Use Of Noninvasive Mechanical Ventilation Research Articles

The Effect of Non-Invasive Mechanical Ventilation on Respiratory and Inflammatory Parameters in Patients with Chronic Obstructive Pulmonary Disease

Background: Chronic Obstructive Pulmonary Disease (COPD) is an airway obstructive disease that is often caused by smoking. The disease is currently the third leading cause of death worldwide. The current therapeutic approach is based on Non-Invasive Ventilation (NIV) therapy, which can reduce mortality, the need for hospitalization in the intensive care unit, and to some extent therapeutic complications. Therefore, this study was performed to determine the effect of non-invasive ventilation along with routine treatments on respiratory markers, inflammation, and clinical status of patients with COPD. Methods: A total of 30 patients with COPD referred to Masih Daneshvari Hospital were divided into control and intervention groups. In the intervention group, 15 patients underwent non-invasive ventilation in addition to the usual treatments, and in the control group, the patients underwent only the usual treatments. After completing the mMRC (Modified Medical Research Council) questionnaire and evaluating FEV1 (Forced Expiratory Value in one score), 5 ml of blood samples were taken from these patients at the beginning of the study, on the seventh to tenth day, and also in the third month, and the results of this evaluation were compared between the two groups. Results: Based on the results of this study, the mMRC score of the intervention group was significantly lower than the control group in the first week (p=0.043) and three months after treatment (p=0.049). However, indices such as FEV1, and IL-8(Interleukin-8) did not change significantly in both groups. Conclusion: The use of non-invasive mechanical ventilation along with standard treatments can play a relative role in improving patient outcomes.

Secretion management in patients with ineffective airway clearance with non-invasive mechanical ventilation use: Expert guidance for clinical practice.

Non-invasive ventilation (NIV) is a mainstay of management of chronic respiratory failure in many disorders which are known to cause abnormal airway secretion clearance. Currently, there is no guidance regarding either the secretion handling during NIV use or the role of NIV in secretion management in these patients. The aim of this document was to provide an overview of the various techniques available in the management of respiratory secretions and their use in conjunction with NIV. Literature search was performed using the keywords, "(secretion OR secretions) AND (noninvasive ventilation OR NIV)" on PubMed and EMBASE. The search yielded 1681 and 509 titles from PubMed and EMBASE, respectively. After screening, 19 articles were included in this review. Suggestions of the expert panel were formulated by mutual consensus after reviewing the relevant literature. The draft of the expert panel's suggestions was circulated among all authors via electronic mail for comments. Any conflicts were resolved by mutual discussion to achieve agreement. The final document was approved by all. This document by the International Network for Airway Secretions Management in NIV describes various airway secretion clearance techniques. It provides the expert panel's suggestions for the use of these techniques in conjunction with NIV for patients with muco-obstructive and neuromuscular disorders.

Clinical factors associated with death in 3044 COVID-19 patients managed in internal medicine wards in Italy: results from the SIMI-COVID-19 study of the Italian Society of Internal Medicine (SIMI).

During the COVID-19 2020 outbreak, a large body of data has been provided on general management and outcomes of hospitalized COVID-19 patients. Yet, relatively little is known on characteristics and outcome of patients managed in Internal Medicine Units (IMU). To address this gap, the Italian Society of Internal Medicine has conducted a nationwide cohort multicentre study on death outcome in adult COVID-19 patients admitted and managed in IMU. This study assessed 3044 COVID-19 patients at 41 referral hospitals across Italy from February 3rd to May 8th 2020. Demographics, comorbidities, organ dysfunction, treatment, and outcomes including death were assessed. During the study period, 697 patients (22.9%) were transferred to intensive care units, and 351 died in IMU (death rate 14.9%). At admission, factors independently associated with in-hospital mortality were age (OR 2.46, p = 0.000), productive cough (OR 2.04, p = 0.000), pre-existing chronic heart failure (OR 1.58, p = 0.017) and chronic obstructive pulmonary disease (OR 1.17, p = 0.048), the number of comorbidities (OR 1.34, p = 0.000) and polypharmacy (OR 1.20, p = 0.000). Of note, up to 40% of elderly patients did not report fever at admission. Decreasing PaO2/FiO2 ratio at admission was strongly inversely associated with survival. The use of conventional oxygen supplementation increased with the number of pre-existing comorbidities, but it did not associate with better survival in patients with PaO2/FiO2 ratio < 100. The latter, significantly benefited by the early use of non-invasive mechanical ventilation. Our study identified PaO2/FiO2 ratio at admission and comorbidity as the main alert signs to inform clinical decisions and resource allocation in non-critically ill COVID-19 patients admitted to IMU.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11739-021-02742-8.

