgery: A Single-Center Randomized Placebo-Controlled Trial.

Single-center, randomized, double-blind, placebo-controlled trial. University-based cardiothoracic ICU. Patients (n = 90) undergoing elective aortic valve replacement (AVR) and/or coronary artery bypass grafting (CABG) surgery. Participants were randomized to receive either sugammadex (2 mg/kg) or placebo after arrival to the ICU. The primary study endpoint was time from study drug administration to extubation. Of the 90 patients included in the study (45 in each group), a total of 68 patients underwent CABG, 13 AVR, and nine combined AVR and CABG. Baseline characteristics and intraoperative anesthetic medications were comparable between groups. Patients in sugammadex group had reduced time to extubation compared with the placebo group (median [interquartile range (IQR)]-sugammadex group: 126.0 min [84.0-274.0 min] vs placebo: 219.0 min [121.0-323.0 min]; difference in means [95% CI], 72.8 [1.5-144.1 min]; p = 0.01. There were no differences in negative inspiratory force (mean [sd]-sugammadex group: 33.79 cm H2O [8.39 cm H2O] vs placebo: -31.11 cm H2O [7.17 cm H2O]) and vital capacity (median [IQR]-sugammadex group: 1.1 L [0.9-1.3 L] vs placebo: 1.0 L [0.9-1.2 L]). There were no differences between groups in postoperative blood product requirement, dysrhythmias, length of ICU, or hospital stay. There were no serious adverse events in either group. This randomized trial showed that the administration of sugammadex after cardiac surgery decreased time to extubation by approximately 1 hour. Larger trials may be required to confirm these findings and determine the clinical implications.

WEST NILE-INDUCED MYASTHENIA GRAVIS CRISIS: AN UNEXPECTED CASE OF RESPIRATORY FAILURE

WEST NILE-INDUCED MYASTHENIA GRAVIS CRISIS: AN UNEXPECTED CASE OF RESPIRATORY FAILURE

Acute Flaccid Myelitis.

Acute Flaccid Myelitis.

Prediction of extubation outcome in critically ill patients: a systematic review and meta-analysis

BackgroundExtubation failure is an important issue in ventilated patients and its risk factors remain a matter of research. We conducted a systematic review and meta-analysis to explore factors associated with extubation failure in ventilated patients who passed a spontaneous breathing trial and underwent planned extubation. This systematic review was registered in PROPERO with the Registration ID CRD42019137003.MethodsWe searched the PubMed, Web of Science and Cochrane Controlled Register of Trials for studies published from January 1998 to December 2018. We included observational studies involving risk factors associated with extubation failure in adult intensive care unit patients who underwent invasive mechanical ventilation. Two authors independently extracted data and assessed the validity of included studies.ResultsSixty-seven studies (involving 26,847 participants) met the inclusion criteria and were included in our meta-analysis. We analyzed 49 variables and, among them, we identified 26 factors significantly associated with extubation failure. Risk factors were distributed into three domains (comorbidities, acute disease severity and characteristics at time of extubation) involving mainly three functions (circulatory, respiratory and neurological). Among these, the physiological respiratory characteristics at time of extubation were the most represented. The individual topic of secretion management was the one with the largest number of variables. By Bayesian multivariable meta-analysis, twelve factors were significantly associated with extubation failure: age, history of cardiac disease, history of respiratory disease, Simplified Acute Physiologic Score II score, pneumonia, duration of mechanical ventilation, heart rate, Rapid Shallow Breathing Index, negative inspiratory force, lower PaO2/FiO2 ratio, lower hemoglobin level and lower Glasgow Coma Scale before extubation, with the latest factor having the strongest association with extubation outcome.ConclusionsNumerous factors are associated with extubation failure in critically ill patients who have passed a spontaneous breathing trial. Robust multiparametric clinical scores and/or artificial intelligence algorithms should be tested based on the selected independent variables in order to improve the prediction of extubation outcome in the clinical scenario.

