Duration Of Noninvasive Ventilation Research Articles

High-flow nasal cannula and bilevel positive airway pressure for pediatric status asthmaticus: a single center, retrospective descriptive and comparative cohort study

Introduction We aimed to describe patient characteristics and clinical outcomes for children hospitalized for status asthmaticus (SA) receiving high-flow nasal cannula (HFNC) or bilevel positive airway pressure (BiPAP). Methods We performed a single center, retrospective cohort study among 39 children admitted for SA aged 5–17 years from January 2016 to May 2019 to a quaternary pediatric intensive care unit (PICU). Cohorts were defined by BiPAP versus HFNC exposure and assessed to determine if differences existed in demographics, anthropometrics, comorbidities, asthma severity indices, historical factors, duration of noninvasive ventilation, and asthma-related clinical outcomes (i.e. length of stay, mechanical ventilation rates, exposure to concurrent sedatives/anxiolysis, and rate of adjunctive therapy exposure). Results Thirty-three percent (n = 13) received HFNC (33%) and 67% (n = 26) BiPAP. Children receiving BiPAP had greater age (10.9 ± 3.7 vs. 6.8 ± 2.2 years, P < 0.01), asthma severity (proportion with severe NHLBI classification: 38% vs. 0%, P < 0.01; median pediatric asthma severity score: 13[12,14] vs. 10[9,12], P < 0.01), previous PICU admissions (62% vs. 15%, P = 0.01), frequency of prescribed anxiolysis/sedation (42% vs. 8%, P = 0.02), and median duration of continuous albuterol (1.7[1,3.1] vs. 0.9[0.7,1.6] days, P = 0.03) compared to those on HFNC. Those on HFNC more commonly were treated comorbid bacterial pneumonia (69% vs. 19%, P < 0.01). No differences in NIV duration, mortality, mechanical ventilation rates, or LOS were observed. Conclusions Our data suggest a trial of BiPAP or HFNC appears well tolerated in children with SA. Prospective trials are needed to establish modality superiority and identify patient or clinical characteristics that prompt use of HFNC over BiPAP.

Predicting Failure of Non-Invasive Ventilation With RAM Cannula in Bronchiolitis.

In infants hospitalized for bronchiolitis on non-invasive ventilation (NIV) via the RAM cannula nasal interface, variables predicting subsequent intubation, or NIV non-response, are understudied. We sought to identify predictors of NIV non-response. We performed a retrospective cohort study in infants admitted for respiratory failure from bronchiolitis placed on NIV in a quaternary children's hospital. We excluded children with concurrent sepsis, critical congenital heart disease, or with preexisting tracheostomy. The primary outcome was NIV non-response defined as intubation after a trial of NIV. Secondary outcomes were vital sign values before and after NIV initiation, duration of NIV and intubation, and mortality. Primary analyses included Chi-square, Wilcoxon rank-sum, student's t test, paired analyses, and adjusted and unadjusted logistic regression assessing heart rate (HR) and respiratory rate (RR) before and after NIV initiation. Of 138 infants studied, 34% were non-responders. There were no differences in baseline characteristics of responders and non-responders. HR decreased after NIV initiation in responders (156 [143-156] to149 [141-158], p < 0.01) compared to non-responders (158 [149-166] to 158 [145-171], p = 0.73). RR decreased in responders (50 [43-58] vs 47 [41-54]) and non-responders (52 [48-58] vs 51 [40-55], both p < 0.01). Concurrent bacterial pneumonia (OR 6.06, 95% CI: 2.54-14.51) and persistently elevated HR (OR: 1.04, 95% CI: 1.01-1.07) were associated with NIV non-response. In children with acute bronchiolitis who fail to respond to NIV and require subsequent intubation, we noted associations with persistently elevated HR after NIV initiation and concurrent bacterial pneumonia.

PREDICTORS OF BRONCHOPULMONARY DYSPLASIA DEVELOPMENT AND COMORBIDITIES OF PREMATURITY ASSOCIATED WITH RESPIRATORY SUPPORT TECHNIQUES IN PREMATURE NEONATES

