Noninvasive Ventilatory Support Research Articles

Comparison of clinical features of cystic fibrosis patients eligible but not on CFTR modulators to ineligible for CFTR modulators.

Cystic fibrosis transmembrane conductance regulator (CFTR) modulator drugs target the underlying defect and improve CFTR function. They are a part of standard care in many countries, but not all patients are eligible for these drugs due to age and genotype. Here, we aimed to determine the characteristics of non-eligible patients for CFTR modulators in the CF registry of Turkey (CFRT) to highlight their clinical needs. This retrospective cohort study included CF patient data from the CFRT in 2021. The decision of eligibility for the CFTR modulator was determined according to the 'Vertex treatment-Finder' on the Vertex® website. Demographic and clinical characteristics of patients were compared between eligible (group 1) and ineligible (group 2) groups for CFTR modulators. Among the study population (N = 1527), 873 (57.2%) were in group 1 and 654 (42.8%) were in group 2. There was no statistical difference between groups regarding sex, meconium ileus history, diagnoses via newborn screening, FEV1 z-score, CF-associated complications, organ transplant history, and death. Patients in group 2 had a higher incidence of pancreatic insufficiency (87.7% vs. 83.2%, p = .010), lower median height z-scores (-0.87 vs. -0.55, p < .001), lower median body mass index z-scores (-0.65 vs. -0.50, p < .001), longer days receiving antibiotics due to pulmonary exacerbation (0 [interquartile range, IQR: 0-2] vs. 0 [IQR: 0-7], p = 0.001), and more non-invasive ventilation support (2.6% vs. 0.9%, p = 0.008) than patients in group 1. The ineligible group had worse clinical outcomes than the eligible group. This highlights their need for life-changing drugs to improve clinical outcomes.

A Phase I trial of Non-invasive Ventilation and seizure prophylaxis with levetiracetam In Children with Cerebral Malaria Trial (NOVICE-M Trial)

Background African children with cerebral malaria and seizures caused Plasmodium falciparum are at greater risk of poor outcomes including death and neurological sequelae. The agonal events are severe hypoventilation and respiratory arrest often triggered by seizures. We hypothesised that prophylactic anti-seizure medication (ASM) could avert ‘spikes’ of intracranial pressure during or following seizures and that adequate ventilation could be supported by biphasic Cuirass Ventilation (BCV) which requires no intubation. Methods A Phase I trial conducted in Kilifi, Kenya designed to provide data on safety, feasibility and preliminary data on seizure control using prophylactic ASM (levetiracetam) and BCV as non-invasive ventilatory support in children with cerebral malaria. Children aged 3 months to 12-years hospitalised with P falciparum malaria (positive rapid diagnostic test or a malaria slide), a Blantyre Coma Score ≤2 and a history of acute seizures in this illness are eligible for the trial. In a phased evaluation we will study i) BCV alone for respiratory support (n=10); ii) prophylactic LVT: 40mg/kg loading dose then 30mg/kg every 12 hours given via nasogastric tube for 72 hours (or until fully conscious) plus BCV support (n=10) and; iii) prophylactic LVT: 60mg/kg loading dose then 45mg/kg every 12 hours given via nasogastric tube for 72 hours (or until fully conscious) plus BCV support (n=10). Primary outcome measure: cumulative time with a clinically detected seizures or number of observed seizures over 36 hours. Secondary outcomes will be assessed by feasibility or ability to implement BCV, and recovery from coma within 36 hours. Safety endpoints include: aspiration during admission; death at 28 days and 180 days; and de-novo neurological impairments at 180 days. Conclusions This is a Phase I trial largely designed to test the feasibility, tolerability and safety of using non-invasive ventilatory support and LVT prophylaxis in cerebral malaria. Registration ISRCTN76942974 (5.02.2019); PACTR202112749708968 (20.12.2021).

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.

Non-Invasive Ventilation Support during Hospitalization for SARS-CoV-2 and the Risk of Venous Thromboembolism.