The Impact of Upper Lateral Cartilage Release on Patient-Perceived Nasal Appearance and Obstruction.

Although upper lateral cartilages are commonly released from the dorsum of the septum during spreader graft placement in septorhinoplasty (SRP), there has been a focus on maintaining integrity of connections in the middle vault. Avoiding release of upper lateral cartilages in certain patient groups may represent an early step in this paradigm shift. We aim to assess satisfaction with nasal appearance and correction of nasal obstruction in patients who underwent SRP with spreader graft placement without upper lateral cartilage release and compared it to the traditional upper lateral cartilage release cohort. Prospective cohort study. A total of 559 patients who underwent SRP with spreader graft placement with upper lateral cartilage release and 30 patients who underwent SRP with spreader graft placement without release between 2012 and 2020 were administered the Nasal Obstruction Symptom Evaluation (NOSE), FACE-Q Satisfaction with Nose, and FACE-Q Social Functioning scales pre- and postoperatively. Pre- and postoperative NOSE FACE-Q, and negative inspiratory force (NIF) scores and changes were compared between groups. Results demonstrated clinically and statistically significant improvement at follow-up for both groups. There was no significant difference between groups in mean improvement of NOSE, FACE-Q, and NIF scores at time of last follow-up. SRP with spreader graft placement with and without upper lateral cartilage release provide clinically and statistically significant improvement, and no significant difference in functional outcome. This suggests that upper lateral cartilages do not need to be released to achieve functional improvement and that surgeons should consider whether release is necessary to achieve goals of surgery. 3 Laryngoscope, 132:1189-1195, 2022.

BAMLANIVIMAB-INDUCED GUILLAIN-BARRÉ SYNDROME

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Guillain-Barre syndrome (GBS) is an autoimmune post-infectious neuropathy resulting in acute ascending flaccid paralysis 1. To the best of our knowledge and review of literature, this is the first reported case of GBS after receiving bamlanivimab a monoclonal antibody immunotherapy, now authorized for use in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. CASE PRESENTATION: A 61-year-old male presented with acute progressive ascending bilateral lower extremity weakness and fever. Previous medical history included Chronic obstructive pulmonary disease and a recent diagnosis of SARS-CoV-2 for which he received monoclonal antibody (Bamlanivimab) one week prior to admission. On admission, neurological exam was remarkable for decreased bilateral lower and upper extremity strength with poor hand grip strength. Patient was being monitored in the intensive care unit for respiratory failure using negative inspiratory force and vital capacity. Lumbar puncture results were remarkable for normal glucose (62 mg/dL), elevated protein (122.4 mg/dL) without an elevated white blood count. The patient was diagnosed with GBS and initially treated with Intravenous Immunoglobin (IVIG) for five days. However, he continued to be symptomatic and developed mild dysarthria and facial weakness. He was subsequently treated with plasmapheresis for five days. Neurological and respiratory function improved after plasmapheresis therapy. DISCUSSION: The case illustrates GBS presentation after treatment with monoclonal antibody therapy in the setting of SARS-CoV-2. Bamlanivimab is an IgG1κ monoclonal antibody that targets the spike protein of SARS-CoV-2 and prevents the attachment and entry of the virus into human cells. In mild-moderate cases, Bamlanivimab was authorized to treat mild-moderate SARS-CoV-2 in patients above 12 years old, weight more than 40 kg, and high risk of disease progression and/or hospitalization.2,3 In this case report, the patient developed GBS within a short time period after receiving Bamlanivimab. Other case studies have also reported subsequent development of GBS after treatment with monoclonal antibodies.4,5,6 Ipilimumab, an IgG1 monoclonal antibody that inhibits cytotoxic T lymphocyte-associated antigen 4 (CTLA-4), was associated with GBS development after its use as an adjuvant therapy for patients with melanoma. 4,5 Adalimumab (a tumor necrosis factor alpha inhibitor) was also reported with GBS development when used as therapy for psoriasis and psoriatic arthritis. 6 These monoclonal antibodies have different mechanisms of action and were used in other disorders. CONCLUSIONS: This case report demonstrates that monoclonal antibodies may develop an autoimmune response. This case report is important in highlighting GBS as a potential side effect of Bamlanivimab given its potential for respiratory compromise and its current use in mild to moderate SARS-CoV-2.1,3 REFERENCE #1: Leonhard, S.E., Mandarakas, M.R., Gondim, F.A.A. et al. Diagnosis and management of Guillain–Barre syndrome in ten steps. Nat Rev Neurol 2019;15:671–683. REFERENCE #2: Chen, P., Nirula, A., Heller B. et al. SARS-CoV-2 Neutralizing Antibody LY-CoV555 in Outpatients with Covid-19. N Engl J Med 2021;384:229-237 REFERENCE #3: U.S. Food and Drug Administration. (2021, March 31). Coronavirus (COVID-19) Update: FDA Authorizes Monoclonal Antibody for Treatment of COVID-19. Retrieved from https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-monoclonal-antibody-treatment-covid-19 DISCLOSURES: no disclosure on file for Nia Jagroop;No relevant relationships by Visala Natarajan, source=Web Response No relevant relationships by Gladys Palaguachi, source=Web Response no disclosure on file for Benhoor Shamian;