Risk and Prognostic Factors in Perinatal Hemorrhagic Stroke.

Background:Perinatal stroke encompasses a heterogeneous group of focal neurological injuries early in brain development. In this study, we aimed to compare risk and prognostic factors in preterm and term infants with perinatal hemorrhagic stroke (PHS).Patients and Methods:The study includes 66 infants with PHS. The infants were evaluated for demographic characteristics, fetal and maternal risk factors, perinatal events, clinical and neuroimaging findings, complications, and sequales.Results:Of 66 infants with PHS, 44 (66.70%) were preterm and 22 (33.30%) were term infants. Primiparity, mucosal bleeding, and multiple lobes involvement were more common in term infants than preterm infants (P < 0.05); however, respiratory insufficiency, neonatal sepsis, perinatal asphyxia, respiratory distress syndrome, use of invasive mechanical ventilation, use of noninvasive mechanical ventilation, and prolonged hospitalization were more common in preterm infants than term infants (P < 0.05). Eight (12.12%) infants died during infancy period. Small for gestational age and mucosal bleeding were more common in infants who are dead than those alive (P < 0.05). Forty-two (63.63%) infants were followed. Cerebral palsy and/or epilepsy and/or hydrocephalus were diagnosed in 36 (85.72%) infants during follow-up.Conclusion:Our findings showed that PHS was much more common in preterm infants. Mucosal bleeding and multiple lobes involvement were more common in term infants. PHS has high morbidity and mortality rates. Small for gestational age and mucosal bleeding were more common in infants who are dead.

Diaphragmatic dysfunction at the first visit to a chest diseases outpatient clinic in 500 patients with amyotrophic lateral sclerosis

In this study, we aimed to evaluate diaphragmatic dysfunction (DD) by using a practical approach in patients with amyotrophic lateral sclerosis (ALS) at the first visit to a chest diseases outpatient clinic. Patients with ALS seen in our outpatient clinic for the past 5 y and followed up for at least 1 y, were retrospectively evaluated. Having at least one of the following three criteria was accepted as DD: (a) paradoxical abdominal movement (PAM), (b) sitting-supine forced vital capacity (FVC) difference ≥ 20%, (c) sitting-supine arterial oxygen saturation measured by pulse oximetry (SpO2 ) difference ≥ 4%. Respiratory symptoms, arterial blood gas analysis, sleep studies, noninvasive mechanical ventilation use, and mortality were recorded. Five-hundred patients with ALS were included (female/male: 220/280, age: 58.9 ± 11.3 y). Of the patients, 22.8% had daytime hypercapnia. DD was observed in 55% of the patients (PAM in 112, sitting-supine FVC difference ≥ 20% in 50, and sitting-supine SpO2 difference ≥ 4% in 113 patients). Of the patients with DD, 31.6% (n = 87) had no respiratory symptoms, 46.4% had FVC > 70% and 33.5% had FVC <50%. Nocturnal hypoxemia (sleep time spent with SpO2 < 90% ≥30%) was present in 59.7%, and all patients with nocturnal hypoxemia had DD. Obstructive sleep apnea (8 severe, 14 moderate, 39 mild) was detected in 55% of the patients with polysomnography (n = 61) or polygraphy (n = 50). During follow-up, 52.2% of the patients died. Mean survival time was shorter in patients with DD (P < .001). Paradoxical abdomimal movement (PAM), sitting-supine SpO2 difference ≥ 4% and sitting-supine FVC difference ≥ 20% are indicators of DD, which should be routinely evaluated at every outpatient visit.