Background/Objectives: Although SARS-CoV-2 infection is a significant risk factor for venous thromboembolism (VTE), data on the impact of the use of non-invasive ventilation support (NIVS) to mitigate the risk of VTE during hospitalization are scarce. Methods: Data for 1471 SARS-CoV-2 patients, hospitalized in a single hub during the first pandemic wave, were collected from clinical records, including symptom duration and type, information on lung abnormalities on chest computed tomography (CT), laboratory parameters and the use of NIVS. Determining VTE occurrence during hospital stays was the main endpoint. Results: Patients with VTE (1.8%) had an increased prevalence of obesity (26% vs. 11%), diabetes (41% vs. 21%), higher CHA2DS2VASC score (4, IQR 2-5 vs. 3, IQR 1-4, age- and sex-adjusted, p = 0.021) and cough (65% vs. 44%) and experienced significantly higher rates of NIVS (44% vs. 8%). Using a stepwise multivariate logistic regression model, the prevalence of electrocardiogram abnormalities (odds ratio (OR) 2.722, 95% confidence interval (CI) 1.039-7.133, p = 0.042), cough (OR 3.019, 95% CI 1.265-7.202, p = 0.013), CHA2DS2-VASC score > 3 (OR 3.404, 95% CI 1.362-8.513, p = 0.009) and the use of NIVS (OR 15.530, 95% CI 6.244-38.627, p < 0.001) were independently associated with a risk of VTE during hospitalization. NIVS remained an independent risk factor for VTE even after adjustment for the period of admission within the pandemic wave. Conclusions: Our study suggests that NIVS is a risk factor for VTE during hospitalization in SARS-CoV-2 patients. Future studies should assess the optimal prophylactic strategy against VTE in patients with a SARS-CoV-2 infection candidate to non-invasive ventilatory support.

Management of Refractory Chronic Obstructive Pulmonary Disease: A Review.

Chronic obstructive pulmonary disease (COPD) is a common condition with an estimated prevalence of 12% in adults over the age of 30 years worldwide. COPD is a leading cause of morbidity and mortality globally, with a substantial economic and social burden. There are an estimated 3 million deaths annually due to COPD. However, most of the patients with COPD respond to routine interventions like bronchodilator therapy, assessing supplemental oxygen needs, smoking cessation, vaccinations, and pulmonary rehabilitation. There is a significant number of patients who unfortunately progress to have persistent symptoms despite these interventions. Refractory COPD is not yet formally defined. Patients with severe persistent symptoms or exacerbations despite appropriate care can be considered to have refractory COPD. Managing refractory COPD needs a multidimensional approach. In this review article, we will discuss essential interventions like ensuring adequate inhaler techniques, exploring the need for non-invasive ventilatory support, use of chronic antibiotics and phosphodiesterase inhibitors to advanced therapies like bronchoscopic lung volume reduction surgery, and the upcoming role of anti-IL5 agents in managing patients with refractory COPD. We will also discuss non-pharmacologic interventions like psycho-social support and nutritional support. We will conclude by discussing the palliative care aspect of managing patients with refractory COPD. Through this review article, we aim to better the approach to managing patients with refractory COPD and discuss new upcoming therapies.

Comparison of BAP65, DECAF, PEARL, and MEWS Scores in Predicting Respiratory Support Need in Hospitalized Exacerbation of Chronic Obstructive Lung Disease Patients

