Noninvasive Ventilation Failure Research Articles

Role of Heart Rate, Acidosis, Consciousness, Oxygenation, and Respiratory Rate Score in Predicting Outcomes of Noninvasive Ventilation in Chronic Obstructive Pulmonary Disease Patients.

In patients with chronic obstructive pulmonary disease (COPD), early detection of noninvasive ventilation (NIV) failure is a promising technique for decreasing mortality. The objective of this study was to evaluate the efficacy of heart rate, acidosis, consciousness, oxygenation, and respiratory rate (HACOR) score in predicting NIV outcome in COPD-associated respiratory failure. A prospective observational study was conducted on 100 COPD patients with acute respiratory failure who were initiated on NIV. HACOR score was calculated at the start of NIV and after 1-2, 12, and 24 hours. NIV failure was defined as progression to invasive mechanical ventilation or death. NIV success was defined as liberation from NIV prior to hospital day seven and not meeting criteria for failure. In this study, 100 patients with COPD and respiratory failure were enrolled. Their mean age was 65.34 years [standard deviation (SD) 8.19]. Male patients were predominant (n = 81). Eighty-nine percent of patients were smokers, and the remaining had exposure to biomass fuel. At the initiation of NIV, the median HACOR score was 3 (interquartile: 2, 4). In 13% of patients, there was NIV failure. There were 17 (17%) patients whose HACOR score at initiation was ≥5. In patients with a HACOR score ≥5, the NIV failure rate was 76.4% and mortality was 41.1%. The area under the curve (AUC) for prediction of NIV failure by HACOR score at initiation was 0.980 (p-value < 0.05). The HACOR score had high sensitivity as well as specificity at initiation in the prediction of NIV failure. A higher HACOR score predicts a high chance of NIV failure. Obtaining the HACOR score at the bedside makes it convenient for assessing the efficacy of NIV in patients with COPD.

New noninvasive modalities in long-term pediatric ventilation: a scoping review.

Long-term noninvasive ventilation modalities for the pediatric population have undergone a continuous evolution. Hybrid noninvasive ventilation modalities have been recently introduced in clinical practice. Combining the advantages of conventional ventilation, hybrid modes use algorithms that automatically adjust the ventilator's settings to achieve a predefined ventilation target. Most of the recommendations on the use and settings of hybrid noninvasive ventilation modalities in children are derived from adult experience. Therefore, there is a lack of evidence on its implementation in pediatric chronic respiratory diseases. This scoping review aims to map the existing information regarding the use of hybrid ventilation modalities in the pediatric population and identify knowledge or research gaps. We performed a literature search using MEDLINE and Pubmed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. We included 13 studies (ten studies on average volume-assured pressure-support ventilation; two studies on intelligent volume-assured pressure-support ventilation; and one study on adaptive servoventilation). The use of new noninvasive ventilation modes in the pediatric population has been applied for the treatment of neuromuscular and hypoventilation syndromes as an alternative therapeutic option in the case of the failure of conventional noninvasive ventilation. Their widespread use has been hampered by the limited evidence available. Longitudinal studies on a larger number of patients are needed to confirm their effectiveness and evaluate their long-term clinical and functional outcomes.

Implications of sedation during the use of noninvasive ventilation in children with acute respiratory failure (SEDANIV Study)

BackgroundThe objective of this study was to analyze the effects of sedation administration on clinical parameters, comfort status, intubation requirements, and the pediatric intensive care unit (PICU) length of stay (LOS) in children with acute respiratory failure (ARF) receiving noninvasive ventilation (NIV).MethodsThirteen PICUs in Spain participated in a prospective, multicenter, observational trial from January to December 2021. Children with ARF under the age of five who were receiving NIV were included. Clinical information and comfort levels were documented at the time of NIV initiation, as well as at 3, 6, 12, 24, and 48 h. The COMFORT-behavior (COMFORT-B) scale was used to assess the patients’ level of comfort. NIV failure was considered to be a requirement for endotracheal intubation.ResultsA total of 457 patients were included, with a median age of 3.3 months (IQR 1.3–16.1). Two hundred and thirteen children (46.6%) received sedation (sedation group); these patients had a higher heart rate, higher COMFORT-B score, and lower SpO2/FiO2 ratio than did those who did not receive sedation (non-sedation group). A significantly greater improvement in the COMFORT-B score at 3, 6, 12, and 24 h, heart rate at 6 and 12 h, and SpO2/FiO2 ratio at 6 h was observed in the sedation group. Overall, the NIV success rate was 95.6%-intubation was required in 6.1% of the sedation group and in 2.9% of the other group (p = 0.092). Multivariate analysis revealed that the PRISM III score at NIV initiation (OR 1.408; 95% CI 1.230–1.611) and respiratory rate at 3 h (OR 1.043; 95% CI 1.009–1.079) were found to be independent predictors of NIV failure. The PICU LOS was correlated with weight, PRISM III score, respiratory rate at 12 h, SpO2 at 3 h, FiO2 at 12 h, NIV failure and NIV duration. Sedation use was not found to be independently related to NIV failure or to the PICU LOS.ConclusionsSedation use may be useful in children with ARF treated with NIV, as it seems to improve clinical parameters and comfort status but may not increase the NIV failure rate or PICU LOS, even though sedated children were more severe at technique initiation in the present sample.