The aim of the study was to analyze and identify risk factors for the development of moderate and severe bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis in preterm neonates in intensive care unit and during any kind of respiratory support. Materials and methods: A simple retrospective-prospective blind controlled non-randomised study included 28-32 weeks of gestational age 122 newborns with respiratory distress syndrom, who were treated in the neonatal intensive care units of two medical institutions of Dnipro from 2016 to 2020. Among 122 children neonates were divided into two groups according to particularities of respiratory support, prior type of noinvasive ventilation and infusion volume per day. The uni-variate Cox regressions using clinical variables identified specific clinical variables associated with development of moderate and severe BPD, retinopathy of prematurity, necrotizing enterocolitis, mortality rate (based on odds ratio and 95% confidence interval (95% CI). Then, significant clinical variables were used to build a multivariate Cox regression models. by backwards elimination of non-significant clinical variables. To estimate discriminative ability of comorbidities predictors we conducted ROC-analysis. Results: The patients with moderate and severe BPD significantly longer were mechanically ventilated and received О2 more than 30% in inhaled gas mixture, therefore every day of MV and/or additional oxygen &gt;30% led to increase in probability of BPD development by 15% (p=0,01), АUC=0,78 (95% CI 0,66-0,89). Significant predictors of moderate and severe retinopathy of prematurity were body weight (AUC 0,64 (95% CI 0,51-0,77) (p=0.03), duration of non-invasive ventilation by NIV PC (AUC 0,68 (95% CI 0,54-0,83) (p &lt;0.01), CPAP (AUC 0.63) (95% CI 0.49-0.76) (p = 0,04) and caffeine administration (AUC 0,68 (95% CI 0,59-0,77) (p=0.01). Patients who developed NEC had a statistically significantly lower daily infusion volume AUC 0,68 (0,59-0,77) p &lt;0.01, later onset of enteral nutrition AUC 0,68 (95% CI 0,59-0,77) p &lt;0.01, lower hemoglobin levels on the first, third and seventh days of life AUC 0,67 (95% CI 0,57-0,77) p &lt;0.01, as well as the level of leukocytes AUC 0,65 (95% CI 0,56-0,75) p = 0,01 and platelet count AUC 0,67 (0,58-0,77) (p &lt;0.01) during the first 7 days of life. Conclusions: The results of the study revealed risk factors for intensive care in general and respiratory support in particular, which significantly increase the risk of developing comorbidities of prematurity. Among them are relatively controlled, it is the duration of mechanical ventilation and NIV, which increase the risk of BPD and retinopathy of prematurity. Other risk factors which we can manage include nutrition state, anemia and supplemental oxygen.

Head-To-Head Comparison of Treatment Failure and Costs among COPD Patients Who Used Noninvasive Ventilation in the Ward versus in the ICU: A Propensity-Matched Cohort Study.

Background Head-to-head comparison of treatment failure and costs among chronic obstruct pulmonary disease (COPD) patients who used noninvasive ventilation (NIV) in the ward versus in the ICU is lacking. Methods This retrospective study was performed in a department of respiratory and critical care medicine in a teaching hospital. COPD patients who used NIV in the respiratory ward or respiratory ICU were screened. We enrolled patients with PaCO2 more than 45 mmHg and pH less than 7.35 before the use of NIV. Results We enrolled 83 patients who initiated NIV in the ward and 319 patients in the ICU. Only 5 (6%) patients in the ward were required to transfer to ICU for intensive care. The vital signs were worse but improved faster within 24 h of NIV among patients in the ICU than those in the ward. The NIV failure, hospital mortality, and the length of stay in hospital did not differ between the two groups. However, the duration of NIV was shorter (median 4.0 vs. 6.1 days, p < 0.01) and hospital costs were higher (median 4638 vs. 3093 $USD, p < 0.01) among patients in the ICU than those in the ward. After propensity matching, 42 patients were left in each group, and the baseline data were comparable between the two groups. The findings in the overall cohort were confirmed again in the propensity-matched cohort. Conclusions Among COPD patients, the use of NIV in the ward leads to longer duration of NIV, but lower hospital costs, and similar NIV failure and mortality compared with those in the ICU.

Factors associated with postmenstrual age at full oral feeding in very preterm infants.

AimWe aimed to identify variables associated with gestational age at full oral feeding in a cohort of very preterm infants.MethodsIn this retrospective study, all infants born below 32 weeks of gestation and admitted to a level III neonatal unit in 2015 were included. We dichotomized our population of 122 infants through the median age at full oral feeding, and explored which variables were statistically different between the two groups. We then used linear regression analysis to study the association between variables known from the literature and variables we had identified and age at full oral feeding.ResultsThe median postnatal age at full oral feeding was 36 6/7weeks post menstrual age (Q1-Q3 35 6/7-392/7), and was associated with the duration of hospital of stay. In the univariable linear regression, the variables significantly associated with full oral feeding were gestational age, socioeconomic status, sepsis, patent ductus arteriosus, duration of supplementary oxygen, of non-invasive and invasive ventilation, and bronchopulmonary dysplasia. In the multivariable regression analysis, duration of non-invasive ventilation and oxygen therapy, bronchopulmonary dysplasia, and patent ductus arteriosus were associated with an older age at full oral feeding, with bronchopulmonary dysplasia the single most potent predictor.DiscussionLung disease severity is a major determinant of age at full oral feeding and thus length of stay in this population. Other factors associated with FOF include socioeconomic status and patent ductus arteriosus, There is a need for research addressing evidence-based bundles of care for these infants at risk of long-lasting feeding and neurodevelopmental impairments.