Penggunaan Ventilasi Mekanik non Invansif Untuk Mengatasi Kegagalan Pernafasan pada Pasien dengan Edema Pulmo Akut Kardiogenik

Background: Cardiogenic Pulmo edema can cause a heterogeneous syndrome with a mortality rate of up to 9.5% (Aliberti et all., 2018).Objective: The purpose of this paper was to explain how effective the use of non-invasive mechanical ventilation in patients with acute pulmonary edema with respiratory failure.&#x0D; Methods: The literature review was compiled by synthesizing and comparing various relevant scientific articles from the literature search results using the online database of Proquest and Clinicalkey Elsevier that have significance related to the management of acute cardiogenic pulmo edema.&#x0D; Result: Compared with conservative therapy, noninvasive mechanical ventilation has been shown more effective in improving oxygenation in patients with acute cardiogenic pulmo edema Non-invasive ventilation can reduce dyspnea, acidosis and hypercapnea faster than standard oxygen therapy. Studies show that compared to endotracheal intubation, non-invasive mechanical ventilation is associated with a lower risk of nosocomial infection, lower antibiotic use, shorter length of stay in intensive care units and lower mortality. Study found that there were no differences betwen the two setting of non-invasive mechanical ventilation used, Bilevel positive Airway Pressure (BiPAP) and Continues positive Airway Pressure (CPAP) in patients outcomes. However, there are absolute and relative contraindications that must be considered, including the effectiveness of the therapy being insignificant when given too late&#x0D; Conclusion: Noninvasive mechanical ventilation can be considered as the first choice in the management of acute cardiogenic pulmonary edema because of its high clinical effectiveness representing a rescue action for patients not improving with conventional oxygen therapy.

Predictors for long-term mortality in COPD patients requiring non-invasive positive pressure ventilation for the treatment of acute respiratory failure.

IntroductionThe effectiveness of non‐invasive mechanical ventilation (NIV) in the management of COPD patients suffering from acute respiratory failure (ARF) as a consequence of exacerbation of the disease, is well established. However, data on long‐term outcomes and their predictors, including the individual response to NIV, are scarce.ObjectivesTo investigate predictors for short‐ and long‐term mortality in this study population.MethodsA retrospective cohort study was performed including all patients admitted to the Medium Respiratory Care Unit of Maastricht University Medical Center in Maastricht, the Netherlands, with hospitalized exacerbation of COPD (H‐ECOPD) with ARF requiring NIV for the first time between January 2009 and December 2011. An extensive number of potential predictors of outcomes, including the response to NIV, were determined on admission and during hospitalization. Univariate and multivariate logistic regression was used for statistical analysis.ResultsSeventy‐eight consecutive patients with moderate to severe COPD (mean age 71.0 ± 10.7 years; 48.7% males) were included; In‐hospital, 1‐year and 2‐year mortality rates were 14.1%, 43.6% and 56.4%, respectively. Independent risk factors for 2‐year mortality were: advanced age (odds ratio(OR) 1.025; confidence interval (CI) 1.002‐1.049; P = 0.037), prolonged NIV use more than 8 days (OR:1.054;CI:1.006‐1.104; P = 0.027) and no successful response to NIV (OR:2.392;CI:1.297‐4.413; P = 0.005).ConclusionPatients with an H‐ECOPD requiring NIV for the first time, constitute a severely ill patient group with high in‐hospital and 2‐year mortality. This study identified advanced age, NIV use more than 8 days and unsuccessful response to NIV as clinical important independent predictors for long‐term mortality.