Establishment and Validation of a Risk Prediction Model for Non-Invasive Ventilation Failure After Birth in Premature Infants with Gestational Age < 32 Weeks.

This study was performed to construct and validate a risk prediction model for non-invasive ventilation (NIV) failure after birth in premature infants with gestational age < 32weeks. The data were derived from the multicenter retrospective study program - Jiangsu Provincial Neonatal Respiratory Failure Collaboration Network from Jan 2019 to Dec 2021. The subjects finally included were preterm infants using NIV after birth with gestational age less than 32weeks and admission age within 72h. After screening by inclusion and exclusion criteria, 1436 babies were subsequently recruited in the study, including 1235 infants in the successful NIV group and 201 infants in the failed NIV group. (1) Gestational age, 5min Apgar, Max FiO2 during NIV, and FiO2 fluctuation value during NIV were selected by univariate and multivariate analysis. (2) The area under the curve of the prediction model was 0.807 (95% CI: 0.767-0.847) in the training set and 0.825 (95% CI: 0.766-0.883) in the test set. The calibration curve showed good agreement between the predicted probability and the actual observed probability (Mean absolute error = 0.008 for the training set; Mean absolute error = 0.012 for the test set). Decision curve analysis showed good clinical validity of the risk model in the training and test cohorts. This model performed well on dimensions of discrimination, calibration, and clinical validity. This model can serve as a useful tool for neonatologists to predict whether premature infants will experience NIV failure after birth.

Ultrasound Diaphragmatic Assessment as a Predictor of Successful Non-Invasive Mechanical Ventilation in Patients with Acute Exacerbation COPD: an Observational Study

Abstract Background Non-invasive ventilation (NIV) is successful as first-line treatment for patients admitted to hospital with hypercapnic respiratory failure due to AECOPD. Significant diaphragmatic muscle dysfunction (DD) exits in different disease-related and physiological conditions, including COPD. Ultrasonography is considered as a non- invasive and bedside method and commonly applied in intensive care unit (ICU) to assess diaphragmatic function. Objective To demonstrate the value of diaphragmatic ultrasound assessment for patients with AECOPD undergoing NIMV. Patients and Methods A population of 24 consecutive patients with AECOPD admitted to Ain Shams University Hospitals’ Intensive Care units (ICU) were enrolled. Change in diaphragmatic thickness fraction (ΔDTF) &amp;lt; 20% and diaphragm excursion&amp;lt; 10 mm during tidal volume was the predefined cut-off for identifying DD. Correlations between ΔDTF &amp;lt; 20%, diaphragm excursion&amp;lt; 10 mm and NIV failure and other clinical outcomes were investigated. Results 24 cases with AECOPD, 33.3% of them (8 cases) had diaphragm dysfunction (DD+) but after NICPAP 2 cases improved and only 6 cases remain with DD and 16 Patients without DD (DD−). DD+ patients had a higher risk for NIV failure than DD−patients (p &amp;lt; 0.011), and this finding was significantly associated with higher in-hospital, and 30-day mortality rates; longer mechanical ventilation duration; higher tracheostomy rate; and longer ICU stay. Conclusion AECOPD patients with diaphragmatic dysfunction as diagnosed by US showed higher incidence of NIMV failure, longer MV, ICU length of stay, In- hospital mortality, ICU and MV duration were significantly longer in group with DD. Insignificant difference was found considering mortality after 30 days in patients with or without diaphragm dysfunction.

