Noninvasive Mechanical Ventilation Failure Research Articles

Benefits of dexmedetomidine during noninvasive mechanical ventilation in major abdominal surgery patients with postoperative respiratory failure.

The efficacy of non-invasive mechanical ventilation (NIMV) on the postoperative ARF is conflicting and the failure rate of NIMV in this patient population is high. In our study, we hypothesized that the use of dexmedetomidine during NIMV in major abdominal surgical patients can reduce NIMV failure without significant side affect. Medical records of patients who underwent major abdominal surgery, admitted to our general surgery intensive care unit (ICU), developed postoperative ARF, received NIMV (with oro-nasal mask) and dexmedetomidine infusion were enrolled in this study. The infusion rate was adjusted to maintain a target sedation level of a Richmond Agitation-Sedation Scale (RASS) (-2)-(-3). The sedation was stopped when NIMV was discontinued. A total of 60 patients, 42 (70.0%) male, and 18 (30.0%) female, with a mean age of 68 ± 11 years were included in the study. The mean APACHE II score was 20 ± 6. Dexmedetomidine was infused for a median of 25 h (loading dose of 0.2 mcg/kg for 10 min, maintained at 0.2-0.7 mcg/kg/h, titrated every 30 min). RASS score of all study group significantly improved at the 2 h of dexmedetomidine initiation (+3 vs. -2, p = 0.01). A targeted sedation level was achieved in 92.5% of patients. Six (10.0%) patients developed bradycardia and 5 (8.3%) patients had hypotension. The mean NIMV application time was 23.4 ± 6.1 h. Seven (11.6%) patients experienced NIMV failure, all due to worsening pulmonary conditions, and required intubation and invasive ventilation. Fifty-three (88.3%) patients were successfully weaned from NIMV with dexmedetomidine sedation and discharged from ICU. The duration of NIMV application and ICU stay was shorter in NIMV succeded group (21.4 ± 3.2 vs. 29.9 ± 6.4; p = 0.012). Our study suggests that dexmedetomidine demonstrates effective sedation in patients with postoperative ARF during NIMV application after abdominal surgery. Dexmedetomidine can be considered safe and capable of improving NIMV success.

Use of non-invasive mechanical ventilation in the Emergency Department, clinical outcomes and correlates of failure

Background: Despite several studies having been carried in this organizational context, there is an absence of information about the effectiveness of non-invasive mechanical ventilation (NIV) in Emergency Departments (ED), based on a number of suitable patients with acute respiratory failure (ARF) of different aetiology. In particular, it has not yet been defined as to whether the context of the ED suits the necessary requirement of quality for the correct application of the method and if the obtained results are different from those taken in other studies in general or respiratory intensive care unit. Finally there are few data related to the predictive factors to NIV failure (endotracheal intubation, in-hospital mortality) when applied in the emergency setting. Methods: To answer these questions we have retrospectively studied a population of 210 patients (95 with COPD exsacerbation ; 92 with acute cardiogenic pulmonary oedema; 23 with severe community acquired pneumonia) treated for ARF in the “critical area” of four Italian level II Emergency Departments. For all patients demographic data; some comorbidities (diabetes, dementia, sopraventricular arrhythmias, obesity); the physiological scores (Kelly, SAPS II, Apache II); the need for pharmacological sedation; vital and blood gas parameters (evaluated at entry, after one hour of treatment and before its suspension); the ventilatory modality applied (CPAP or PSV + PEEP) and some parameters of in-hospital stay (duration of the hospitalization in the critical area, duration of ventilation, compliance to the treatment, patient's refusal to continue it, development of skin necrosis, need for endotracheal intubation, in-hospital mortality) were considered. Finally demographic, event of death with Cox regression or to the need for ETI through linear regression analysis. Results: Globally, in-hospital mortality reached 13,3%, the percentage of failure with consequent endotracheal intubation amounted to 10,4% . Considering the single aetiologic groups in the patients with COPD, exsacerbation mortality and ETI percentage were 12,6% and 13,7% respectively; in ACPO patients these data respectively amounted to 3,3% and 4,3%; while for patients with severe CAP they respectively reached 34,7% and 21,7%. The following factors were independently correlated with in-hospital mortality: SAPS II > 35, presence of dementia for COPD patients; SAPS II > 35; presence of dementia, presence of sopraventricular arrhythmias for ACPO patients; SAPS II > 35, presence of sopraventricular arrhythmias, presence of dementia for CAP patients. Considering the whole population of 210 patients, the predictive factors of in-hospital mortality were the following: SAPS II > 35; presence of dementia; presence of sopraventricular arrhythmias; maintenance of a respiratory rate above 24 bpm during tratment. The following were factors independently correlated with the need for endotracheal intubation: male gender, pH < 7,32, respiratory rate > 24 bpm, mean arterial pressure > 96 mmHg, all measured at one hour of treatment, for COPD patients; male gender sex, pH < 7,32 , respiratory rate > 24 bpm, PaCO2> 54,5 mm Hg all measured after one hour treatment for ACPO patients. Given the low number of patients, it was not possible to perform the logistic regression and to calculate the matrix of covariance of the parameter for the CAP group. Considering the whole series of patients, the factors independently correlated to ETI resulting in the following: male gender; diagnosis of COPD; pH < 7,32, respiratory rate > 24 bpm, mean arterial pressure > 96 mm Hg, PaCO2 > 54,5 mm Hg, all measured after one hour treatment. Conclusions: In conclusion, our study shows that NIV is racticable in the ED with safety and clinical results I T A L I A N J O U R N A L O F P U B L I C H E A L T H JPH - Year 6, Volume 5, Number 3, 2008 T H E M E P A P E R S 1 9 9