Objective: Prognostic models aid clinical practice with decision-making on treatment and hospitalization in exacerbation of chronic obstructive lung disease (ECOPD). Although there are many studies with prognostic models, diagnostic accuracy is variable within and between models. Subjects and Methods: We compared the prognostic performance of the BAP65 score, DECAF score, PEARL score, and modified early warning score (MEWS) in hospitalized patients with ECOPD, to estimate ventilatory support need. Results: This cross-sectional study consisted of 139 patients. Patients in need of noninvasive or invasive mechanical ventilation support are grouped as ventilatory support groups (n = 54). Comparison between receiver operating characteristic curves revealed that the DECAF score is significantly superior to the PEARL score (p = 0.04) in discriminating patients in need of ventilatory support. DECAF score with a cutoff value of 1 presented the highest sensitivity and BAP65 score with a cutoff value of 2 presented the highest specificity in predicting ventilatory support need. Multivariable analysis revealed that gender played a significant role in COPD exacerbation outcome, and arterial pCO2 and RDW measurements were also predictors of ventilatory support need. Within severity indexes, only the DECAF score was independently associated with the outcome. One-point increase in DECAF score created a 1.43 times higher risk of ventilatory support need. All severity indexes showed a correlation with age, comorbidity index, and dyspnea. BAP65 and DECAF scores also showed a correlation with length of stay. Conclusion: Objective and practical classifications are needed by clinicians to assess prognosis and initiate treatment accordingly. DECAF score is a strong candidate among severity indexes.

Anti-synthase syndrome associated with SARS-Cov-2 infection

BackgroundAnti-synthetase syndrome (AS) is a rare autoimmune idiopathic inflammatory myopathy (IIM) with diverse manifestations, including arthritis, interstitial lung disease (ILD), Raynaud’s phenomenon, unexplained persistent fever, and mechanic’s hands.Case presentationWe present the case of a 72-year-old woman, previously healthy, who was admitted to our hospital for treatment of cough and rapid breathing. The patient had elevated white blood cells and C-reactive protein, and tested negative for severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2). She was initially diagnosed with community-acquired pneumonia and received tamoxifen for anti-infection treatment, but her dystonia worsened. She eventually required non-invasive ventilator support, tested positive for SARS-Cov-2 again, and started antiviral therapy, corticosteroids to reduce alveolar effusion, anticoagulation, and other treatments. However, her condition continued to deteriorate, with the lowest oxygenation index reaching only 80mmHg. Ultimately, she underwent tracheal intubation and mechanical ventilation. Chest CT revealed rapid progressive interstitial changes in her lungs, and her hands showed noticeable fraternization changes. At this point, we suspected that the novel coronavirus infection might be associated with autoimmune diseases. The patient’s autoimmune antibody spectrum showed positive results for anti-recombinant RO-52 antibody and myositis-specific antibody anti-alanyl tRNA synthetase (anti-PL-12). The patient was treated with dexamethasone sodium phosphate for anti-inflammatory and anti-fibrotic effects. After successful extubation, the patient was discharged with only oral prednisone tablets at a dose of 30 mg.ConclusionsThis case presents an early diagnosis and successful treatment of anti-synthetase syndrome combined with SARS-Cov-2 infection, emphasizing the importance of comprehensive physical examination. Additionally, it highlights the rapid progression of interstitial lung disease under SARS-Cov-2 infection, which is often difficult to distinguish on imaging. In cases where treatment for SARS-Cov-2 infection is ineffective, early screening for autoimmune diseases is recommended. As there is currently no standardized method for treating AS-ILD, the successful treatment of this case provides a reference for clinical research on anti-synthetase syndrome in the later stage.

Decision day – A retrospective analysis of COVID-19 patients treated with high PEEP non-invasive ventilation

Background and objectives. This retrospective analysis investigates the effect of high levels of Positive End-Expiratory Pressure (PEEP) during Non-Invasive Ventilation (NIV) in patients with COVID 19 Acute Respiratory Distress Syndrome (ARDS). Materials and methods. In the University Hospital Center Zagreb from October 2021 to February 2022, the study analyzed data from 97 patients who received NIV for acute respiratory support during ICU stay. The effect of NIV on survival, the length of stay in the ICU as well as the duration of the support itself was investigated. Results. Results show that despite low mortality in patients with NIV support, mortality is quite high in patients who required intubation. There is also a divergence of the respiratory support level parameter after the 3rd day on NIV, which suggests that moment as pivotal for assessing the continuation of NIV support. Conclusions. The results show that high level PEEP is a viable option for starting respiratory support in ARDS, but also the importance of timely assessment to optimize patient outcomes.

Spinal Muscular Atrophy (SMA) Mortality Despite Novel Medications: Case Reports.