Azithromycin in addition to standard of care versus standard of care alone in the treatment of patients admitted to the hospital with severe COVID-19 in Brazil (COALITION II): a randomised clinical trial

BackgroundThe efficacy and safety of azithromycin in the treatment of COVID-19 remain uncertain. We assessed whether adding azithromycin to standard of care, which included hydroxychloroquine, would improve clinical outcomes of patients admitted to the hospital with severe COVID-19.MethodsWe did an open-label, randomised clinical trial at 57 centres in Brazil. We enrolled patients admitted to hospital with suspected or confirmed COVID-19 and at least one additional severity criteria as follows: use of oxygen supplementation of more than 4 L/min flow; use of high-flow nasal cannula; use of non-invasive mechanical ventilation; or use of invasive mechanical ventilation. Patients were randomly assigned (1:1) to azithromycin (500 mg via oral, nasogastric, or intravenous administration once daily for 10 days) plus standard of care or to standard of care without macrolides. All patients received hydroxychloroquine (400 mg twice daily for 10 days) because that was part of standard of care treatment in Brazil for patients with severe COVID-19. The primary outcome, assessed by an independent adjudication committee masked to treatment allocation, was clinical status at day 15 after randomisation, assessed by a six-point ordinal scale, with levels ranging from 1 to 6 and higher scores indicating a worse condition (with odds ratio [OR] greater than 1·00 favouring the control group). The primary outcome was assessed in all patients in the intention-to-treat (ITT) population who had severe acute respiratory syndrome coronavirus 2 infection confirmed by molecular or serological testing before randomisation (ie, modified ITT [mITT] population). Safety was assessed in all patients according to which treatment they received, regardless of original group assignment. This trial was registered at ClinicalTrials.gov, NCT04321278.Findings447 patients were enrolled from March 28 to May 19, 2020. COVID-19 was confirmed in 397 patients who constituted the mITT population, of whom 214 were assigned to the azithromycin group and 183 to the control group. In the mITT population, the primary endpoint was not significantly different between the azithromycin and control groups (OR 1·36 [95% CI 0·94–1·97], p=0·11). Rates of adverse events, including clinically relevant ventricular arrhythmias, resuscitated cardiac arrest, acute kidney failure, and corrected QT interval prolongation, were not significantly different between groups.InterpretationIn patients with severe COVID-19, adding azithromycin to standard of care treatment (which included hydroxychloroquine) did not improve clinical outcomes. Our findings do not support the routine use of azithromycin in combination with hydroxychloroquine in patients with severe COVID-19.FundingCOALITION COVID-19 Brazil and EMS.

The burden of obstructive sleep apnea in pediatric sickle cell disease: a Kids' inpatient database study.

Obstructive sleep apnea (OSA) is associated with cardiovascular and cerebrovascular morbidity. Patients with sickle cell disease (SCD) are at increased risk for both neurologic complications (NC) and OSA. However, the relationship between OSA and SCD complications is unclear. We hypothesized that there would be an association between OSA diagnosis and SCD complications. Hospital discharge records of patients with SCD aged < 19 years were obtained for the years 1997, 2000, 2003, 2006, 2009, and 2012 from the Kid's Inpatient Database. The primary outcome, NC, a composite of stroke, transient ischemic attack, and seizures. Secondary outcomes included acute chest syndrome (ACS), vaso-occlusive crisis, length of hospital stay, and inflation-adjusted cost of hospitalization. Multivariable regression was conducted to ascertain the association of OSA with primary and secondary outcomes. Analyses were adjusted for the use of noninvasive mechanical ventilation (NIMV) to determine its role as NC risk modifier. There were 203,705 SCD discharges included in the analysis, of which 2,820 (1.4%) and 4,447 (2.2%) also included OSA and NC diagnoses. Multivariable logistic regression indicated that OSA was associated with NC (adjusted odds ratio [OR], 1.50 [95% CI 1.02-2.21], p = 0.039) and ACS (OR, 1.34 [95% CI 1.08-1.67], p = 0.009) in children with SCD. In the multivariable analysis adjusted for NIMV, the significant association between OSA and NC was no longer observed (OR, 1.39 [95% CI 0.94-2.05], p = 0.100). OSA is associated with a 50% increase of odds of NC in children with SCD in this nationwide dataset. The use of NIMV to treat OSA may modify the risk of OSA-associated NC.

Clinical Profiles in Renal Patients with COVID-19.