POST-INFECTIOUS DEMYELINATING POLYNEUROPATHY SECONDARY TO COVID-19 INFECTION

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Coronavirus disease 2019 (Covid-19) began late 2019 in Wuhan, China, declared health care emergency in January 2020 and by March 2020 was declared a pandemic by the WHO. Although respiratory symptoms are most commonly reported, it is important to notice that neurologic complications have been increasingly recognized. Symptoms include headache, dizziness, anosmia, ageusia, and encephalopathy. Demyelinating polyneuropathy presenting as post infectious sequela has not yet been well described. CASE PRESENTATION: Three weeks after being diagnosed with Covid-19, when fully recovered, a 66-year-old man presented with sudden onset walking difficulties owning to symmetric weakness in the lower extremities that rapidly progressed to the upper extremities. Once in respiratory distress with a negative inspiratory force of negative 12, he was intubated due to neuromuscular failure. The diagnosis of Guillain-Barre syndrome (GBS) was made through clinical evaluation in junction with Cerebrospinal Fluid (CSF) analysis (revealing albumin-cytological dissociation), electromyography, and magnetic resonance imaging. He had no significant improvement with intravenous immunoglobulin (400mg/kg/day for five days) and, thus, was started on plasmapheresis treatment (five sessions every other day). Although he only had a mild response, the patient was able to answer simple questions and was enrolled in a long-term physical and occupational therapy. DISCUSSION: Guillain-Barre is an immune-mediated disease that affects the peripheral neurons and nerve roots usually after a preceding respiratory or gastrointestinal illness. There are several proposed mechanisms through which Covid-19 can affect the nervous system. It is thought that the virus can enter the cells via an angiotensin-converting enzyme 2 receptor, invading the peripheral nerve terminals and spreading to the dorsal root ganglion. Then, it potentially shares epitopes similar to neurons, allowing the activation of a cell-mediated immunity leading to neuronal dysfunction. GBS as a sequela of Covid-19 has not been well reported in literature. The case hereby presented had a temporal relationship between the resolution of Covid-19 and the neurologic symptoms. Its rapid progression affecting the peripheral nerves and the albumin-cytological evidence dissociation on CSF analysis led us to consider Guillain-Barre as a strong differential. The poor clinical response despite aggressive treatments is usually associated with a worse prognosis and significant likelihood of reliance on mechanical ventilation. CONCLUSIONS: By reporting this case, we aim to reiterate the importance of fully understanding the spectrum of Covid-19 related complications, in order to prevent further mortality. REFERENCE #1: Huang C, Wang Y, Li X et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497-506. REFERENCE #2: Zubair AS, McAlpine LS, Gardin T, et al. Neuropathogenesis and Neurologic Manifestations of the Coronaviruses in the Age of Coronavirus Disease 2019: A Review. JAMA Neurol. 2020;77(8):1018–1027. REFERENCE #3: Hughes RA, Cornblath DR. Guillain-Barre syndrome. Lancet. 2005 Nov 5;366(9497):1653-66. DISCLOSURES: No relevant relationships by Christiana Atuaka, source=Web Response No relevant relationships by Nishil Dalsania, source=Web Response No relevant relationships by Claudia De Araujo Duarte, source=Web Response No relevant relationships by Bruno De Brito Gomes, source=Web Response No relevant relationships by Varun tej Gonuguntla, source=Web Response No relevant relationships by Ravikaran Patti, source=Web Response No relevant relationships by Chanaka Seneviratne, source=Web Response No relevant relationships by Navjot Somal, source=Web Response