Factor for Predicting Non-Invasive Ventilation Failure in Very Old Patients with Hypoxemic Respiratory Failure in Intensive Care Unit

Aims: This study aimed to investigate the efficacy of NIV in patients with pneumonia-associated acute hypoxemic respiratory failure (AHRF) and to identify factors that predict NIV failure. Methods: A total of 50 very elderly patients (aged 85 and older) with pneumonia-associated AHRF were retrospectively evaluated from January 2021 to August 2022. Failure of NIV was defined was characterized by a transition to mechanical ventilation (either through tracheal intubation or tracheostomy), discharge under "hopeless" conditions while still on NIV, or death during NIV. Results: The mean age of the patients was 87.4±2.4 years, median SOFA score was 5, median duration of NIV was 4 days, and median length of stay in the ICU for the patients was 7 days. It was determined that 48% of the patients experienced NIV failure due to worsening clinical conditions. The SOFA score, levels of procalcitonin, CRP, heart rate, and respiratory rate were higher in the NIV failure group compared to the NIV successful group. An increased SOFA score (OR= 1.51, 95% CI= 1.11-2.06, p= 0.009), elevated CRP levels (OR= 1.03, 95% CI= 1.01-1.05, p= 0.003), and increased respiratory rate (OR= 1.18, 95% CI= 1.01-1.38, p= 0.039) were identified as independent predictors of NIV failure. Conclusion: In very elderly patients with AHRF due to pneumonia, the use of NIV may offer a significant survival benefit if patients are closely monitored and potential risk factors such as systemic inflammation parameters, SOFA score, and respiratory rate are considered.

Noninvasive Ventilation in Critically Ill Patients With Severe Acute Respiratory Infections.

The objective of this study was to evaluate the association between noninvasive ventilation (NIV) compared with invasive ventilation and mortality in subjects with severe acute respiratory infection. This was a retrospective multi-center study of subjects with severe acute respiratory infection treated with ventilatory support between September 2012 and June 2018. We compared the 90-d mortality of subjects managed initially with NIV (NIV group) with those managed with invasive ventilation only (invasive ventilation group), adjusting by propensity score. Of 383 subjects, 189 (49%) were in the NIV group and 194 (51%) were in the invasive ventilation group. Of the subjects initially treated with NIV, 117 (62%) were eventually intubated. Crude 90-d mortality was lower in the NIV group versus the invasive ventilation group (42 [22.2%] vs 77 [39.7%]; P < .001). After propensity score adjustment, NIV was associated with lower 90-d mortality than invasive ventilation (odds ratio 0.54, 95% CI 0.38-0.76; P < .001). The association of NIV with mortality compared with invasive ventilation was not different across the studied subgroups. In subjects with severe acute respiratory infection and acute respiratory failure, NIV was commonly used. NIV was associated with a lower 90-d mortality. The observed high failure rate suggests the need for further research to optimize patient selection and facilitate early recognition of NIV failure.

Efficacy and Safety of High PEEP NIV in COVID-19 Patients.

To investigate the efficacy and safety of non-invasive ventilation (NIV) with high PEEP levels application in patients with COVID-19-related acute respiratory distress syndrome (ARDS). This is a retrospective cohort study with data collected from 95 patients who were administered NIV as part of their treatment in the COVID-19 intensive care unit (ICU) at University Hospital Centre Zagreb between October 2021 and February 2022. The definite outcome was NIV failure. High PEEP NIV was applied in all 95 patients; 54 (56.84%) patients could be kept solely on NIV, while 41 (43.16%) patients required intubation. ICU mortality of patients solely on NIV was 3.70%, while total ICU mortality was 35.79%. The most significant difference in the dynamic of respiratory parameters between 2 patient groups was visible on Day 3 of ICU stay: By that day, patients kept solely on NIV required significantly lower PEEP levels and had better improvement in PaO2, P/F ratio, and HACOR score. High PEEP applied by NIV was a safe option for the initial respiratory treatment of all patients, despite the severity of ARDS. For some patients, it was also shown to be the only necessary form of oxygen supplementation.

Digital Twins of Acute Hypoxemic Respiratory Failure Patients Suggest a Mechanistic Basis for Success and Failure of Noninvasive Ventilation.

To clarify the mechanistic basis for the success or failure of noninvasive ventilation (NIV) in acute hypoxemic respiratory failure (AHRF). We created digital twins based on mechanistic computational models of individual patients with AHRF. Interdisciplinary Collaboration in Systems Medicine Research Network. We used individual patient data from 30 moderate-to-severe AHRF patients who had failed high-flow nasal cannula (HFNC) therapy and subsequently underwent a trial of NIV. Using the digital twins, we evaluated lung mechanics, quantified the separate contributions of external support and patient respiratory effort to lung injury indices, and investigated their relative impact on NIV success or failure. In digital twins of patients who successfully completed/failed NIV, after 2 hours of the trial the mean (sd) of the change in total lung stress was -10.9 (6.2)/-0.35 (3.38) cm H2O, mechanical power -13.4 (12.2)/-1.0 (5.4) J/min, and total lung strain 0.02 (0.24)/0.16 (0.30). In the digital twins, positive end-expiratory pressure (PEEP) produced by HFNC was similar to that set during NIV. In digital twins of patients who failed NIV vs. those who succeeded, intrinsic PEEP was 3.5 (0.6) vs. 2.3 (0.8) cm H2O, inspiratory pressure support was 8.3 (5.9) vs. 22.3 (7.2) cm H2O, and tidal volume was 10.9 (1.2) vs. 9.4 (1.8) mL/kg. In digital twins, successful NIV increased respiratory system compliance +25.0 (16.4) mL/cm H2O, lowered inspiratory muscle pressure -9.7 (9.6) cm H2O, and reduced the contribution of patient spontaneous breathing to total driving pressure by 57.0%. In digital twins of AHRF patients, successful NIV improved lung mechanics, lowering respiratory effort and indices associated with lung injury. NIV failed in patients for whom only low levels of positive inspiratory pressure support could be applied without risking patient self-inflicted lung injury due to excessive tidal volumes.