The COVID-19 pandemic has led to frequent referrals to the emergency department on suspicion of this infection in maintenance hemodialysis (MHD) and kidney transplant (KT) patients. We aimed to describe their clinical features comparing confirmed and suspected non-confirmed COVID-19 cases during the Spanish epidemic peak. Confirmed COVID-19 ((+)COVID-19) corresponds to patient with positive RT-PCR SARS-CoV-2 assay. Non-confirmed COVID-19 ((−)COVID-19) corresponds to patients with negative RT-PCR. COVID-19 was suspected in 61 patients (40/803 KT (4.9%), 21/220 MHD (9.5%)). Prevalence of (+)COVID-19 was 3.2% in KT and 3.6% in MHD patients. Thirty-four (26 KT and 8 MHD) were (+)COVID-19 and 27 (14 KT and 13 MHD) (−)COVID-19. In comparison with (−)COVID-19 patients, (+)COVID-19 showed higher frequency of typical viral symptoms (cough, dyspnea, asthenia and myalgias), pneumonia (88.2% vs. 14.3%) and LDH and CRP while lower phosphate levels, need of hospital admission (100% vs. 63%), use of non-invasive mechanical ventilation (36% vs. 11%) and mortality (38% vs. 0%) (p < 0.001). Time from symptoms onset to admission was longer in patients who finally died than in survivors (8.5 vs. 3.8, p = 0.007). In KT and MHD patients, (+)COVID-19 shows more clinical severity than suspected non-confirmed cases. Prompt RT-PCR is mandatory to confirm COVID-19 diagnosis.

Supports non invasifs d’oxygénation et de ventilation chez les patients de réanimation considérés comme « palliatifs »

L’admission en réanimation de patients en détresse respiratoire aiguë considérés comme « palliatifs » conduit à l’utilisation privilégiée de ventilation non invasive. Plus récemment l’oxygénothérapie nasale à haut débit humidifi é est venuecompléter les possibilités de prise en charge. Le pronostic de ces patients est à l’évidence réservé, notamment si lapathologie sous-jacente est un cancer ou une hémopathie évolutive. Cependant un certain nombre de ces patientspeut avoir une évolution favorable et retrouver une qualité de vie satisfaisante. Cet article passe en revue les pratiquesutilisées pour ces patients.

Protocol for two-arm pragmatic cluster randomized hybrid implementation-effectiveness trial comparing two education strategies for improving the uptake of noninvasive ventilation in patients with severe COPD exacerbation

BackgroundCOPD is the fourth leading cause of death in the US, and COPD exacerbations result in approximately 700,000 hospitalizations annually. Patients with acute respiratory failure due to severe COPD exacerbation are treated with invasive (IMV) or noninvasive mechanical ventilation (NIV). Although IMV reverses hypercapnia/hypoxia, it causes significant morbidity and mortality. There is strong evidence that patients treated with NIV have better outcomes, and NIV is recommended as first line therapy in these patients. Yet, several studies have demonstrated substantial variation in the use of NIV across hospitals, leading to preventable morbidity and mortality. Through a series of mixed-methods studies, we have found that successful implementation of NIV requires physicians, respiratory therapists (RTs), and nurses to communicate and collaborate effectively, suggesting that efforts to increase the use of NIV in COPD need to account for the complex and interdisciplinary nature of NIV delivery and the need for team coordination. Therefore, we propose to compare two educational strategies: online education (OLE) and interprofessional education (IPE) which targets complex team-based care in NIV delivery.Methods and designTwenty hospitals with low baseline rates of NIV use will be randomized to either the OLE or IPE study arm. The primary outcome of the trial is change in the hospital rate of NIV use among patients with COPD requiring ventilatory support. In aim 1, we will compare the uptake change over time of NIV use among patients with COPD in hospitals enrolled in the two arms. In aim 2, we will explore mediators’ role (respiratory therapist autonomy and team functionality) on the relationship between the implementation strategies and implementation effectiveness. Finally, in aim 3, through interviews with providers, we will assess acceptability and feasibility of the educational training.DiscussionsThis study will be among the first to carefully test the impact of IPE in the inpatient setting. This work promises to change practice by offering approaches to facilitate greater uptake of NIV and may generalize to other interventions directed to seriously-ill patients.Trial registrationName of registry: ClinicalTrials.govTrial registration number: NCT04206735Date of Registration: December 20, 2019

The application of non-invasive and invasive mechanical ventilation in the first episode of acute respiratory failure.