Feasibility study of respiratory function home monitoring for patients with Myasthenia Gravis.

Myasthenia gravis (MG) is a rare and chronic autoimmune neuromuscular disease that causes weakness among skeletal muscles responsible for mobility and breathing. Individuals with MG who have difficulty breathing may need to schedule an emergent provider visit where a negative inspiratory force (NIF) measurement test is performed to measure respiratory strength. Examine the feasibility of individuals with MG to perform NIF respiratory function monitoring in the home setting and determine its impact on their perceived quality of life. This is a quantitative one-group pretest-posttest study of 30 individuals (18-75 years old) who carry the diagnosis of MG and have been stable with treatment for at least 30 days. Participants completed the Brunnsviken Brief Quality of Life Scale (BBQ-LS) and the System Usability Scale (SUS) prestudy. Participants were required to independently perform and record their NIF measurements twice daily for 14 days. After completing the 14 days, participants completed the BBQ-LS, SUS, and an end-of-study survey. There was a significant difference in BBQ-LS scores at baseline (M = 62.97, SD = 17.84) and poststudy (M = 98.2, SD = 13.63) (t[29] = -5.39, p <.000). System Usability Scale scores were significantly different at baseline (M = 77.25, SD = 11.05) than at study completion (M = 94.42, SD = 5.64) (t[29], = -8.04, p = .000). Study results indicate that it is feasible for individuals with MG to perform NIF readings in the home setting and demonstrated an increase in the perceived quality of life. Future large-scale studies can help determine the adoption of handheld NIF monitoring at home for individuals with MG.

Substantiation of the possibility of osteopathic correction inclusion in the measures complex for the preoperative preparation of patients planned for extended abdominal surgery

Introduction. The problem of predicting and preventing of the complications development in the intra- and postoperative period is acutely relevant. There is strong evidence for a correlation between the patient’s preoperative status and the incidence of perioperative complications. At the same time, the search for additional methods for assessing and correcting the preoperative status remains an important task of modern medical science. In the context of this task, more and more attention is being paid to the approaches to diagnosis and treatment developed by osteopathy. Information about such studies for patients planned for abdominal surgery is practically absent in open sources today.The goal of research — is to substantiate the possibility of osteopathic correction inclusion in the measures complex for the preoperative preparation of patients planned for extended abdominal surgery.Materials and methods. The study involved 30 patients planned for extended abdominal surgery. The main and control groups were formed by the method of simple randomization, 15 people were included in each group. The participants of the control group received a standard set of measures for preoperative preparation, and the participants of the main group additionally underwent a course of osteopathic correction. The functioning indicators of the respiratory system [including the rapid shallow breathing index (RSBI) and the maximum value of the negative inspiratory force (NIF)] and the autonomic nervous system (Kerdo index), the pain syndrome severity (assessed by a visual analogue scale), and the actual time of transfer opportunity of patients from intensive care to a profile department (assessed by a modified Aldrete–Kroulik scale).Results. It was found that after the premedication with the previous osteopathic correction course, the number of patients in a state of eutonia has significantly increased, and the number of patients with increased sympathetic tone has decreased. The patients who received osteopathic correction had a statistically significantly lower RSBI index and higher NIF values than those who did not receive the correction (p&lt;0,05). The actual time of the patients transfer to a profile department was also statistically significantly shorter in patients who received osteopathic correction (p&lt;0,05).Conclusion. The obtained results make it possible to recommend the inclusion of osteopathic correction in the complex of measures for the preoperative preparation of patients planned for extended abdominal operations.