Ultrasonographic Evaluation of Diaphragmatic Thickness versus Excursion as a Predictor of Weaning in Mechanically Ventilated Patients

Abstract Background Best predictor of successful extubation after mechanical ventilation is a matter of debate. Objective The aim of this study was to assess the efficiency of diaphragm thickness and/or diaphragm excursion as measured by means of ultrasound as a predictor of extubation in mechanically ventilated patients in ICU. Methods We performed a prospective study on fifty patients who successfully passed spontaneous breathing trial (SBT). During T-tube spontaneous breathing trial (SBT) we evaluated the right hemidiaphragm excursion by using the M mode and diaphragmatic thickness fraction (DTF%) using B mode, and they were classified in to the successful extubation group and the failure group. Primary outcome: defined as weaning failure and requirement of either noninvasive ventilation or mechanical ventilation. Secondary outcome: To investigate possible factors related to weaning failure Results Of the 50 patients in the study, 35 patients were successfully weaned and 15 failed weaning. The mean diaphragmatic thickness fraction with respect to cut-off value was higher in the failure group during SBT whereas the diaphragmatic excursion with respect to cut off value was less in the failure group during SBT while there was increase in both DTF and diaphragmatic excursion with respect to cut off value in the success group. The diaphragmatic excursion cut-off value predictive of weaning was 10 mm with a specificity 78% and sensitivity 82% respectively and the diaphragmatic thickness cut-off value predictive of weaning was 21.5% with a specificity of 71% and sensitivity of 76% respectively. There was negative correlation between diaphragmatic function and duration of mechanical ventilation. Conclusion The diaphragmatic ultrasonography was found to be a promising tool for predicting the extubation outcome for mechanically ventilated patients.

Morbimortality and Six-Month Survival Among Elderly Patients Treated With Noninvasive Mechanical Ventilation in an Intermediate Care Unit: A Retrospective Evaluation.