Acute respiratory failure (RF) is a life-threatening syndrome. This study investigated the application of two major clinical strategies, non-invasive mechanical ventilation (NIV) and invasive mechanical ventilation (IMV), in the first episode of acute RF. Data from the longitudinal health insurance database, which included 1,000,000 insured citizens, were used. The NIV group consisted of 1201 patients and the IMV group consisted of 16,072 patients. Chi-square test and t test were applied to determine the differences in categorical and continuous variables. Further analysis was performed by using univariate and multivariable logistic regression and Poisson regression. There was a significant increase of 733% in the number of NIV users from 2000 to 2012. NIV use was frequently observed in old-age persons (aOR 3.99, 95% CI 3.06–5.21 for those aged ≥ 80 years), women (aOR 1.33, 95% CI 1.18–1.50), patients admitted to a high-level hospital (aOR 1.95, 95% CI 1.63−2.34 for those admitted to a medical center), and patients with a higher Charlson comorbidity index (CCI, aOR 1.38−1.66 for those CCI ≥ 2). In addition, patients with chronic pulmonary disease, cancer, and congestive heart failure were predominant in NIV users and were significantly associated with NIV use. Overall, the use of NIV has markedly increased over the past few years. Persons of advanced age, women, patients admitted to a high-level hospital, and patients with multiple comorbidities were associated with more frequent NIV use. Chronic pulmonary disease, cancer, and congestive heart failure were most important comorbidities for NIV use.Electronic supplementary materialThe online version of this article (10.1007/s11739-020-02315-1) contains supplementary material, which is available to authorized users.

Noninvasive ventilation in a pediatric ICU: factors associated with failure.

Objective Evaluate the efficacy of Noninvasive Mechanical Ventilation (NIV) in preventing Endotracheal Intubation (ETI) in a heterogeneous pediatric population and identify predictive factors associated with NIV failure in Pediatric Intensive Care Unit (PICU). Methods Prospective non-randomized clinical trial conducted with patients aged 0-10 years, hospitalized in a PICU with NIV indication, who presented acute or chronic respiratory failure. Demographic data and clinical and cardiorespiratory parameters were evaluated, and patients who did not progress to ETI in 48 h after withdrawal of NIV were classified as "success group", whereas those who progressed to ETI were included in the "failure group". Multivariate logistic regression was performed to identify the predictive factors of failure to prevent ETI. Results Fifty-two patients, 27 (51.9%) males, with median age of 6 (1-120) months were included in the study. When evaluating the effectiveness of NIV, 36 (69.2%) patients were successful, with no need for ETI. After analyzing the predictive factors associated with failure, patients with tachypnea after 2 h of NIV were 4.8 times more likely to require ETI in 48 h. Regardless of outcome, heart (p<0.001) and respiratory (p<0.001) rates decreased and oxygen saturation (p<0.001) increased after 2 h of NIV. Conclusion We concluded that use of NIV was effective in the studied population, with significant improvement in cardiorespiratory parameters after 2 h of NIV, and that tachypnea was a predictive factor of failure to prevent ETI.