HACOR score to predict NIV failure in patients with COVID-related hypoxemic respiratory failure managed in the ordinary ward and in the critical care setting.

We evaluated the prevalence of non-invasive ventilation (NIV) failure among patients with COVID-19-related pneumonia, managed in the ordinary ward and in the HDU/ICU and we tested the prognostic role of the HACOR score in those different settings. This is a retrospective study, conducted in the University-Hospital Careggi. We included all subjects with COVID-19 and ARF requiring NIV between March 2020 and May 2021, respectively managed in the ordinary ward (G1) and in the critical care setting (G2). Clinical parameters, HACOR and SOFA score were evaluated at Day 0 and after 1, 2 and 5days of treatment. The primary outcome was NIV failure. 13% G1 patients and 40% G2 patients underwent endotracheal intubation (ETI). NIV was successful in 60% G1 AND 43% G2 patients (p < 0.001). In G1, compared to those with successful NIV, patients who underwent ETI, had a higher HACOR since the baseline evaluation (T0: 6 [5-6] vs 5 [3-6]; T1: 6 [5-6] vs 5 [3-6], all p < 0.05). An HACOR score > 5 was associated with an increased prevalence of ETI independent to an advanced age and a SOFA score > 5 both in G1 (T1: RR 4.87, 95% CI 1.462-16.275; T5: 3.630, 95% CI 0.979-13.462) and G2 (T0: 1.76, 95% CI 0.906-3.422; T1: 3.38, 95% CI 1.386-8.265). Among patients with COVID-related-ARF, NIV could be managed in the ordinary ward in a consistent proportion of patients and, among them, an HACOR score > 5 was independently associated with increased NIV failure from the earliest evaluations.

PaCO2 is nonlinearly associated with NIV failure in patients with hypoxemic respiratory failure

ObjectiveTo explore the association between PaCO2 and noninvasive ventilation (NIV) failure in patients with hypoxemic respiratory failure.MethodsA retrospective study was performed in a respiratory ICU of a teaching hospital. Patients admitted to ICU between 2011 and 2019 were screened. We enrolled the patients with hypoxemic respiratory failure. However, patients who used NIV due to acute-on-chronic respiratory failure or heart failure were excluded. Data before the use of NIV were collected. Requirement of intubation was defined as NIV failure.ResultsA total of 1029 patients were enrolled in final analysis. The rate of NIV failure was 45% (461/1029). A nonlinear relationship between PaCO2 and NIV failure was found by restricted cubic splines (p = 0.03). The inflection point was 32 mmHg. The rate of NIV failure was 42% (224/535) in patients with PaCO2 >32 mmHg. However, it increased to 48% (237/494) in those with PaCO2 ≤ 32 mmHg. The crude and adjusted hazard ratio (HR) for NIV failure was 1.36 (95%CI:1.13–1.64) and 1.23(1.01–1.49), respectively, if the patients with PaCO2 >32 mmHg were set as reference. In patients with PaCO2 ≤ 32 mmHg, one unit increment of PaCO2 was associated with 5% reduction of NIV failure. However, it did not associate with NIV failure in patients with PaCO2 >32 mmHg.ConclusionsPaCO2 and NIV failure was nonlinear relationship. The inflection point was 32 mmHg. Below the inflection point, lower PaCO2 was associated with higher NIV failure. However, it did not associate with NIV failure above this point.