Non-Invasive Ventilation in Preventing Intubation and Reintubation in The Intensive Care Unit of Pediatrics Zagazig University Hospital

Background: Non-invasive ventilation (NIV) refers to methods of respiratory assistance without an indwelling endotracheal tube. Objectives: To evaluate the efficacy, identify possible predictors for the success of NIV in preventing intubation and re-intubation, and to determine the characteristics, and outcomes associated with NIV therapy in Pediatric intensive care units (PICUs) settings. Patients and Methods: A clinical trial study was conducted at the Pediatric Intensive Care Units, Children Hospital, Zagazig University and Al-Ahrar Educational Hospital on 60 patients divided equally into two groups; group A with NIV as the first line and group B with NIV after extubation. Patients were followed up till weaning. Results: Male constituted a larger percentage with both groups. One-sixth and 20% of patients within group A and B respectively had failed to wean. There is a statistically significant difference between the outcome of weaning among group A and all of PIM-2 score, PIM-2 percent, and NIV duration. While the relation is significant between the outcome of weaning among group B and patients’ age, body weight, and NIV duration. Increasing NIV duration significantly predicts weaning success in group A while increasing body weight predicts it in group B. Conclusion: Non-invasive ventilation as the first line of treatment in acute respiratory failure provides significant avoidance of intubation and lowers the incidence and risk of complications. Non-invasive ventilation if considered after weaning of invasive mechanical ventilation it helps to avoid re-intubation and failure of weaning. The most important significant predictors of NIV outcome are NIV duration and body weight.

Non-Invasive Ventilation in Preventing Intubation and Reintubation in The Intensive Care Unit of Pediatrics Zagazig University Hospital

Background: Non-invasive ventilation (NIV) refers to methods of respiratory assistance without an indwelling endotracheal tube. Objectives: To evaluate the efficacy, identify possible predictors for the success of NIV in preventing intubation and re-intubation, and to determine the characteristics, and outcomes associated with NIV therapy in Pediatric intensive care units (PICUs) settings. Patients and Methods: A clinical trial study was conducted at the Pediatric Intensive Care Units, Children Hospital, Zagazig University and Al-Ahrar Educational Hospital on 60 patients divided equally into two groups; group A with NIV as the first line and group B with NIV after extubation. Patients were followed up till weaning. Results: Male constituted a larger percentage with both groups. One-sixth and 20% of patients within group A and B respectively had failed to wean. There is a statistically significant difference between the outcome of weaning among group A and all of PIM-2 score, PIM-2 percent, and NIV duration. While the relation is significant between the outcome of weaning among group B and patients’ age, body weight, and NIV duration. Increasing NIV duration significantly predicts weaning success in group A while increasing body weight predicts it in group B. Conclusion: Non-invasive ventilation as the first line of treatment in acute respiratory failure provides significant avoidance of intubation and lowers the incidence and risk of complications. Non-invasive ventilation if considered after weaning of invasive mechanical ventilation it helps to avoid re-intubation and failure of weaning. The most important significant predictors of NIV outcome are NIV duration and body weight.

Use of bilevel positive pressure ventilation in patients with bronchiolitis.

This study aims at describing the use of bilevel positive airway pressure (BiPAP) in infants with severe bronchiolitis. The use of BiPAP in infants with bronchiolitis may be associated with a worst outcome. A single-center retrospective study performed from October 2013 to April 2016. All infants from 1 day to 6 months of age admitted in the pediatric intensive care unit (PICU) were included if they had a clinical diagnosis of bronchiolitis and if they required any type of noninvasive ventilation (NIV), including high flow nasal cannula, continuous positive airway pressure and BiPAP at admission in PICU. There was no local written protocol regarding the ventilator management during the study. Overall, 252 infants (median age 45 (26-72) days) were included in the study and 110 infants (44%) were supported by BiPAP at admission. More infants were born preterm in the group of patients supported by BiPAP at admission. No complication related to NIV occurred. Patients in the BiPAP group had a longer duration of noninvasive support as well as a longer PICU length of stay. However, hospital length of stay did not differ according to the type of respiratory support at admission. The use of BiPAP was not associated with endotracheal intubation, however it was associated with increased PICU length of stay and increased duration of NIV.