Ventilación mecánica no invasiva en pacientes con traumatismo de tórax

Mechanical ventilation in patients with chest injury becomes a challenge due to physiological changes. Currently, chest injuries account for 10-15% of all traumas, and are responsible for 17-25% of all deaths caused by trauma. However, there is no clinical evidence to make recommendations for the use of any of the ventilation modes. The objective of this study is to demonstrate that non-invasive mechanical ventilation (NIMV) corrects hypoxaemia in chest trauma patients. Materials and methodsProspective descriptive, observational and analytical study was conducted on 19 patients with chest trauma managed with NIMV in the continuous positive airway pressure (CPAP) mode. The age of the patients was between 18 and 67 years. For those patients with criteria for NIMV, the protocol implemented was 4hours of NIMV in CPAP mode with full mask. The parameters included: A pressure support variable plus a positive end-expiratory pressure of 10cm H2O, and FiO2 at 50% for 4h of venturi mask at 50%. Arterial blood samples were taken one hour after NIMV withdrawal. Failure was defined if continued with venturi, returned to NIMV, or went on to invasive mechanical ventilation. ResultsThe study included 89.5% males, and all (100%) of the patients had a mean Revised Trauma Score of less than 11 on admission to the emergency department, as well as a mean Injury Severity Score of 19, a mean Thorax Trauma Severity Score of 10, as well as a mean base excess −2.0. The mean time of NIMV was 3.2 days. An improvement of PO2 and PaO2/FiO2 index (PAFI) was observed in relation to the use of NIMV in CPAP mode, as well as a relationship with the classification of thoracic trauma (TTSS), and the time of NIMV. With this study, it can be concluded that NIMV in patients with chest trauma reduces intubation time and reduces mortality, as well as improving hypoxaemia in this group of patients.

Avaliação do desenvolvimento motor de recém-nascidos prematuros extremos e moderados em uma unidade de terapia intensiva neonatal

Objetivo: avaliar o desenvolvimento motor de recém nascidos prematuros extremos e comparar ao desenvolvimento motor dos recém-nascidos prematuros moderados, em uma UTI Neonatal. Métodos: estudo transversal onde foram avaliados 16 neonatos, cinco prematuros extremos e 11 prematuros moderados, classificados pelo Test of Infant Motor Performance. Resultados: Não houve diferença significativa no desempenho motor entre o grupo de prematuros extremos e moderados, entretanto, a prematuridade extrema reduziu 4,74 pontos no escore. Na correlação entre os fatores de risco e o desenvolvimento motor, o uso de ventilação mecânica não invasiva e o Apgar no 1º minuto foram associados estatisticamente com o desempenho motor atípico. As demais variáveis não apresentaram correlação significativa com o desenvolvimento motor. Conclusão: não houve associação entre a idade gestacional e o desenvolvimento motor de neonatos prematuros.

Survival benefit of multidisciplinary care in amyotrophic lateral sclerosis in Spain: association with noninvasive mechanical ventilation.

PurposeMultidisciplinary care has become the preferred model of care for patients with amyotrophic lateral sclerosis (ALS). It is assumed that the sum of interventions associated with this approach has a positive effect on survival. The objective of the study was to evaluate the impact of a multidisciplinary care approach on the survival of patients with ALS.Patients and methodsWe performed a retrospective review of prospectively collected data in a tertiary referral center in Spain. Participants were patients with definite or probable ALS managed in a multidisciplinary care program. We compared demographic and survival data of patients with definite or probable ALS treated in a referral center without and with implementation of a multidisciplinary care program. We performed time-dependent multivariate survival analysis of the use of noninvasive mechanical ventilation (NIMV) and gastrostomy.ResultsWe evaluated 398 consecutive patients, of whom 54 were treated by a general neurologist and 344 were treated in the multidisciplinary care clinic. Patients receiving multidisciplinary care were older (62 vs 58 years), tended to have bulbar onset disease (30% vs 17.7%), and were more likely to receive riluzole (88.7% vs 29.6%, p<0.01), NIMV (48.8% vs 29.6%, p>0.001), and nutrition via gastrostomy (32.3% vs 3.7%, p<0.01). Kaplan–Meier analysis showed a 6-month increase in survival (log-rank, 16.03, p<0.001). Application of the Andersen-Gill model showed that the variables associated with reduced mortality were reduced time to NIMV and gastrostomy and the duration of both, thus reflecting compliance.ConclusionsMultidisciplinary care increased the survival of ALS patients in our study population. Timely use of respiratory support and gastrostomy are fundamental aspects of this benefit.