Predictors of extubation failure in mechanically ventilated patients with chronic obstructive pulmonary disease

Background Extubation failure is defined as the need for reinstitution of artificial airway within 48–72 h after planned extubation. It is associated with prolonged ICU and hospital stay and is more liable to serious complications and mortality. Objectives To evaluate the frequency of incidence and predictors of extubation failure in mechanically ventilated patients with chronic obstructive pulmonary disease (COPD) and its effect on their outcome. Patients and methods This observational descriptive cross-sectional study was carried out on 150 mechanically ventilated patients with COPD. All patients were assessed regarding the severity of the disease using both acute physiology and chronic health evaluation (APACHE) II and simplified acute physiology score scores and cough strength by white card test, with assessment of the amount of the secretion. All ventilatory parameters were monitored, with more attention given to the following: rapid shallow breathing index, negative inspiratory force (NIF), airway occlusion pressure, and weaning indices. Duration of sedation, complications, length of ICU stay, and also mortality rate were recorded. Results According to outcome of extubation, patients were classified into two basic groups: successfully extubated and failed extubation. Extubation failure occurred in 14.7% of the studied patients. Independent predictors of extubation failure were APACHE II more than 26, NIF less than −19, negative white card, CROP less than 11.5, large amount of secretions, and need for sedation more than 2 days. There were significant increases in the incidence of ventilator-associated pneumonia, mortality, ICU, and hospital stay among reintubated group. Conclusion APACHE II more than 26, NIF less than −19, negative white card, CROP less than 11.5, large amount of secretions, and need for sedation more than 2 days are good predictors of extubation failure in patients with COPD. Extubation failure is associated with more frequent morbidity and mortality.

A Reassessment of Weaning Parameters in Patients With Spontaneous Intracerebral Hemorrhage.

Background and purposePatients with spontaneous intracerebral haemorrhage have significant morbidity and mortality. One aspect of their care is the need for mechanical ventilation. Extubating a patient safely and efficiently is important in advancing their care; however, traditional extubation criteria using the rapid shallow breathing index and negative inspiratory force do not predict success in these patients as well as they do in other intubated patients. This study aimed to evaluate these criteria in patients with spontaneous intracerebral haemorrhage to improve the extubation success rate.MethodsWe conducted a retrospective chart review of patients with spontaneous intracerebral haemorrhage (sICH) who underwent spontaneous breathing trials from 2018 to 2020. Twenty-nine patients met the inclusion criteria, and of these 29, 20 had a trial of extubation. Rapid shallow breathing index (RSBI), negative inspiratory force (NIF), and cuff leak were recorded to analyze breathing parameters at the time of extubation. Patients who required reintubation were noted.ResultsAll trials of extubation required a cuff leak. Using RSBI, patients with values <105 or <85, as the only other extubation criteria, were associated with a 70.6% and 71.4% success rate, respectively. With RSBI <105 and NIF <-25 cm water, the success rate was 88.9%. Any patient with a cuff leak that had a NIF <-30 had a success rate of 100%, regardless of RSBI.ConclusionThe RSBI was not a reliable isolated measure to predict 100% extubation success. Using a NIF <-30 predicts a 100% extubation success rate if a cuff leak is present. This demonstrates that the NIF may be a more useful metric in sICH patients, as it accounts for patient participation and innate ability to draw a breath spontaneously. Future studies are warranted to evaluate further and optimize the extubation criteria in these patients.

Botulism.