15-Year trends in respiratory care of extremely preterm infants: Contributing factors and consequences on health and growth during hospitalization.

To review 15-year trends in respiratory care of extremely preterm infants managed in a tertiary perinatal center; to identify the factors contributing to their evolution; and to determine whether these changes had an impact on infant mortality, severe morbidity, and growth. Retrospective cohort study of infants born at 23 to 26 weeks' gestation between 2003 and 2017. Changes in respiratory care were assessed in three 5-year periods. Logistic regression was used to examine the factors associated with prolonged duration (ie, greater than the median) of invasive mechanical ventilation (IMV), noninvasive ventilation (NIV), and overall respiratory support (ORS), and those associated with adequate weight and head circumference growth. Of the 396 actively treated neonates, 268 (68%) survived to discharge. Between the first and third periods, IMV duration decreased from 22 (6-37) to 4 (1-14.0) days (P < .001), that of NIV increased from 24 (14-34) to 56 (44-66) days (P < .001), and that of ORS from 50 (34-68) to 63 (52-77) days (P < .001). Study period (2003-2007 vs 2013-2017) was the main factor associated with prolonged IMV (P < .001). Use of high-flow nasal cannula was the main factor associated with prolonged NIV (P = .02) and ORS (P = .02). NIV duration was associated with adequate postnatal weight (P = .003) and head circumference (P = .03) growth. Severe morbidities in survivors, including bronchopulmonary dysplasia, and survival at hospital discharge were comparable across the study periods. Respiratory management was characterized by a marked reduction in IMV. NIV withdrawal protocols are necessary to limit ORS duration while respecting postnatal growth requirements.

Use of Noninvasive Ventilation in Respiratory Failure After Extubation During Postoperative Care in Pediatrics.

The purpose of this study was to determine the rate of failure of noninvasive ventilation (NIV) after cardiac surgery in pediatric patients with respiratory failure after extubation and to identify predictive success factors. This was a prospective cohort study of pediatric patients diagnosed with congenital heart disease who underwent heart surgery and used NIV. Data were collected from 170 patients with a median age of 2 months. No patient presented cardiorespiratory arrest nor any other complication during the use of NIV. The success rate for the use of NIV was 61.8%. Subjects were divided for analysis into successful and failed NIV groups. Statistical analysis used Chi-square, Mann–Whitney, and Student’s t tests, which were performed after univariate and multivariate logistic regression for p < 0.05. In the multivariate analysis, only the minimal pressure gradient (OR 1.45 with p = 0.007), maximum oxygen saturation (OR 0.88 with p = 0.011), and maximum fraction of inspired oxygen (FiO2) (OR 1.16 with p < 0.001) influenced NIV failure. The following variables did not present a statistical difference: extracorporeal circulation time (p = 0.669), pulmonary hypertension (p = 0.254), genetic syndrome (p = 0.342), RACHS-1 score (p = 0.097), age (p = 0.098), invasive mechanical ventilation duration (p = 0.186), and NIV duration (p = 0.804). In conclusion, NIV can be successfully used in children who, after cardiac surgery, develop respiratory failure in the 48 h following extubation. Although the use of higher pressure gradients and higher FiO2 are associated with a greater failure rate for NIV use, it was found to be generally safe.

Noninvasive tri-level positive airway pressure ventilation: is it a new challenging mode in management of patients with chronic obstructive pulmonary disease?

Background Chronic obstructive pulmonary disease (COPD) is a serious issue of sickness and rise in global fatality rates. Noninvasive positive pressure ventilation is the first-line therapy in patients with COPD with respiratory fialure (RF). Tri-level positive airway pressure (Tri-PAP) is new challenging mode of noninvasive ventilation (NIV). Objectives To compare between two modes of noninvasive positive pressure ventilation [bi-level positive airway pressure (Bi-PAP) and Tri-PAP] and to spell out outcomes, complication, and predictors of favorable outcome of NIV in patients with COPD with respiratory failure. Patients and methods This prospective comparative study was accomplished on 30 patients with COPD with respiratory failure, who were subjected to NIV (Bi-PAP or Tri-PAP) and standard conventional therapy. Arterial-blood gases (ABGs) (initially, 6 h, and finally) were analyzed. NIV outcomes, complications, and predictors of success were encountered. Results Patients were categorized according to managerial therapeutic NIV into Bi-PAP (n=15) or Tri-PAP (n=15) groups. Initial, 6-h, and final ABGs analyses (pH, PO2, PCO2, HCO3, and O2 sat) and NIV outcomes (successful or failed weaning) were analogous, without considerable variation between both Bi-PAP and Tri-PAP groups. pH showed crucial advancement after 6 h of initiation of Tri-PAP NIV. Terminal ABG interpretation (pH, PaCO2, PaO2, and O2 sat) had better outcomes than initial and 6-h ABG analyses of Tri-PAP NIV group. Irritations and ulcerations of nasal bridge, dry nose or mouth, nasal congestion, hypotension, and PaCO2 increase were the most hazardous events in both Bi-PAP and Tri-PAP NIV groups. Shorter duration of NIV, lower BMI, higher pH, and lower PCO2 (initially, 6 h, and final ABGs) as well as higher O2 saturation (in final ABG) were predictors of successful weaning in NIV (Bi-PAP and Tri-PAP) groups collectively. Conclusion Bi-PAP and Tri-PAP are appropriate mode of NIV in patients with COPD with RF with minimal complication and better outcomes. Tri-PAP had no superiority of utilization than Bi-PAP mode. pH and PCO2 are the powerful predictors of favorable NIV outcomes.