Despite new effective medications, patients with SMA types 1-3 can continue to have inadequate cough flows to prevent episodes of acute respiratory failure. Ventilator unweanable intubated patients are thought to require tracheostomy tubes. As a result, potentially beneficial medications may be discontinued and patients die despite receiving these medications. Three cases are presented of medically treated, physically strengthening children, with SMA type 1. All three subsequently died or underwent tracheotomy. However, there is no evidence of extubation attempts to noninvasive ventilatory support settings or optimal mechanical insufflation-exsufflation despite this option being described to be over 98% successful for extubating unweanable medically untreated children with SMA1.

Comparison of two different Nasal Interfaces used in Non-Invasive Respiratory support in terms of Neonate comfort

Background Non-Invasive Ventilation (NIV) is the first choice approach in neonates with sufficient respiratory effort that require respiratory support. The type of nasal interface used in NIV affects both efficacy and patient comfort. The aim of this study is to investigate the effects of different nasal interfaces used in NIV support on neonatal patient comfort.MethodsOur study evaluated patients who received NIV support for 24 hours. The patients were randomly divided into two groups according to the type of nasal interface used, which were RAM cannula and short binasal prong (SBP). The patients’ demographic and clinical data were noted. Their sleep was monitored for 24 hours with an actigraphy device.ResultsA total of 82 patients were evaluated. The sleep efficiency in the RAM cannula group was significantly higher (respectively, 65.7% [10.22-95.25] vs. 57.81% [2.49-77], p=0.004). Although not statistically significant, the neonates in the RAM cannula group exhibited longer total sleep time (respectively, 10.4 ± 4.28 hours vs. 9.02 ± 3.73 hours, p=0.161). Comparison of heart rates and respiratory rates indicate that the patients in the RAM cannula group were more comfortable.Conclusions Our study found that infants who received NIV support through a RAM cannula experienced more efficient sleep. Holistic approaches in neonatal intensive care units are vital for better neurodevelopmental outcomes in newborns. Although non-invasive, the interface used in NIV should also be a part of this holistic approach.

Temporal trends of severity and outcomes of critically ill patients with COVID-19 after the emergence of variants of concern: A comparison of two waves.

The emergence of SARS-CoV-2 variants led to subsequent waves of COVID-19 worldwide. In many countries, the second wave of COVID-19 was marked by record deaths, raising the concern that variants associated with that wave might be more deadly. Our aim was to compare outcomes of critically-ill patients of the first two waves of COVID-19. This retrospective cohort included critically-ill patients admitted between March-June 2020 and April-July 2021 in the largest academic hospital in Brazil, which has free-access universal health care system. We compared admission characteristics and hospital outcomes. The main outcome was 60-day survival and we built multivariable Cox model based on a conceptual causal diagram in the format of directed acyclic graph (DAG). We included 1583 patients (1315 in the first and 268 in the second wave). Patients in the second wave were younger, had lower severity scores, used prone and non-invasive ventilatory support more often, and fewer patients required mechanical ventilation (70% vs 80%, p<0.001), vasopressors (60 vs 74%, p<0.001), and dialysis (22% vs 37%, p<0.001). Survival was higher in the second wave (HR 0.61, 95%CI 0.50-0.76). In the multivariable model, admission during the second wave, adjusted for age, SAPS3 and vaccination, was not associated with survival (aHR 0.85, 95%CI 0.65-1.12). In this cohort study, patients with COVID-19 admitted to the ICU in the second wave were younger and had better prognostic scores. Adjusted survival was similar in the two waves, contrasting with record number of hospitalizations, daily deaths and health system collapse seen across the country in the second wave. Our findings suggest that the combination of the burden of severe cases and factors such as resource allocation and health disparities may have had an impact in the excess mortality found in many countries in the second wave.