Akut Hipoksemik Solunum Yetmezliğinde Noninvaziv Mekanik Ventilasyon

Noninvasive mechanical ventilation is widely used for acute respiratory failure in a variety of etiologies. The recommended specific conditions were the exacerbation of chronic obstructive pulmonary disease, cardiogenic pulmonary edema, de novo acute hypoxemic respiratory failure, immunocompromized pneumonia, palliation, postoperative period, weaning and postextubation. Pneumonia and acute respiratory distress syndrome are common causes of acute hypoxemic respiratory failure. Noninvasive mechanical ventilation failure is high in this disease group compared to acute hypercapnic respiratory failure. Noninvasive mechanical ventilation can be recommended in patients with mild even in moderate acute respiratory distress syndrome and not in patients with severe acute respiratory distress syndrome. Due to insufficient evidence in patients with pneumonia and acute respiratory distress syndrome, no recommendation can be given for routine use of noninvasive mechanical ventilation. Although some patients benefit from noninvasive mechanical ventilation, they should be used by a team experienced on noninvasive mechanical ventilation in pneumonia and early acute respiratory distress syndrome. A skilled team, proper place, patient and devices can optimize prognosis. There should be a particular attention to shock, multiorgan failure and change of consciousness. Patient selection should be made correctly, considering that mortality can be seen in case of delayed intubation.

Predictive Factors and Safety of Noninvasive Mechanical Ventilation in Combination With Propofol Deep Sedation in Left Atrial Ablation Procedures

Catheter ablation is nowadays the core treatment of atrial fibrillation (AF). Propofol infusion sedation is an accepted safety strategy; however, respiratory depression with respiratory variations is frequent. Noninvasive mechanical ventilation (NIV) added to deep sedation could improve procedural safety and success. We sought to assess the predictive factors and safety of NIV in combination to propofol deep sedation in left atrial ablation procedures. Procedural data from 252 consecutive patients who underwent left atrial ablation (166 [66%] persistent, 86 [34%] for paroxysmal AF) were analyzed. Sedation with 1% propofol was used in all procedures and controlled by electrophysiologists. Arterial blood gas analysis was performed regularly during the procedure. NIV was indicated for respiratory depression with pH <7.25 and pCO2 >50 mm Hg or agitated patient with the need for more profound sedation. No patient needed endotracheal intubation, and no procedure was abandoned due to adverse effects of sedation. NIV was used in 25 patients (10%). Predictive factors for the use of NIV were high-dose propofol sedation (p = 0.010), persistent AF (p = 0.029), prolonged procedure time (p = 0.006), increased body mass index (p = 0.008) and presence of obstructive sleep apnea (OSA; p <0.001). In a Cox regression analysis, OSA was an independent factor for NIV use (p = 0.016). In conclusion, propofol deep sedation for patients who underwent left atrial ablation is safe. Adding NIV in high-risk patients (i.e., OSA, high body mass index, and lengthy procedure duration) provides better respiratory homeostasis and could impact long-term procedure results.

Sialorrhea in patients with ALS: current treatment options.

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disorder of the motor neuron, which selectively affects it both at central (first motor-neuron) and peripheral level (second motor-neuron). The disease shows up at a mean age of 56 years and the most affected are males. Although ALS may start as a bulbar or spinal disease, with the progression of the disease typically both become evident. Pharmacological approved treatments for ALS are still limited and include riluzole and edaravone which improve survival over time. Despite this, ALS leads to progressive muscle involvement and requires a complex multidisciplinary approach to manage increasing disability which goes beyond motor neurons. Sialorrhea is, amongst others, one of the most disabling symptoms in ALS. The complexity in managing saliva is due to a muscular spasticity and to a scarce palatino-lingual muscles control, rather than to an overproduction of saliva. These features could increase the risk of aspiration pneumonia and limit the use of noninvasive mechanical ventilation. We reviewed the treatment for sialorrhea in ALS patients that are available at this time, emphasizing pros and cons for each approach. Our purpose is to create a practical tool for the diagnosis, in order to facilitate the quantification and management of sialorrhea in everyday practice.