A comparison of three strategies for withdrawal of noninvasive ventilation in chronic obstructive pulmonary disease with acute respiratory failure: Randomized trial.

Background:The optimal strategy for the withdrawal of noninvasive ventilation (NIV) remains unknown. This study was planned to compare three different strategies for the withdrawal of NIV among patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with hypercapnic respiratory failure (HcRF).Materials and Methods:Patients with AECOPD with HcRF who improved on NIV were randomized into three groups – immediate withdrawal (Group A), stepwise reduction of pressure support (Group B), and stepwise reduction of duration (Group C) of NIV. The probability of successful withdrawal was compared among the groups.Results:This study included 90 patients (males – 86.6%) with a mean (±standard deviation [SD]) age of 59.9 ± 8.3 years. The mean (±SD) pH and PaCO2 at admission were 7.23 ± 0.04 and 84.4 ± 12.0 mm Hg, respectively. The duration of NIV received before randomization was 31.6 ± 9.2 h with maximum inspiratory positive airway pressure and expiratory positive airway pressure of 17.6 ± 2.7 cm H2O and 7.4 ± 1.4 cm H2O, respectively. NIV was successfully withdrawn in 23/30 (76.6%) in Group A, 27/30 (90%) in Group B, and 26/30 (86.6%) in Group C (P = 0.31). The total duration of NIV use and length of hospital stay was lower in Group A and B as compared to Group C (P = 0.001).Conclusions:Immediate withdrawal of the NIV after recovery of respiratory failure among patients with exacerbation of COPD is feasible. Immediate withdrawal did not increase the risk of weaning failure from the NIV.

Assessment of preoperative noninvasive ventilation before lung cancer surgery: The preOVNI randomized controlled study

ObjectivesThe preOVNI study was a randomized, controlled, open-label study that investigated whether preoperative noninvasive ventilation (NIV) could reduce postoperative complications after lung cancer surgery. MethodsAdult patients with planned lung cancer resection and with at least 1 cardiac or respiratory comorbidity were included and randomly assigned to preoperative NIV (at least 7 days and 4 h/day) or no NIV. The primary endpoint was the rate of postoperative protocol-defined complications. ResultsThree hundred patients were included. In the NIV group, the median NIV duration was 8 days. No difference of postoperative complication rates was evidenced: 42.6% in NIV group and 44.8% in no-NIV group (P = .75). The rate of pneumonia was greater in no-NIV group compared with the NIV group, but statistical significance was not achieved (28.0 vs 37.7%, respectively; P = .08). The type of surgery (open or minimally invasive) did not impact these results after multivariable analysis. ConclusionsNo benefit was evidenced for preoperative NIV before lung cancer surgery. Further studies should determine the optimal perioperative management to decrease the rate of postoperative complications.

Intubation rate, duration of noninvasive ventilation and mortality after noninvasive neurally adjusted ventilatory assist (NIV-NAVA).