Noninvasive mechanical ventilation (NIMV) has been established as a successful therapeutic option for patients with acute respiratory failure (ARF) with a specific etiology. This study evaluated the morbimortality of patients with ARF treated with NIMV in a medical intermediate care unit (UCINT) to identify factors associated with higher in-hospital mortality, six-month mortality, and three- and six-month hospital readmission rates. This retrospective cohort study included elderly patients admitted for ARF and treated with NIMV in the UCINTbetween 2015 and 2019. In the sample of 102 patients, the median age was84.2(±5.5) years, and 57% were women. In total, 28% were on long-term oxygen therapy, and 68% had a do-not-resuscitate order. At admission, the median Charlson comorbidity index and Barthel index of activities of daily living were 7[6; 8]and 30[20; 57,5],respectively. The simplified acute physiology score IIwas 39.1±10.7, and 92% of patients had type 2 ARF. Median days on NIMV and days in UCINT were 10[6; 16]and 6[3; 10], respectively. The main conditions requiring UCINT admission for NIMV were heart failure, pneumonia, and exacerbation of the chronic obstructive pulmonary disease. The NIMV failure rate was 7%. At discharge, the average Barthel index was 35[10; 55]. The in-hospital mortality rate was 23%. Older age, higher simplified acute physiology score II, higher Charlson comorbidity index, and higher number of days on NIMV were associated with higher in-hospital mortality. Long-term oxygen therapy was associated with higher three-month mortality. A higher Barthel index at the time of hospital discharge was associated with a higher six-month readmission rate. NIMV can be used successfully in elderly patients and less studied ARF etiologies, such as pneumonia.

Success and failure of non-invasive mechanical ventilation in the management of patients with COVID-19


 
 
 
 
 
 
 The Article Abstract is not available.
 
 
 
 
 
 
 
 
 

Clinical significance of the neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in acute exacerbations of COPD: present and future.

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a leading cause of hospitalisation and death in COPD patients. In addition to the identification of better strategies to prevent AECOPD, there is an intense focus on discovering novel markers of disease severity that enhance risk stratification on hospital admission for the targeted institution of aggressive versus supportive treatments. In the quest for such biomarkers, an increasing body of evidence suggests that specific indexes derived from routine complete blood counts, i.e. the neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR), can significantly predict adverse outcomes in AECOPD. This narrative review discusses the current evidence regarding the association between the NLR and the PLR on admission and several clinical end-points (need for invasive ventilation, noninvasive mechanical ventilation failure, admission to an intensive care unit, pulmonary hypertension, length of hospitalisation, and mortality) in AECOPD. Future research directions and potential clinical applications of these haematological indexes in this patient group are also discussed.

Noninvasive Mechanical Ventilation with Average Volume-Assured Pressure Support versus BiPAP S/T in De Novo Hypoxemic Respiratory Failure.

Background Bilevel positive airway pressure in spontaneous/time and average volume-assured pressure support (BiPAP·S/T–AVAPS) could maintain an adequate tidal volume by reducing the patient's inspiratory effort; however, this ventilatory strategy has not been compared with other ventilatory modes, especially the conventional BiPAP S/T mode, when noninvasive mechanical ventilation (NIMV) is used. The primary objective of this study was to determine the rate of success and failure of the use of BiPAP·S/T-AVAPS versus BiPAP·S/T alone in patients with mild-to-moderate “de novo” hypoxemic respiratory failure. Methods This was a matched-cohort study. Subjects with mild-to-moderate de novo hypoxemic respiratory failure were divided into two groups according to the ventilatory strategy used. The subjects in the BiPAP·S/T group were paired with those in the BiPAP·S/T-AVAPS group. Results A total of 58 subjects were studied. Twenty-nine subjects in the BiPAP·S/T group were paired with 29 subjects in the BiPAP·S/T-AVAPS group. Twenty patients (34.5%) presented with “failure of NIMV,” while 38 (65.5%) patients did not. In addition, 13 (22.4%) patients died, while 45 (77.6%) recovered. No differences were found in the percentage of intubation (P=0.44) and mortality (P=0.1). Conclusion The BiPAP S/T-AVAPS ventilator mode was not superior to the BiPAP·S/T mode. A high mortality rate was observed in patients with NIMV failure in both modes. This trial is registered with https://doi.org/10.1186/ISRCTN17904857.

Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary diseaseon general respiratory wards

Background- Chronic Obstructive Pulmonary disease (COPD) as defined by Global Initiative for Obstructive Lung Disease (GOLD) is a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Objectives-To evaluate outcome of NIV in terms ofTime for reversion of pH to normal, Duration of NIV, Hospital stay, Failure of NIV, Mortality and to compare the effect of noninvasive mechanical ventilation (NIV) in severelyacidotic (pH < 7.25) with mildly acidotic (pH 7.25–7.35) patients with acute hypercapnic chronic obstructive lung disease (COPD) Methods-This is a prospective observational study of COPD patients with acute Type 2 respiratory failure initiated on NIV conducted in Christian Medical College, Vellore, Tamil Nadu. The study was conducted in the Department of Pulmonary Medicine, Christian Medical College, Vellore.Assuming the mean as 12h (SD=6h), the sample size is Hence it is decided to sample 25 mild acidosis and 25 severe acidosis cases for this study. In the present study, 53 patients were recruited from April 2017 to June 2018.

Predictor factors for non-invasive mechanical ventilation failure in severe COVID-19 patients in the intensive care unit: a single-center retrospective study

BackgroundDuring the COVID-19 pandemia, non-invasive mechanical ventilation (NIV) has been largely applied. Few data are available about predictors of NIV failure in critical COVID-19 patients admitted to ICU. The aim of this study is to analyze clinical and laboratory features able to predict non-invasive ventilation success in avoiding endotracheal intubation.MethodsA retrospective observational study was performed in our COVID-19 ICU during a 6-month period. Demographic, clinical, laboratory, imaging, and outcome data were extracted from electronic and paper medical records and anonymously collected.ResultsEighty-two severe COVID-19 patients were supported by NIV at ICU admission. The median PaO2/FiO2 ratio was 125 [98.5–177.7]. NIV failed in 44 cases (53%). Patients who experienced NIV failure had a higher Charlson Comorbidity Index (median value 4) compared to those who were dismissed without endotracheal intubation (median 2, p < 0.0001). At Cox regression analysis, the Charlson Comorbidity Index represented a predictive factor related to NIV failure. PaO2/FiO2, CPK, INR, and AT III at ICU admission showed a significant relationship with the outcome, when single variables were adjusted for the Charlson Comorbidity Index.ConclusionThe Charlson Comorbidity Index may be helpful to stratify patients’ risk of NIV failure in a severe COVID-19 population; even if this study, retrospective design does not allow definitive conclusions.

Noninvasive or Invasive Mechanical Ventilation in Oncohematologic Patients with Acute Respiratory Failure: A Systematic Review and Meta-Analysis

Background: Acute respiratory failure (ARF) in oncohematologic subjects is one of the most common causes of high mortality rates. Noninvasive mechanical ventilation (NIMV) has arisen as an accessory treatment in this clinical scenario. Objective: This study aimed to compare mortality rates and severity of illness associated with NIMV or invasive mechanical ventilation (IMV) in oncohematologic patients with ARF. Methods: A search was conducted in the PubMed, SCOPUS, Cochrane Library, LILACS, Web of Science, and gray literature databases, published between November 2007 and May 2021. Results: Eight studies with a total of 570 patients were included. Patients with good responses to NIMV showed lower values of the Simplified Acute Physiology Score III (SAPS 3) (range: 42±7 to 53±17) when compared to those intubated following NIMV failure (range: 50±11 to 63.3±17.4) and those who underwent IMV as the primary ventilator support (range: 64.9±17.5 to 66±17). Similarly, patients whose NIMV treatment failed and those that initially used IMV had higher baseline values of Sequential Organ Failure Assessment Score (SOFA) when compared to the group with a good response to NIMV. ICU mortality ranged from 40% to 68% in NIMV success, 54% to 79% in NIMV failure, and from 54% to 80% in the group treated with IMV. NIMV therapy had a significant protective effect on mortality (RR=0.71, 95% CI: 0.53-0.94, p=0.02). Conclusions: NIMV use in oncohematologic patients admitted to the intensive care units (ICU) with ARF was associated with lower mortality. Patients successfully treated in the NIMV group showed lower values of SOFA and SAPS 3 (Prospero Systematic Review -protocol number: 132770).