Respiratory Support Practices for Bronchiolitis in the Pediatric Intensive Care Unit

Admissions to the pediatric intensive care unit (PICU) due to bronchiolitis are increasing. Whether this increase is associated with changes in noninvasive respiratory support practices is unknown. To assess whether the number of PICU admissions for bronchiolitis between 2013 and 2022 was associated with changes in the use of high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) and to identify factors associated with HFNC and NIV success and failure. This cross-sectional study examined encounter data from the Virtual Pediatric Systems database on annual PICU admissions for bronchiolitis and ventilation practices among patients aged younger than 2 years admitted to 27 PICUs between January 1, 2013, and December 31, 2022. Use of HFNC and NIV was defined as successful if patients were weaned to less invasive support (room air or low-flow nasal cannula for HFNC; room air, low-flow nasal cannula, or HFNC for NIV). The main outcome was the number of PICU admissions for bronchiolitis requiring the use of HFNC, NIV, or IMV. Linear regression was used to analyze the association between admission year and absolute numbers of encounters stratified by the maximum level of respiratory support required. Multivariable logistic regression was used to analyze factors associated with HFNC and NIV success and failure (defined as not meeting the criteria for success). Included in the analysis were 33 816 encounters for patients with bronchiolitis (20 186 males [59.7%]; 1910 patients [5.6%] aged ≤28 days and 31 906 patients [94.4%] aged 29 days to <2 years) treated at 27 PICUs from 2013 to 2022. A total of 7615 of 15 518 patients (49.1%) had respiratory syncytial virus infection and 1522 of 33 816 (4.5%) had preexisting cardiac disease. Admissions to the PICU increased by 350 (95% CI, 170-531) encounters annually. When data were grouped by the maximum level of respiratory support required, HFNC use increased by 242 (95% CI, 139-345) encounters per year and NIV use increased by 126 (95% CI, 64-189) encounters per year. The use of IMV did not significantly change (10 [95% CI, -11 to 31] encounters per year). In all, 22 381 patients (81.8%) were successfully weaned from HFNC to low-flow oxygen therapy or room air, 431 (1.6%) were restarted on HFNC, 3057 (11.2%) were escalated to NIV, and 1476 (5.4%) were escalated to IMV or extracorporeal membrane oxygenation (ECMO). Successful use of HFNC increased from 820 of 1027 encounters (79.8%) in 2013 to 3693 of 4399 encounters (84.0%) in 2022 (P = .002). In all, 8476 patients (81.5%) were successfully weaned from NIV, 787 (7.6%) were restarted on NIV, and 1135 (10.9%) were escalated to IMV or ECMO. Success with NIV increased from 224 of 306 encounters (73.2%) in 2013 to 1335 of 1589 encounters (84.0%) in 2022 (P < .001). In multivariable logistic regression, lower weight, higher Pediatric Risk of Mortality III score, cardiac disease, and PICU admission from outside the emergency department were associated with greater odds of HFNC and NIV failure. Findings of this cross-sectional study of patients aged younger than 2 years admitted for bronchiolitis suggest there was a 3-fold increase in PICU admissions between 2013 and 2022 associated with a 4.8-fold increase in HFNC use and a 5.8-fold increase in NIV use. Further research is needed to standardize approaches to HFNC and NIV support in bronchiolitis to reduce resource strain.

The role of electrical impedance tomography in predicting the failure of non-invasive ventilation in patients with COVID-19-associated hypoxemic acute respiratory failure: a prospective observational study

INTRODUCTION: Data on prediction of the failure of non-invasive lung ventilation (NIV) in patients with respiratory failure associated with COVID-19, based on electrical impedance tomography (EIT) patterns are limited. OBJECTIVE: To identify predictors of non-invasive lung ventilation failure in patients with respiratory insufficiency associated with COVID-19, using electrical impedance tomography data. MATERIALS AND METHODS: A monocenter prospective cohort observational study was conducted in patients with moderate-to-severe COVID-19-associated acute respiratory failure, who underwent NIV in the ICU (n = 43). EIT was used to measure the actual ventilation area (SVENT), hyperinflation area (SHYPER), ventilation delay zone (SRVD), and calculate the proportion of ventilated lungs (AVENT), proportion of hyperinflation area (ZHYPER), proportion of RVD area (ZRVD), as well as the duration of hyperinflation during one respiratory cycle (THYPER), and the ratio of hyperinflation time to inhalation time. RESULTS: The study included 43 patients admitted 15 (10–22) days after the onset of COVID-19. Patients with NIV failure (n = 34) had higher ZHYPER values on the first day (19.5 (16.3–30.5) in the NIV success group and 35.2 (25.0–45.0) in the failure group, AUROC 0.80, p = 0.004, Cut-off 39.7, Se 85 %, Sp 89 %) and the last day (20.6 (10.4–28.5) in the success group and 32.7 (26.4–43.3) in the failure group, AUROC 0.92, p = 0.003, Cut-off 32.7, Se 50 %, Sp 100 %), as well as a higher THYPER/TINSP ratio on the last day of NIV (37.5 (31.0–47.9) in the success group and 65.3 (43.7–88.4) in the failure group, AUROC 0.87, p = 0.001, Cut-off 52.7, Se 71 %, Sp 100 %). AVENT, ZRVD, and inhalation time did not show prognostic significance. CONCLUSIONS: EIT can predict the NIV failure in moderate-to-severe ARDS associated with COVID-19, based on the assessment of alveolar overdistention zones. Further research are needed to investigate this theory.