Asynchrony is a common problem in patients treated with noninvasive ventilation (NIV). Neurally adjusted ventilatory assist (NAVA) has shown to improve patient-ventilator interaction. However, it is unknown whether NIV-NAVA improves outcomes compared to noninvasive pressure support (NIV-PS). This observational cohort study included patients 18years or older receiving noninvasive ventilation using an oro-nasal face mask for more than 2hours in a Danish ICU. The study included a NIV-NAVA cohort (year 2013-2015) and two comparison cohorts: (a) a historical NIV-PS cohort (year 2011-2012) before the implementation of NIV-NAVA at the ICU in 2013, and (b) a concurrent NIV-PS cohort (year 2013-2015). Outcomes of NIV-NAVA (intubation rate, duration of NIV and 90-day mortality) were assessed and compared using multivariable linear and logistic regression adjusted for relevant confounders. The study included 427 patients (91 in the NIV-NAVA, 134 in the historic NIV-PS and 202 in the concurrent NIV-PS cohort). Patients treated with NIV-NAVA did not have improved outcome after adjustment for measured confounders. Actually, there were statistically imprecise higher odds for intubation in NIV-NAVA patients compared with both the historical [OR 1.48, CI (0.74-2.97)] and the concurrent NIV-PS cohort [OR 1.67, CI (0.87-3.19)]. NIV-NAVA might also have a longer length of NIV [63%, CI (19%-125%)] and [139%, CI (80%-213%)], and might have a higher 90-day mortality [OR 1.24, CI (0.69-2.25)] and [OR 1.39, CI (0.81-2.39)]. Residual confounding cannot be excluded. This present study found no improved clinical outcomes in patients treated with NIV-NAVA compared to NIV-PS.

Safety of aerosol therapy in children during noninvasive ventilation with helmet and total face mask

PurposeTo evaluate the consequences of using nebulized drugs in patients subjected to noninvasive ventilation (NIV) with total face mask (TFM) and helmet. DesignA descriptive analytical study of a prospective patient cohort was carried out. AmbitPediatric intensive care unit (PICU) of a tertiary hospital. PatientsConsecutive sampling was used to include all patients admitted to the PICU and requiring NIV with helmet or TFM over a period of 29 months. No patients were excluded. InterventionsNebulized treatment was added according to medical criteria. Variables of interestIndependent variables were age, sex, diagnosis, disease severity, ventilation parameters and nebulized drugs (if administered). Secondary outcomes were duration and failure of NIV, and length of PICU stay. ResultsThe most frequent diagnoses were bronchiolitis (60.5%) and asthma (23%). Patients received NIV for a median of 43h. Nebulized drugs were administered in 40% of the cases during NIV, and no adverse effects were registered. Using Bayesian statistics, the calculated probability of suffering an adverse effect was 1.3% with helmet and 0.5% with TFM (high density 95% probability intervals). Patients with helmet and nebulized therapy were in more serious condition than those who did not receive nebulization; nevertheless, no differences were observed regarding the need to change to bilevel modality. With TFM, PICU stay was shorter for the same degree of severity (p=0.033), and the NIV failure rate was higher in patients who did not receive inhaled drugs (p=0.024). ConclusionsThe probability of suffering an adverse effect related to nebulization is extremely low when using a helmet or TFM. Inhaled therapy with TFM may shorten PICU stay in some patients.

Neurally-Adjusted Ventilatory Assist Versus Noninvasive Pressure Support Ventilation in COPD Exacerbation: The NAVA-NICE Trial.

This study was conducted to compare the effectiveness of noninvasive ventilation (NIV) with pressure support (NIV-PSV) to noninvasive neurally-adjusted ventilatory assist (NIV-NAVA) during COPD exacerbation. In this study, 40 subjects with COPD and acute hypercapnic respiratory failure were randomized to receive either NIV-NAVA (n = 20) or NIV-PSV (n = 20) via a critical care ventilator. Subjects' vital parameters, arterial blood gas values, patient-ventilator asynchrony events, and asynchrony index were noted at specific time intervals in both groups. The duration of NIV, rate of NIV failure, and length hospital stay were also recorded for these 2 modes of NIV. NIV-NAVA significantly reduced the total number (median [interquartile range]) of asynchrony events compared to NIV-PSV: 22 (15-32.5) versus 65 (50.75-104.25), respectively, P = .002. Severe asynchrony defined as asynchrony index > 10% was also significantly lower in NIV-NAVA than in NIV-PSV (P < .001). There was no significant difference between the 2 groups regarding improvement in gas exchange and vital parameters. Rate of failure of NIV (P = .73), duration of the requirement of ventilatory support (P = .40), and hospital length of stay (P = .46) were also comparable between the 2 modes of ventilation. Compared to NIV-PSV, NIV-NAVA was associated with better patient-ventilator synchrony and a reduction in the number of asynchrony events in subjects with an exacerbation of COPD, with similar effects on improvement in gas exchange, duration of NIV, hospital lenght of stay, and rate of NIV failure. (Clinicaltrials.gov registration NCT02912689.).