Exacerbation of COPD Treatment Combination Therapy NIV with Thermal Helium- Oxygen Plus Nitric Oxide: A Case Report

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide despite increased health care efforts, financial costs, and research concerning its early diagnosis and proper management [1]. The most relevant event affecting COPD mortality is the acute exacerbation of COPD (AECOPD), a catastrophic event during the clinical course of the disease [2]. In cases of acute respiratory acidosis, noninvasive mechanical ventilation (NIV) is considered. Nevertheless, in 30% of patients with severe exacerbation of COPD, NIV does not lead to the desired results [3]. However, there have been cases of NIV failure in patients with severe respiratory acidosis, and associated pulmonary arterial hypertension. Many studies have shown that thermal helium-oxygen and nitric oxide gas heat treatment has many effects. Here we are reporting a case of severe exacerbation COPD, 67 years old male patient, who came to us with shortness of breath, fever, wheezing and a cough with yellow phlegm. He had a history of smoking 30 pack-year smoker many years. He was given NIV treatment with a combination of helium and nitric oxide heat. And we have had very good results.

The Neutrophil/Lymphocyte Ratio Could Predict Noninvasive Mechanical Ventilation Failure in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Retrospective Observational Study.

PurposeTo determine the effectiveness of neutrophil/lymphocyte ratio (NLR), compared to traditional inflammatory markers, for predicting noninvasive mechanical ventilation (NIMV) failure in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients.Patients and MethodsWe conducted this retrospective observational study including 212 AECOPD patients who required NIMV during hospitalization from January 2015 to December 2020 in the department of respiratory and critical care medicine of Beijing Chao-Yang Hospital (west campus). We reviewed the medical record to determine if NIMV succeeded or failed for each patient, and compared NLR with traditional markers (leukocyte, C-reactive protein [CRP] and procalcitonin [PCT]) between NIMV failure and NIMV success group. Receiver-operating characteristic (ROC) curve and multivariate logistic regression analysis were used to assess the accuracy of these markers for predicting NIMV failure.ResultsA total of 38 (17.9%) patients experienced NIMV failure. NLR was a more sensitive biomarker to predict NIMV failure (AUC, 0.858; 95% CI 0.785–0.931) than leukocyte counts (AUC, 0.723; 95% CI 0.623–0.823), CRP (AUC, 0.670; 95% CI 0.567–0.773) and PCT (AUC, 0.719; 95% CI 0.615–0.823). There was statistically positive correlation between NLR and leukocytes count (r=0.35, p<0.001), between NLR and CRP (r=0.258, p<0.001), between NLR and PCT (r=0.306, p<0.001). The cutoff value of NLR to predict NIMV failure was 8.9 with sensitivity 0.688, specificity 0.886 and diagnostic accuracy 0.868. NLR>8.9 (odds ratio, 10.783; 95% CI, 2.069–56.194; P=0.05) was an independent predictor of NIMV failure in the multivariate logistic regression model.ConclusionNLR may be an effective marker for predicting NIMV failure in AECOPD patients, and the patients with NLR>8.9 should be handled with caution since they are at higher risk of NIMV failure and require intubation. Further study with a larger sample size and with more data is necessary to confirm our study.

Predictive factors for noninvasive mechanical ventilation failure among COVID-19 critically ill patients - a retrospective cohort study.

Aim To identify predictive factors related with noninvasive ventilation (NIV) failure that are not based on the patient's respiratory status or acid base gas analyses in COVID-19 critically ill patients, and to create a predictive model of NIV failure. Methods A total of 73 COVID-19 critically ill patients who developed acute respiratory failure and underwent NIV were divided into two groups: Group 1, patients who required endotracheal intubation and invasive mechanical ventilation after NIV and Group 2, patients with successful weaning from NIV. Demographic data, clinical symptoms and signs, clinical index and scores, duration indicators and laboratory data were analysed. Predictive factors of NIV failure were assessed using univariate and multivariate regression analyses followed by the receiver operating characteristic (ROC) curve. Results In the Group 1 (NIV failure) there were 54 (73.97%) patients. Predictive factors for NIV failure were: the presence of dyspnoea on the day of admission at hospital (p<0.05; sensitivity 44.40%; specificity 84.20%), higher radiographic assessment of lung oedema score (RALES) on the day of starting NIV (p<0.009; sensitivity 70.40%; specificity 73.75%), higher length of NIV (p<0.014; sensitivity 48%; specificity 84.10%) and higher urea on the day of starting NIV (p<0.004; sensitivity 70.44%; specificity 73.72%) Conclusion NIV treatment in COVID-19 critically ill patients has a high failure rate. In addition to respiratory parameters, dyspnoea, higher RALES, higher length of NIV and increased urea value could predict NIV failure. These factors should be considered in treatment decision making.