Combined cardiac, lung, and diaphragm ultrasound for predicting weaning failure during spontaneous breathing trial

BackgroundWeaning from invasive mechanical ventilation (MV) is a complex and challenging process that involves multiple pathophysiological mechanisms. A combined ultrasound evaluation of the heart, lungs, and diaphragm during the weaning phase can help to identify risk factors and underlying mechanisms for weaning failure. This study aimed to investigate the accuracy of lung ultrasound (LUS), transthoracic echocardiography (TTE), and diaphragm ultrasound for predicting weaning failure in critically ill patients.MethodsPatients undergoing invasive MV for > 48 h and who were readied for their first spontaneous breathing trial (SBT) were studied. Patients were scheduled for a 2-h SBT using low-level pressure support ventilation. LUS and TTE were performed prospectively before and 30 min after starting the SBT, and diaphragm ultrasound was only performed 30 min after starting the SBT. Weaning failure was defined as failure of SBT, re-intubation, or non-invasive ventilation within 48 h.ResultsFifty-one patients were included, of whom 15 experienced weaning failure. During the SBT, the global, anterior, and antero-lateral LUS scores were higher in the failed group than in the successful group. Receiver operating characteristic curve analysis showed that the areas under the curves for diaphragm thickening fraction (DTF) and global and antero-lateral LUS scores during the SBT to predict weaning failure were 0.678, 0.719, and 0.721, respectively. There was no correlation between the LUS scores and the average E/e’ ratio during the SBT. Multivariate analysis identified antero-lateral LUS score > 7 and DTF < 31% during the SBT as independent predictors of weaning failure.ConclusionLUS and diaphragm ultrasound can help to predict weaning failure in patients undergoing an SBT with low-level pressure support. An antero-lateral LUS score > 7 and DTF < 31% during the SBT were associated with weaning failure.Graphical

Intercostal Muscle Function During Noninvasive Ventilation and Acute Hypercapnic Respiratory Failure.

Noninvasive ventilation (NIV) is a widely used and well-established treatment modality for respiratory failure. In patients with increased respiratory work of breathing, accessory muscles are commonly activated along with the diaphragm. Whereas diaphragm ultrasound has been utilized to assess outcomes of mechanical ventilation, the data on intercostal muscle ultrasound remain limited. We aimed to investigate the association between intercostal muscle thickening fraction (TF) and NIV failure in critical care patients with hypercapnic respiratory failure. Critical care subjects receiving NIV for hypercapnic respiratory failure were enrolled in the study. The intercostal muscle TF was measured on admission day (day 0) and the following day (day 1). NIV failure was defined as the need for invasive mechanical ventilation or death during NIV therapy. A total of 158 subjects were enrolled, and 30 experienced NIV failure. Age, sex, and body mass index (BMI) were similar in the NIV success and failure groups. Acute Physiology And Chronic Health Evaluation II (APACHE II) and the Sequential Organ Failure Assessment (SOFA) scores were higher in the NIV failure group. In terms of causes of respiratory failure, the COPD exacerbation rate was higher in the NIV success group. TF was higher in the NIV failure group on both day 0 and day 1. The increased TF on the ICU admission day, with a cutoff value of 12%, was associated with NIV failure after adjusting for age, sex, BMI, APACHE II, and SOFA. Persistence of a higher TF value on both day 0 and day 1 was also associated with NIV failure risk. There was a positive relation between intercostal muscle TF measured by ultrasound and NIV failure, even after adjusting for APACHE II and SOFA scores.

First-Line Respiratory Support for Children With Hematologic Malignancy and Acute Respiratory Failure.