PREDICTORS OF NONINVASIVE VENTILATION FAILURE IN PATIENTS WITH COPD EXACERBATIONS IN THE ICU

SESSION TITLE: Identifying Successes and Failures of NIV and Airway Clearance: From COPD to Neuromuscular Disease SESSION TYPE: Original Investigations PRESENTED ON: 10/21/2019 1:30 PM - 2:30 PM PURPOSE: Acute exacerbation of COPD is a major mortality and morbidity. Noninvasive ventilation (NIV) is proven to be effective in majority of patients with acute COPD exacerbation. NIV could be lifesaving but also can delay mechanical ventilation if its efficacy is not assessed in a timely manner. In this study we analyzed predictors that can be associated with failure of NIV in acute exacerbation of COPD in a large tertiary care ICU. In particular, we wondered whether duration of NIV among those who failed may be associated with poorer outcomes. METHODS: A retrospective review of consecutive patients with a primary diagnosis of acute exacerbation of COPD requiring NIV admitted to the Cleveland Clinic Main Campus medical ICU was conducted for the period between 2012 and 2017. Baseline data included demographics, APACHE score, albumin level, blood lactate and blood gas elements. Additional chart review was performed to collect NIV setting parameters on presentation to the ICU. Clinical outcome variables collected included outcome and duration of NIV, duration of invasive mechanical ventilation, ICU length of stay, hospital length of stay, and patient survival status. Multivariate regression analysis was performed to determine independent variables associated with clinical outcomes. RESULTS: There were 370 patients who met the inclusion criteria. 53.4% were male. Mean age was 64.7 ± 11.2 years old. Average baseline FEV1 was34 ±17% of predicted. Patients had mean pH of 7.20 ± 0.54 and PaCO2 of 70.3 ± 28.7 on presentation. 323 patients (87.3%) were successfully weaned off NIV. 47 patients (12.7%) failed NIV and required invasive mechanical ventilation. 12 patients (3.2 %)died, 8 in NIV success and 4 in failure groups ,APACHE III score was higher among patients who failed NIV (68.3±18.9 versus 48.8± 15.2, p-value <0.001). In the subset of 47 patients who failed NIV requiring intubation, duration of NIV was 25.0 ± 58.8 hours. Multivariate regression analysis yielded a model consisting of APACHE III score, having had an ABG at baseline and BMI as predictive variables for NIV success. ROC curve revealed c-statistic of 0.815 for the final model; Duration of NIV did not predict clinical outcomes among patients who failed NIV. CONCLUSIONS: NIV is successful in preventing mechanical ventilation in majority of patients with acute respiratory failure due to COPD. Patients with worse clinical status at presentation are more likely to fail noninvasive ventilation and require mechanical ventilation. In the subgroup of patients who failed NIV, duration of NIV prior to intubation was not associated with clinical outcomes. CLINICAL IMPLICATIONS: Clinical outcomes of NIV can be accurately predicted by baseline clinical parameters on presentation. Duration of the trial of NIV was not associated with clinical outcomes in the subgroup of patients who failed NIV. DISCLOSURES: No relevant relationships by Erin Covert, source=Web Response No relevant relationships by Tanya Devnani, source=Web Response No relevant relationships by Abhijit Duggal, source=Web Response No relevant relationships by Katelyn Edwards, source=Web Response No relevant relationships by Andrew Fiore, source=Web Response No relevant relationships by Laith Ghazala, source=Web Response No relevant relationships by Justin Hanks, source=Web Response No relevant relationships by Umur Hatipoglu, source=Web Response

Comprehensive approach to weaning in difficult-to-wean infantile and juvenile-onset glycogen-storage disease type II patients: a case series

BackgroundGlycogen storage disease type II (GSD II) is caused by acid alpha-glucosidase (GAA) deficiency. Both infantile-onset and juvenile-onset GSD II lead to proximal muscle weakness and respiratory insufficiency and require mechanical ventilation. However, GSD II is also independently associated with delayed weaning from mechanical ventilation. This study aimed to describe a comprehensive approach including sequential invasive-noninvasive mechanical ventilation weaning and enzyme replacement therapy (ERT) in patients with weaning difficulties.Case presentationWe studied six difficult-to-wean GSD II (three juvenile-onset, three infantile-onset) patients at the First Affiliated Hospital, Sun Yat-sen University from October 2015 to December 2017. Difficulty in weaning was defined as follows: the need for more than three spontaneous breathing trials or more than 1 week to achieve successful weaning. All patients received comprehensive treatment including sequential invasive-noninvasive mechanical ventilation weaning, ERT and general treatment. Recombinant human acid alpha-glucosidase enzyme therapy (20 mg/kg every 14 days) was used after diagnosis, and Patients 1–6 received ERT for 15.5, 4.5, 2, 2.5, 17, and 2 months, respectively. The therapeutic effect of the comprehensive treatment was observed.The patients’ respiratory function and limb muscle strength improved after each ERT session. Patients who successfully completed a spontaneous breathing trial could proceed to extubation, and then start non-invasive ventilation. The patients’ age range at initial mechanical ventilation was 3–47 (median 26.5) months, duration of invasive ventilation was 1–36 (median 2.75) months, and duration of noninvasive ventilation was 0–0.6 (median 0.05) month. The patients’ nutritional status improved after enhanced nutritional support. Patients 2, 3, and 5 were successfully weaned off the ventilator. Patient 1 underwent tracheal intubation after six weaning failures, and Patients 4 and 6 died after therapy was abandoned by their parents.Discussion and conclusionsMale sex, GSD II type, and the presence of malnutrition and neurological impairment may predict poor respiratory outcomes. The above-described comprehensive sequential invasive-noninvasive mechanical ventilation weaning strategy may increase the success rate of weaning from mechanical ventilation.