The association between cardiac intensive care unit mechanical ventilation volumes and in-hospital mortality.

The incidence of respiratory failure and use of invasive or non-invasive mechanical ventilation (MV) in the cardiac intensive care units (CICUs) is increasing. While institutional MV volumes are associated with reduced mortality in medical and surgical ICUs, this volume-mortality relationship has not been characterized in the CICU. National population-based data were used to identify patients admitted to CICUs (2005-2015) requiring MV in Canada. CICUs were categorized into low (≤100), intermediate (101-300), and high (>300) volume centres based on spline knots identified in the association between annual MV volume and mortality. Outcomes of interest included all-cause in-hospital mortality, the proportion of patients requiring prolonged MV (>96 h) and CICU length of stay (LOS). Among 47173 CICU admissions requiring MV, 89.5% (42200) required invasive MV. The median annual CICU MV volume was 43 (inter-hospital range 1-490). Compared to low-volume centres (35.9%), in-hospital mortality was lower in intermediate [29.2%, adjusted odds ratio (aOR) 0.84, 95% confidence interval (CI) 0.72-0.97, P = 0.019] and high-volume (18.2%; aOR 0.82, 95% CI 0.66-1.02, P = 0.076) centres. Prolonged MV was higher in low-volume (29.2%) compared to high-volume (14.8%, aOR 0.70, 95% CI 0.55-0.89, P = 0.003) and intermediate-volume (23.0%, aOR 0.85, 95% CI 0.68-1.06, P = 0.14] centres. Mortality and prolonged MV were lower in percutaneous coronary intervention (PCI)-capable and academic centres, but a shorter CICU LOS was observed only in subgroup of PCI-capable intermediate- and high-volume hospitals. In a national dataset, we observed that higher CICU MV volumes were associated with lower incidence of in-hospital mortality, prolonged MV, and CICU LOS. Our data highlight the need for minimum MV volume benchmarks for CICUs caring for patients with respiratory failure.

PH, CRP as Prognostic Indicators for the Success of Treatment with Non-invasive Ventilation in Patients with Chronic Respiratory Failure Type II

Background: Non-invasive mechanical ventilation (NIMV) provides an alternative option to the initiation of invasive mechanical ventilation in patients with acute respiratory failure, avoiding the associated adverse events.&#x0D; Objective: the present study aimed to assess the outcome of the patients who were initially treated with NIMV and identify the prognostic predictive value of PH and CRP for NIMV failure.&#x0D; Materials and methods: This was observational analytical study conducted in the Department of Pulmonology in Tishreen University Hospital –Lattakia- Syria from January 2019 to January 2020. Adult patients with the diagnosis of acute on chronic respiratory failure type 2 were enrolled in the study.&#x0D; Results: A total of 67 patients with acute on chronic respiratory failure type 2 were included in the study. The median age was 63 years and 62.7% were male. The patients in the PH group (7.20-7.25) presented higher rates of mortality and admission to intensive care unit (ICU) which represented 25% and 50% respectively. The NIMV failure rate was 22.4%. Frequency of patients with PH≤ 7.31, ΔPH ≤ 0.04, or CRP ≥53.5 were higher in NIMV failure group; (33.3% vs. 3.8%, p: 0.001), (46.7% vs. 23.1% -, p: 0.03), and (53.3% vs. 32.7%, p: 0.04) respectively. Independent predictors for NIMV failure were: PH≤ 7.31(OR 3.3[0.6-7.8], p:0.01) and ΔPH ≤ 0.04(OR&#x0D; 2.1[1.1-3.9], p: 0.02).&#x0D; Conclusion: NIMV is an effective treatment for hypercapnic respiratory failure. Identification independent predictors for NIMV failure may be useful to avoid the possible complications.