This simulation is targeted to emergency medicine residents and medical students. This case focuses on the diagnosis and management of botulism toxicity, while highlighting the logistical complications of botulism toxicity. Botulism is a potentially life-threatening emergency that often presents with subtle symptoms, which can progress to paralysis and respiratory failure. A descending flaccid paralysis is typical, initially affecting smaller muscles such as oculomotor, then larger facial muscles. 1,2 Early indications of respiratory compromise are important to recognize. It is important for emergency medicine physicians to be familiar with botulism and recognize the presentation quickly to safely treat the patient. Clinical findings may include: dilated pupils, diplopia, xerostomia, dysphagia, and nausea and vomiting. 3 Treatment priorities include assessment and management of the airway, close monitoring, and coordinating with local agencies to obtain botulinum antitoxin.1. By the end of this simulation learners will be able to: 1) develop a differential for descending paralysis and recognize the signs and symptoms of botulism; 2) understand the importance of consulting public health authorities to obtain botulinum antitoxin in a timely fashion; 3) recognize that botulism will progress during the time period antitoxin is obtained. Early indications of respiratory compromise are expected to worsen during this time window.Secondary learning objectives include: 4) employ advanced evaluation for neurogenic respiratory failure such as physical examination, negative inspiratory force (NIF), forced vital capacity (FVC), and partial pressure of carbon dioxide (pCO2), 5) discuss and review the pathophysiology of botulism, 6) discuss the epidemiology of botulism. This simulation was conducted using a high-fidelity mannequin with intubating capabilities and real-time vital sign monitoring. Following the simulation, the participants underwent a debriefing session and discussion on botulism. This case was designed as a high-fidelity simulation, but it can be adapted to a low-fidelity simulation or case discussion. Following the simulation and debriefing session, participants were provided with a survey to rate the simulation and provide feedback to instructors. Participants were asked open-ended questions about the strengths and areas of improvement of the case, and were asked to rate how they valued the learning content of the case on a 5-point scale. Emergency medicine residents expressed positive feedback on the scenario. The residents appreciated the change in clinical course of the patient over time as well as the presentation of botulism.Discussion: This simulation is an effective way of teaching about botulism to emergency medicine residents. We used a primary nurse asking questions to progress the case and stimulate the learners to think about certain specific aspects of the case, such as the patient's weakness or disposition.Topics: Toxicology, botulism, emergency medicine, medical simulation.

Predictive value of the negative inspiratory force index as a predictor of weaning success: a crosssectional study.

Background Identifying when intubated patients are ready to be extubated remains challenging. The negative inspiratory force (NIF) is a recommended predictor of weaning success. However, little is known about the role of NIF in the weaning process for the Asian surgical intensive population, especially for the Vietnamese population. Here, we aimed to investigate the cutoff threshold and predictive value of the NIF index for predicting the success of ventilator weaning in Vietnamese surgical intensive care patients.Methods A cross-sectional study was conducted at the Surgical Intensive Care Unit of Viet Duc Hospital from October 2016 to August 2017. A total of 64 patients aged 16–70 years undergoing ventilatory support through an orotracheal tube satisfied the criteria for readiness to begin weaning. The correlation between the NIF index with outcomes of the weaning process was analyzed. Specificity (Sp), sensitivity (Se), positive predictive value (PPV), negative predictive value (NPV), receiver operating characteristic (ROC) curve, and area under the curve (AUC) were calculated.Results The success rate of the entire weaning process was 67.2% (43/64). The median NIF values were –26.0 cm H2O (interquartile range [IQR], –28.0 to –25.0) in the successful weaning group and –24.0 cm H2O (IQR, –25.0 to –23.0) in the weaning failure group (P<0.001). According to ROC analysis, an NIF value ≤–25 cm H2O predicted weaning success (AUC, 0.836) with 91% Se, 62% Sp, 83% PPV, and 77% NPV.Conclusions An NIF cutoff threshold ≤–25 cm H2O can be used as predictor of weaning success in Vietnamese surgical intensive care patients.