Dexmedetomidine to facilitate non-invasive ventilation after blunt chest trauma: A randomised, double-blind, crossover, placebo-controlled pilot study

BackgroundAlthough non-invasive ventilation (NIV) is recommended in patients with chest trauma, this procedure may expose to discomfort and even failure due to agitation or excessive pain. We tested the impact of dexmedetomidine on the duration of the first session of NIV. MethodsThis randomised, crossover study enrolled 19 patients with blunt chest trauma who needed NIV. During one cycle comprising two NIV sessions, patients received in a random order an intravenous infusion of dexmedetomidine (0.7mcg/kg/h) and placebo (saline solution) that was initiated 60min prior to NIV. Dexmedetomidine (or placebo) was titrated to maintain a Richmond Agitation Sedation Scale (RASS) score between 0 and −3. A 6-h washout period was observed between NIV sessions. The reproducibility of the drug-related effects was tested during a second cycle of two NIV sessions. ResultsDuring the first cycle, dexmedetomidine prolonged the duration of NIV compared to placebo: 280min (118–450) (median, 25–75th quartiles) versus 120min (68–287) respectively, corresponding to a median increased duration of 96min (12–180) (P=0.03). Dexmedetomidine was associated with a lower score for RASS: −0.8 (−1.0;0.0) versus 0.0 (−0.5;0.0) (P<0.01), and reduced respiratory discomfort according to the 10cm visual similar scale: 0.6cm (0.0–3.0) versus 2.2cm (0.0–5.3) (P=0.05). Pain scores, morphine consumption, and blood gas measurements were comparable between groups. No difference in the duration of non-invasive ventilation was found during the second cycle. ConclusionsIn this pilot trial, dexmedetomidine could facilitate the acceptance of the first session of non-invasive ventilation for patients with chest trauma.

Impact of urine osmolality/urine sodium on the timing of diuretic phase and non-invasive ventilation support: Differences from late preterm to term neonates

BackgroundExtracellular fluid retained in the lungs lead to respiratory distress in both late preterm (LP) and term neonates. The relationship between urine parameters toward the diuresis and the duration of ventilation postnatally is unknown. To find the correlation between the diuretic phase with urine parameters in the first 4 days after birth and the duration of non-invasive ventilation (NIV). MethodsSerial measurements of urine osmolality (Uosm), urine sodium (UNa), and urine output (U/O) in neonates were collected at 5 time periods (T1:0–12 postnatal hours, T2:12–24 postnatal hours, T3:24–48 postnatal hours, T4:48–72 postnatal hours, T5:72–96 postnatal hours) were recorded. The correlations were analyzed in late preterm and term neonates. ResultsNinety-seven neonates were included. Negative correlation between Uosm and U/O were observed. LP neonates (n=26) and term neonates (n=71) had differences with Uosm at T2, UNa at T4, T5, and U/O at T2, T3. Factors of U/O < 1 ml/kg/hr at T1 (odds ratio (OR) = 20.0; 95% confidence interval (CI) 1.796-222.776; p = 0.015) or Uosm > 273 mOsm/L at T1 (OR = 9.0; 95% CI 1.031-78.574; p = 0.047) in LP neonates and UNa > 26.5 mEq/L at T5 (OR = 23.625; 95% CI 2.683-79.276; p < 0.01) in term neonates were associated with prolonged NIV use (> 120 hours). ConclusionWe speculate the significant correlation between Uosm/UNa and the diuretic phase. The LP neonates acquire earlier diuretic phase than the term neonates. The Uosm/UNa in the first few postnatal days had the correlation with the duration of NIV support.