Retraction Notice

This study aimed to identify risk factors for noninvasive ventilation (NIV) failure in <30 weeks' gestation preterm neonates and compare morbidity in patients with and without NIV failure. This retrospective study included preterm neonates <30 weeks' gestation who received NIV support for respiratory distress syndrome. Demographic and clinical characteristics were compared between infants with and without NIV failure within the first 72 hours after birth. Of 443 preterm neonates, NIV failure occurred in 101 (22.8%). Of these, initial respiratory support was nasal continuous positive airway pressure (nCPAP) in 76 infants (75.2%) and nasal intermittent positive pressure ventilation (NIPPV) or bilevel positive airway pressure (BiPAP) in 25 infants (24.8%) (p < 0.001). Gestational age, birth weight, and antenatal steroid exposure were significantly lower in patients with NIV failure. Grade III-IV intraventricular hemorrhage, moderate/severe bronchopulmonary dysplasia, and retinopathy of prematurity requiring laser photocoagulation were significantly more common in the NIV failure group. Multivariate logistic regression analysis showed that antenatal steroid therapy reduced NIV failure (odds ratio [OR]: 0.53, 95% CI: 0.29 to 0.94; p = 0.03), while nCPAP (OR: 2.61, 95% CI: 1.53 to 4.48; p < 0.001), surfactant requirement (OR: 2.40, 95% CI: 1.36 to 4.25; p = 0.003), and ≥2 doses of surfactant need (OR: 3.57, 95% CI: 1.89 to 6.74; p < 0.001) were associated with greater NIV failure. The results of this study indicated that administering antenatal steroids and using NIPPV or BiPAP instead of nCPAP as initial respiratory support reduced the likelihood of NIV failure in preterm infants with respiratory distress syndrome.

Valsalva Manoeuvre-Induced Pneumothorax and Pneumomediastinum in a Covid-19 Patient with ARDS: An Unusual Mechanism for this Complication.

Until now, only a few cases of Valsalva-induced barotraumas (pneumothorax, pneumomediastinum and subcutaneous emphysema) have been described, and none of them among COVID-19 patients. A man in his 50s was admitted for SARS-CoV-2-related acute respiratory distress syndrome (ARDS). Initial evolution was favourable with non-invasive ventilatory support, high-flow oxygen nasal cannula and the best supportive drugs available at the time. During the Valsalva manoeuvre while defecating, the patient reported sudden chest pain and showed a new acute hypoxemic respiratory failure due to a pneumothorax. It led to multiple complications (pulmonary embolism, haemoptysis, and cardiac arrest), and despite the best supportive care, led to the patient's death. The Valsalva manoeuvre can be an overlooked cause of pneumothorax in patients with COVID-19. Predisposition to barotrauma in COVID-19 patients could be explained by several factors, including the extensive use of non-invasive and invasive ventilation during the pandemic, and the histological changes observed in the lungs of those infected with COVID-19. We report the first description of a Valsalva-induced barotrauma in a COVID-19 infection. We emphasise the importance of treating constipation particularly in severe COVID-19 cases, to prevent complications such as barotrauma. Pneumothorax is a common complication of severe COVID-19 infection, but Valsalva manoeuvre-induced pneumothorax in COVID-19 patients has never been reported previously.Particular care should be taken to prevent and treat constipation in hospitalised patients as it may cause a wide range of complications, including barotraumatism.The extensive use of non-invasive and invasive ventilation may play a role in barotrauma, but causal association has not been proven.

DCROX and ROX Indices Predict Clinical Outcomes in Patients with COVID-19 Pneumonia Treated with High-Flow Nasal Cannula Oxygen Therapy.