To characterize trends in noninvasive ventilation (NIV) and invasive mechanical ventilation (IMV) use over time in children with hematologic malignancy admitted to the PICU with acute respiratory failure (ARF), and to identify risk factors associated with NIV failure requiring transition to IMV. Retrospective cohort analysis using the Virtual Pediatric Systems (VPS, LLC) between January 1, 2010 and December 31, 2019. One hundred thirteen North American PICUs participating in VPS. Two thousand four hundred eighty children 0-21 years old with hematologic malignancy admitted to participating PICUs for ARF requiring respiratory support. None. There were 3013 total encounters, of which 868 (28.8%) received first-line NIV alone (NIV only), 1544 (51.2%) received first-line IMV (IMV only), and 601 (19.9%) required IMV after a failed NIV trial (NIV failure). From 2010 to 2019, the NIV only group increased from 9.6% to 43.1% and the IMV only group decreased from 80.1% to 34.2% (p < 0.001). The NIV failure group had the highest mortality compared with NIV only and IMV only (36.6% vs. 8.1%, vs. 30.5%, p < 0.001). However, risk-of-mortality (ROM) was highest in the IMV only group compared with NIV only and NIV failure (median Pediatric Risk of Mortality III ROM 8.1% vs. 2.8% vs. 5.5%, p < 0.001). NIV failure patients also had the longest median PICU length of stay compared with the other two study groups (15.2 d vs. 6.1 and 9.0 d, p < 0.001). Higher age was associated with significantly decreased odds of NIV failure, and diagnosis of non-Hodgkin lymphoma was associated with significantly increased odds of NIV failure compared with acute lymphoid leukemia. For children with hematologic malignancy admitted to the PICU with ARF, NIV has replaced IMV as the most common initial therapy. NIV failure rate remains high with high-observed mortality despite lower PICU admission ROM.

Parameters predicting non-invasive ventilation failure in COVID-19 patients

ntroduction. During COVID-19 pandemic, non-invasive ventilation (NIV) was widely used during COVID-19 Pandemic. The factors predicting NIV failure in COVID-19 patients remain debatable. The goal of this research is to identify the parameters that may correlate NIV failure. Materials and methods. A retrospective analysis of COVID-19 patients’ data, who were admitted to ICU of the Institute of Emergency Medicine, Chisinau, during July-October 2020 and connected to NIV. The study analyzed the demographics, laboratory and respiratory parameters (at admission, at NIV initiation, 24-48h and 72-96h of NIV) and their relation with NIV failure. . For continuous variables, the established confidence interval was 95%. The Kruskal-Wallis H test was used for continuous variables and the Fisher’s exact test or chi-squared test was used for category data. Results. In study were included 154 patients. NIV failed in 52 patients. In NIV failure group were registered a higher rate of hypertension (88% vs 74%, p = 0.033), delirium (60% vs 20%, p=0.001) and need for sedation (83% vs 48, p=0.001). The urea levels were lower in NIV success group at admission, at NIV initiation and at 24-48h of NIV. The neutrophil/ lymphocyte ratio was higher in NIV failure group at NIV initiation; at 24-48h and 72-96h of NIV. NIV failure group had a higher level of WBC count and C-reactive protein at 24-48h and 72-96h as well as D-dimer at 72-96h of NIV. The ROX index was higher in NIV success group from NIV initiation and through 72h of NIV. Conclusions. The presence of abnormal values of neutrophil/lymphocyte ratio, urea, lymphocytes, WBC count, C-reactive protein, D-dimer and ROX index during non-invasive ventilation, as well as association of delirium and need for sedation, can be suggestive and informative for high risk of NIV failure in COVID-19 patients. Continuous measurement of these parameters may help the clinicians to decide the optimal timing of conversion to invasive ventilation.

Longitudinal Assessment of ROX and HACOR Scores to Predict Non-Invasive Ventilation Failure in Patients with SARS-CoV-2 Pneumonia.

NIV (Non-invasive ventilation) and HFNC (High Flow nasal cannula) are being used in patients with acute respiratory failure. HACOR score has been exclusively calculated for patients on NIV, on other hand ROX index is being used for patients on HFNC. This is first study where ROX index has been used in patients on NIV to predict failure. This study investigates the comparative diagnostic performance of HACOR score and ROX index to predict NIV failure. We performed a retrospective cohort study of non-invasively ventilated COVID-19 patients admitted between 1st April 2020 to 15th June 2021 to ICU of a tertiary care teaching hospital located in Central India. We assessed factors responsible for NIV failure, and whether these scores HACOR/ROX index have discriminative capacity to predict risk of invasive mechanical ventilation. Of the 441 patients included in the current study, 179 (40.5%) recovered, while remaining 262 (59.4%) had NIV failure. On multivariable analysis, ROX index > 4.47 was found protective for NIV-failure (OR 0.15 (95% CI 0.03-0.23; p<0.001). Age > 60 years and SOFA score were other significant independent predictors of NIV-failure. The AUC for prediction of failure rises from 0.84 to 0.94 from day 1 to day 3 for ROX index and from 0.79 to 0.92 for HACOR score in the same period, hence ROX score was non-inferior to HACOR score in current study. DeLong's test for two correlated ROC curves had insignificant difference expect day-1 (D1: 0.03 to 0.08; p=3.191e-05, D2: -0.002 to 0.02; p = 0.2671, D3: -0.003 to 0.04; p= 0.1065). ROX score of 4.47 at day-3 consists of good discriminatory capacity to predict NIV failure. Considering its non-inferiority to HACOR score, the ROX score can be used in patients with acute respiratory failure who are on NIV.