Outcomes of noninvasive ventilation as the ceiling of treatment in patients with COVID-19.

Non-invasive mechanical ventilation (NIV) is effective for symptom relief and respiratory support in patients with respiratory insufficiency, severe comorbidities and no indication to intubation. Experience with NIV as the ceiling of treatment in severely compromised novel coronavirus disease (COVID-19) patients is lacking. We evaluated 159 patients with COVID-19-related acute respiratory syndrome (ARDS), 38 of whom with NIV as the ceiling of treatment, admitted to an ordinary ward and treated with continuous positive airway pressure (CPAP) and respiratory physiotherapy. Treatment failure and death were correlated with clinical and laboratory parameters in the whole cohort and in patients with NIV as the ceiling of treatment. Patients who had NIV as the ceiling of treatment were elderly, with a low BMI and a high burden of comorbidities, showed clinical and laboratory signs of multiorgan insufficiency on admission and of rapidly deteriorating vital signs during the first week of treatment. NIV failure occurred overall in 77 (48%) patients, and 27/38 patients with NIV as the ceiling of treatment died. Congestive heart failure, chronic benign hematological diseases and inability/refusal to receive respiratory physiotherapy were independently associated to NIV failure and mortality. Need for increased positive end-expiratory pressures and low platelets were associated with NIV failure. Death was associated to cerebrovascular disease, need for CPAP cycles longer than 12 h and, in the subgroup of patients with NIV as the ceiling of treatment, was heralded by vital sign deterioration within 48 h. NIV and physiotherapy are a viable treatment option for patients with severe COVID-19 and severe comorbidities.

P0389 / #794: PEDIATRIC ACUTE RESPIRATORY DISTRESS SYNDROME IN CHILDREN WITH MALIGNANCIES

Aims & Objectives: There are limited data regarding the clinical characteristics and outcome of pediatric acute respiratory distress syndrome (PARDS) in children with malignancies. The objectives were to investigate the clinical course and mortality of PARDS in children with malignancies. Methods: This is a retrospective cohort study from 2016-2019 in single pediatric intensive care unit. Only PARDS patients who are transferred from the hematology and oncology department were included. Results: Of Seventy-five included patients, 52 children had hematological malignancies including 10 allogeneic bone-marrow transplants and 23 children had solid tumors. Etiological categories were primary infection-related PARDS(n= 41), extrapulmonary septic shock-related PARDS (n = 29); noninfectious PARDS (n = 5). Eight patients received non-invasive mechanical ventilation (NIV), 22 received invasive mechanical ventilation(MV), and 45 received both NIV and invasive MV. PICU mortality was 82% in the cohort. The presence of two or more organ failures and bone-marrow transplantation were the independent risk factors for mortality, whereas NIV was associated with low mortality. Conclusions: The mortality of PARDS in critically ill children with malignancies is quite high. Multiple organ failure, bone-marrow transplantation, and NIV failure were risk factors for higher mortality.

Non-invasive mechanical ventilation with average volume-assured pressure support. Results according to the aetiology of acute respiratory failure.

Until now, the ventilatory strategy with BiPAP S/T plus average volume-assured pressure support (AVAPS) has not been evaluated for its use in the different types of acute respiratory failure (ARF). Consequently we report the results of the use of this ventilatory strategy in these clinical scenarios. This is asingle-centre prospective study. The subjects were categorised according to the type of ARF: (1) hypercapnic ARF: chronic obstructive pulmonary disease and bronchial asthma; and (2) hypoxaemic ARF: pneumonia, acute respiratory distress syndrome, congestive heart failure, and interstitial lung disease. Multiple logistic regression was used to determine predictors of non-invasive mechanical ventilation (NIV) failure (intubation). Further, in asubgroup of patients with de novo hypoxaemic ARF, analysis of variances with repeated measures was used to determine factors associated with NIV outcome. Sixty-eight subjects were included in this study. The NIV success rate was 69.1% and the mortality rate was 20.6%. Amultivariate analysis showed that the number of affected lung quadrants on chest X-ray (OR: 4.23, 95% CI: 4.17-4.31; P < 0.001) and ARF precipitating disease (OR: 4.46, 95% CI: 4.43-4.51; P < 0.001) were determinants of NIV failure. In the hypoxaemic ARF subgroup (n = 58), significant differences in several parameters were found between patients with positive and negative outcomes. The use of BiPAP S/T - AVAPS in subjects with hypercapnic ARF is associated with abetter outcome than in those with de novo hypoxaemic ARF.