High-flow nasal cannula (HFNC) therapy is a common respiratory support in patients with COVID-19 pneumonia. Predictive tools for the evaluation of successful weaning from HFNC therapy for COVID-19 pneumonia have been limited. This study aimed to develop a new predictor for weaning success from HFNC treatment in patients with COVID-19 pneumonia. We conducted a retrospective cohort study at Thammasat University Hospital, Thailand. Patients with COVID-19 pneumonia requiring HFNC therapy from April 2020 to September 2021 were included. The ROX index was defined as the ratio of oxygen saturation (SpO2)/fraction of inspired oxygen (FiO2) to respiratory rate. The CROX index was defined as the ratio of C-reactive protein (CRP) to the ROX index. dCROX was defined as the difference in CROX index between 24 hours and 72 hours. Weaning success was defined as the ability to sustain spontaneous breathing after separation from HFNC without any invasive or noninvasive ventilatory support for ≥48 hours or death. A total of 106 patients (49.1% male) were included. The mean age was 62.1 ± 16.2 years. Baseline SpO2/FiO2 was 276.1 ± 124.8. The rate of HFNC weaning success within 14 days was 61.3%. The best cutoff value of the dCROX index to predict HFNC weaning success was 3.15 with 66.2% sensitivity, 70.7% specificity, and an area under the ROC curve (AUC) of 0.71 (95% CI: 0.59-0.81, p < 0.001). The best cutoff value of the ROX index was 9.13, with 75.4% sensitivity, 78.0% specificity, and an AUC of 0.79 (95% CI: 0.69-0.88, p < 0.001). ROX index has the highest accuracy for predicting successful weaning from HFNC in patients with COVID-19 pneumonia. dCROX index is the alternative tool for this setting. However, a larger prospective cohort study is needed to verify these indices for determining separation from HFNC therapy. This trial is registered with TCTR20221107004.

Clinical predictors of severe forms of influenza A(H1N1)pdm09 in adults and children during the 2009 epidemic in Brazil.

The World Health Organization (WHO) raised the global alert level for the A(H1N1) influenza pandemic in June 2009. However, since the beginning of the epidemic, the fight against the epidemic lacked foundations for managing cases to reduce the disease lethality. It was urgent to carry out studies that would indicate a model for predicting severe forms of influenza. This study aimed to identify risk factors for severe forms during the 2009 influenza epidemic and develop a prediction model based on clinical epidemiological data. A case-control of cases notified to the health secretariats of the states of Rio de Janeiro, São Paulo, Minas Gerais, Paraná, and Rio Grande do Sul was conducted. Cases had fever, respiratory symptoms, positive confirmatory test for the presence of the virus associated with one of the three conditions: (i) presenting respiratory complications such as pneumonia, ventilatory failure, severe acute respiratory distress syndrome, sepsis, acute cardiovascular complications or death; or respiratory failure requiring invasive or non-invasive ventilatory support, (ii) having been hospitalized or (iii) having been admitted to an Intensive Care Unit. Controls were individuals diagnosed with the disease on the same date (or same week) as the cases. A total of 1653 individuals were included in the study, (858 cases/795 controls). These participants had a mean age of 26 years, a low level of education, and were mostly female. The most important predictors identified were systolic blood pressure in mmHg, respiratory rate in bpm, dehydration, obesity, pregnancy (in women), and vomiting (in children). Three clinical prediction models of severity were developed, for adults, adult women, and for children. The performance evaluation of these models indicated good predictive capacity. The area values under the ROC curve of these models were 0.89; 0.98 and 0.91 respectively for the model of adults, adult women, and children respectively.

Comparing COVID-19 severity in patients hospitalized for community-associated Delta, BA.1 and BA.4/5 variant infection.

Despite decreasing COVID-19 disease severity during the Omicron waves, a proportion of patients still require hospitalization and intensive care. To compare demographic characteristics, comorbidities, vaccination status, and previous infections in patients hospitalized for community-associated COVID-19 (CAC) in predominantly Delta, Omicron BA.1 and BA.4/5 SARS-CoV-2 waves. Data were extracted from three national databases-the National COVID-19 Database, National Vaccination Registry and National Registry of Hospitalizations. Among the hospitalized CAC patients analyzed in this study, 5,512 were infected with Delta, 1,120 with Omicron BA.1, and 1,143 with the Omicron BA.4/5 variant. The age and sex structure changed from Delta to BA.4/5, with the proportion of women (9.5% increase), children and adolescents (10.4% increase), and octa- and nonagenarians increasing significantly (24.5% increase). Significantly more patients had comorbidities (measured by the Charlson Comorbidity Index), 30.3% in Delta and 43% in BA.4/5 period. The need for non-invasive ventilatory support (NiVS), ICU admission, mechanical ventilation (MV), and in-hospital mortality (IHM) decreased from Delta to Omicron BA.4/5 period for 12.6, 13.5, 11.5, and 6.3%, respectively. Multivariate analysis revealed significantly lower odds for ICU admission (OR 0.68, CI 0.54-0.84, p < 0.001) and IHM (OR 0.74, CI 0.58-0.93, p = 0.011) during the Delta period in patients who had been fully vaccinated or boosted with a COVID-19 vaccine within the previous 6 months. In the BA.1 variant period, patients who had less than 6 months elapsed between the last vaccine dose and SARS-CoV-2 positivity had lower odds for MV (OR 0.38, CI 0.18-0.72, p = 0.005) and IHM (OR 0.56, CI 0.37- 0.83, p = 0.005), but not for NIVS or ICU admission. The likelihood of developing severe CAC in hospitalized patients was higher in those with the Delta and Omicron BA.1 variant compared to BA.4/5.