Switches in non-invasive respiratory support strategies during acute hypoxemic respiratory failure: Need to monitoring from a retrospective observational study

ObjectiveTo explore combined non-invasive-respiratory-support (NIRS) patterns, reasons for NIRS switching, and their potential impact on clinical outcomes in acute-hypoxemic-respiratory-failure (AHRF) patients. DesignRetrospective, single-center observational study. SettingIntensive Care Medicine. PatientsAHRF patients (cardiac origin and respiratory acidosis excluded) underwent combined NIRS therapies such as non-invasive-ventilation (NIV) and High-Flow-Nasal-Cannula (HFNC). InterventionsPatients were classified based on the first NIRS switch performed (HFNC-to-NIV or NIV-to-HFNC), and further specific NIRS switching strategies (NIV trial-like vs. Non-NIV trial-like and single vs. multiples switches) were independently evaluated. Main variables of interestReasons for switching, NIRS failure and mortality rates. ResultsA total of 63 patients with AHRF were included, receiving combined NIRS, 58.7% classified in the HFNC-to-NIV group and 41.3% in the NIV-to-HFNC group. Reason for switching from HFNC to NIV was AHRF worsening (100%), while from NIV to HFNC was respiratory improvement (76.9%). NIRS failure rates were higher in the HFNC-to-NIV than in NIV-to-HFNC group (81% vs. 35%, p < 0.001). Among HFNC-to-NIV patients, there was no difference in the failure rate between the NIV trial-like and non-NIV trial-like groups (86% vs. 78%, p = 0.575) but the mortality rate was significantly lower in NIV trial-like group (14% vs. 52%, p = 0.02). Among NIV to HFNC patients, NIV failure was lower in the single switch group compared to the multiple switches group (15% vs. 53%, p = 0.039), with a shorter length of stay (5 [2–8] vs. 12 [8–30] days, p = 0.001). ConclusionsNIRS combination is used in real life and both switches’ strategies, HFNC to NIV and NIV to HFNC, are common in AHRF management. Transitioning from HFNC to NIV is suggested as a therapeutic escalation and in this context performance of a NIV-trial could be beneficial. Conversely, switching from NIV to HFNC is suggested as a de-escalation strategy that is deemed safe if there is no NIRS failure.

Outcomes of Acute Respiratory Failure in Patients With Cancer in the United States

ObjectiveTo determine the epidemiological effect-magnitude and outcomes of patients with cancer vs those without cancer who are hospitalized with acute respiratory failure (ARF). Patients and MethodsWe reviewed hospitalizations within the National Inpatient Sample (NIS) database between January 1, 2016, and December 31, 2018. Patients were classified based on a diagnosis of solid-organ cancer, hematologic cancer, or no cancer. Noninvasive positive pressure ventilation (NIPPV) failure was defined as patients who initially received NIPPV and had progression to invasive mechanical ventilation. Weighted samples were used to derive population estimates. ResultsDuring the study period, there were an estimated 8,837,209 admissions with ARF in the United States, 8.9% (783,625) of which had solid-organ cancer and 2.0% (176,095) had hematologic cancers. Annually, 319,907 patients with cancer are admitted with ARF, with 27.3% (87,302) requiring invasive mechanical ventilation and 10.0% (31,998) requiring NIPPV. In-hospital mortality was higher in patients with cancer vs those without cancer (24.0% [76,813] vs 12.3% [322,465]; P<.001), and this proprotion persisted when stratified by the highest method of oxygen delivery. Patients with cancer had longer hospital length of stay (7.0 days [3.0 to 12.0 days] vs 5.0 days [3.0 to 10.0 days]; P<.001) and were more likely to have NIPPV failure (14.9% [3,992] vs 12.8% [41,875]). Compared with those with solid-organ cancer, patients with hematologic cancers experienced worse outcomes. The association between underlying cancer diagnosis and outcomes remained consistent when adjusted for age, sex, and comorbidities. ConclusionIn the United States, patients with cancer account for over 10% of ARF hospital admissions (959,720 of 8,837,209). They experience an approximately 2-fold higher mortality versus those without cancer. Those with hematologic cancers appear to experience worse outcomes than patients with solid-organ cancers.