Factors Predicting the Outcome of Noninvasive Ventilation in Acute Respiratory Failure Secondary to Chronic Obstructive Pulmonary Disease Exacerbation

Introduction: Non-invasive Mechanical Ventilation (NIV) is a better alternative for treating respiratory failures of any cause compared to invasive ventilation. Various factors influence the outcomes of patients treated with NIV in acute respiratory failure secondary to Chronic Obstructive Pulmonary Disease (COPD). Aim: To determine the possible early predictors and associated factors influencing the outcome of NIV in acute respiratory failure due to COPD patients. Materials and Methods: This was hospital-based observational study undertaken at SRM Medical Hospital and Research Centre in the Respiratory Medicine Department, after obtaining ethical clearance and informed patient consent. All patients with COPD exacerbation were admitted to the respiratory medicine ward. An Arterial Blood Gas (ABG) analysis was carried out, and those patients with type 2 respiratory failure were included in the study. This study included 42 patients with acute respiratory failure secondary to COPD requiring NIV. Data of patient's ABG parameter, heart rate, blood pressure, and respiratory rate baseline values were noted and at an interval of one hour, six hours, and every 24 hours were recorded. The outcome was divided into two categories depending upon whether patients improved or required invasive ventilation. Data were entered in Microsoft Excel datasheet and was analysed using Statistical Package For The Social Sciences (SPSS) 22 version software. Results: Of 42 patients, 30 (71.42%) were treated successfully with NIV, while 12(28.57%) required invasive ventilation and were declared NIV failure (requiring invasive ventilation). Among the patients, it was observed that patients with mean age &gt;60 years, BMI &gt;26.5, baseline pH &lt;7.2, PaCO2 &gt;78, heart rate &gt;120, respiratory rate &gt;40, co-morbidities and infective exacerbation were requiring invasive ventilation. It was also observed that among the failure category patients treated with conventional Spontaneous and Timed (S/T) mode showed more failure rates than Average Volume Assured Pressure Support (AVAPS) S/T mode. Conclusion: Patients with acute respiratory failure secondary to COPD responds well to NIV. The baseline pH, PaCO2, HR and Respiratory Rate (RR) before initiation of NIV predicts outcome. Also, age, BMI, associated comorbidities and mode of NIV predicts the outcome.

Identification of COVID-19 Clinical Phenotypes by Principal Component Analysis-Based Cluster Analysis

Background: COVID-19 has been quickly spreading, making it a serious public health threat. It is important to identify phenotypes to predict the severity of disease and design an individualized treatment.Methods: We collected data from 213 COVID-19 patients in Wuhan Pulmonary Hospital from January 1 to March 30, 2020. Principal component analysis (PCA) and cluster analysis were used to classify patients.Results: We identified three distinct subgroups of COVID-19. Cluster 1 was the largest group (52.6%) and characterized by oldest age, lowest cellular immune function, and albumin levels. 38.5% of subjects were grouped into Cluster 2. Most of the lab results in Cluster 2 fell between those of Clusters 1 and 3. Cluster 3 was the smallest cluster (8.9%), characterized by youngest age and highest cellular immune function. The incidence of respiratory failure, acute respiratory distress syndrome (ARDS), heart failure, and usage of non-invasive mechanical ventilation in Cluster 1 was significantly higher than others (P < 0.05). Cluster 1 had the highest death rate of 30.4% (P = 0.005). Although there were significant differences in age between Clusters 2 and 3 (P < 0.001), we found that there was no difference in demand for medical resources.Conclusions: We identified three distinct clusters of the COVID-19 patients. The results show that age alone could not be used to assess a patient's condition. Specifically, management of albumin, and immune function are important in reducing the severity of disease.