Physical and respiratory therapy in the critically ill patient with obesity: a narrative review.

Obesity has become increasingly prevalent in the intensive care unit, presenting a significant challenge for healthcare systems and professionals, including rehabilitation teams. Caring for critically ill patients with obesity involves addressing complex issues. Despite the well-established and safe practice of early mobilization during critical illness, in rehabilitation matters, the diverse clinical disturbances and scenarios within the obese patient population necessitate a comprehensive understanding. This includes recognizing the importance of metabolic support, both non-invasive and invasive ventilatory support, and their weaning processes as essential prerequisites. Physiotherapists, working collaboratively with a multidisciplinary team, play a crucial role in ensuring proper assessment and functional rehabilitation in the critical care setting. This review aims to provide critical insights into the key management and rehabilitation principles for obese patients in the intensive care unit.

Comparison of ROX, HROX, and delta-HR indices to predict successful weaning from high-flow oxygen therapy in hospitalized patients with COVID-19 pneumonia.

High-flow nasal cannula (HFNC) therapy is commonly used to treat acute respiratory failure in patients with COVID-19 pneumonia. However, predictors of successful weaning from HFNC in these patients has not been investigated. To assess predictors of successful separation from HFNC in patients with COVID-19 pneumonia. We conducted a retrospective cohort study at a university hospital in Thailand. Patients with COVID-19 pneumonia requiring HFNC therapy between April 2020 and June 2022 were included. ROX index was defined as the ratio of oxygen saturation (SpO2) / fraction of inspired oxygen (FiO2) to respiratory rate. Heart-ROX (HROX) index was defined as ROX multiplied by heart rate (HR) improvement. HR improvement (delta-HR) was defined as a percentage of the difference between the baseline HR and the morning HR at HFNC weaning day 1 divided by the baseline HR. Weaning success was defined as ability to sustain spontaneous breathing after separation from HFNC without any invasive or non-invasive ventilatory support for ≥48 hours or death. A total of 164 patients (54% male) were included. Mean age was 61.1±16.1 years. Baseline SpO2/FiO2 was 265.3±110.8. HFNC weaning success was 77.4%. The best cut-off value of ROX index to predict HFNC weaning success was 7.88 with 100% sensitivity, 97.3% specificity, and area under the ROC curve (AUC) of 0.98 (95% CI: 0.937-1.000, p<0.001). The best cut-off value of delta-HR 3.7 with 88.2% sensitivity, 75.7% specificity, and AUC of 0.83 (95% CI: 0.748-0.919, p<0.001). The best cut-off value of HROX index was 59.2 with 88.2% sensitivity, 81.1% specificity, and AUC of 0.89, (95% CI: 0.835-0.953, p<0.001). The ROX index has the highest accuracy for predicting successful weaning off HFNC treatment in patients with COVID-19 pneumonia. While HROX and delta-HR indices can serve as alternative tools, it is recommended to verify these indices and determine the optimal cut-off value for determining separation from HFNC therapy through a large prospective cohort study. Clinicaltrials.in.th number: TCTR20221108004.

Factors Associated With Failure of Non-invasive Ventilation in Preterm Neonates Requiring Initial Respiratory Support.

Non-invasive ventilation (NIV) modalities minimize the requirement for invasive mechanical ventilation (IMV) in preterm neonates, therefore improving neonatal outcomes, as IMV is linked to increased complications. However, NIV has demonstrated an elevated likelihood of failure, for which various studies have been done, but very little research is available addressing the factors that are responsible for NIV failure in resource-limited areas of developing nations. Understanding the underlying factors and their association with NIV failure in very and moderately preterm neonates at a tertiary care hospital would be important in devising targeted strategies to increase NIV success and newborn outcomes. To compare the following factors in neonates of 28-34 weeks gestational age with or without failure of NIV: fraction of inspired oxygen (FiO2) at the time of initiating NIV, time at surfactant administration, respiratory distress syndrome presence, antenatal steroid use, time taken for post-surfactant administration stabilization, gestational age, development of bronchopulmonary dysplasia, and average weight gained or lost. This was a longitudinal observational study. One hundred two preterm neonates with a gestational age of 28-34 weeks in the neonatal intensive care unit (NICU) requiring NIV support within 24 hours of admission. Eligible newborns were re-evaluated at 72 hours after commencing NIV. Outcome was evaluated as success (no NIV or NIV with positive end-expiratory pressure (PEEP)<8 cm H2O and FiO2<0.7) or failure (NIV with PEEP≥8 cm H2O or FiO2≥0.7,intubation, or death). It was compared with regard to many parameters. About 40 (39%) study participants reported NIV failure within 72 hours of initiating NIV. In the NIV failure group, male babies constituted 75% (P = 0.027), the median gestational age (IQR) was 29 (29-31) weeks (P = 0.015), the median birth weight (IQR) was 1088 (960-1293.5) grams (P = 0.003), and the median weight gain or loss (IQR) was a loss of 21 (-70.5 to 11.75) grams (P<0.001). Vaginal birth comprised 67.5% of the NIV failure group, showing greater failure rates than births out of lower segment cesarean section (LSCS) (P = 0.003) Conclusion: NIV failure showed a significant association with lesser gestational age, male sex, lowerbirth weight, vaginal method of delivery, and lesserweight gain during hospital stay.

Ratio of oxygen saturation index for predicting high-flow nasal cannula outcomes in emergency department for COVID-19 patients with severe hypoxemia: A retrospective study.

High-flow nasal cannula (HFNC) oxygen therapy has been used as an initial ventilatory support for coronavirus disease 2019 (COVID-19) patients with mixed levels of acute hypoxemic respiratory failure (AHRF). However, the effectiveness of HFNC when used as initial ventilatory support in COVID-19 patients with severe AHRF exclusively is not well documented. Ratio of oxygen saturation (ROX) index (ROX = [SpO2/fraction of inspired oxygen]/respiratory rate) was shown to predict the outcome of HFNC in intensive care unit patients. Our study aimed to evaluate the utility of the ROX index for predicting HFNC therapy success/failure in COVID-19 patients with severe AHRF when HFNC is used as the first line of ventilatory support. Retrospective study in 67 COVID-19 patients with severe AHRF receiving HFNC in the emergency department at a tertiary care academic medical center. ROX index was determined at 0, 2, 6, 12, and 24 h of HFNC onset. The need to escalate to noninvasive or invasive ventilatory support was documented. The receiver operating characteristic curves were performed and areas under the curves (AUCs) were calculated to evaluate the accuracy of ROX index for differentiating between patients who will succeed or fail HFNC therapy. HFNC therapy was successful in 19 patients (28.1%) and failed in 48 patients (71.6%). ROX index after 6 h of HFNC initiation had the best predictive capacity for the outcome of HFNC therapy (AUC = 0.78). ROX index >4.4 at 6 h of HFNC onset was significantly associated with HFNC success/failure. ROX index at 6 h after initiating HFNC therapy in COVID-19 patients with severe AHRF has a good predictive capacity for HFNC success/failure.