Noninvasive Mechanical Ventilation Research Articles

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

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

Acute heart failure and acute coronary syndrome: not uncommon duo and dangerous

Abstract Funding Acknowledgements None. Introduction Acute Heart Failure (AHF) is a common cause of hospitalisation. Its ethology and triggering factors influence the prognosis and evolution. Methods and purpose Retrospective analysis of 6330 patients admitted to our hospital's Coronary Care Unit (CCU) between 2012 and 2022. The main objective was to analyse the characteristics during hospital progress and follow-up of patients with AHF after an Acute Coronary Syndrome (ACS) in class Killip III or IV, comparing it with those admitted for AHF not secondary to ACS. Results 698 patients with AHF after ACS and 384 with AHF not secondary to ACS were included. 68.8% of patients presented Acute Coronary Syndrome with ST elevation (STEMI), with a higher prevalence in the anterior location (34,3%). Angioplasty was performed in 53.4% of patiens with STEMI and in 40.3% of patients with NSTEMI. The Cardiovascular risk factors (Figure 1) were similar in both groups, while patients with AHF not secondary to ACS had a history of Coronary Heart Disease (CHD) and atrial fibrilación (AF) more frequently. Patients with AHF after ACS more frequently required treatment with dobutamine and norepinephrine (63.6% and 57.6%, respectively) as well as orotracheal intubation. At the same time, levosimendan was administered more frequently to patients with AHF not secondary to ACS, with non-invasive mechanical ventilation being more frequent in this group. Both groups similarly received neurohormonal treatment, with beta-blockers being used the most. Events during follow-up (Figure 2) were higher in patients with AHF after ACS, except HF events. Cardiovascular mortality was 21.9% in patients with AHF after ACS. Conclusions Patients admitted for ACS complicated with AHF Killip III-IV represented 11.02%. The majority presented previously STEMI. During their admission, compared to patients admitted for AHF not secondary to ACS, they more frequently required vasoactive drugs and orotracheal intubation. Cardiovascular complications and mortality during follow-up were higher in patients with AHF after ACS. Therefore, early identification of patients with ACS at risk of developing AHF and establishing a specific and optimal treatment is crucial in the evolution of these patients.

Clinical characteristics, complications and in-hospital mortality in patients in the coronary care unit requiring invasive mechanical ventilation

Abstract Funding Acknowledgements None. Introduction Mechanical ventilation (MV) is one of the most widely used life support techniques in critically ill patients and, due to the increasing number of coronary care units (CCU), adequate management of this technique is essential. Purpose The aim of our study was to describe the profile of patients requiring invasive MV (IMV) in our CCU, as well as the mode of ventilation, complications and in-hospital mortality. Methods Single-center retrospective observational study of a cohort of patients admitted to a CCU between January 2018 and March 2023 who required IMV. Baseline characteristics, reason for admission and intubation, as well as evolution and complications during admission were analyzed. Results A total of 157 patients were included, 113 (72%) men. The mean age was 66.9 years (SD 12.2). Table 1 summarizes the history and baseline characteristics of the patients. Image 1 summarizes the reasons for admission. Regarding the causes of oro-tracheal intubation, the most frequent was cardiopulmonary arrest (CPA) (49.7%), followed by respiratory failure (32.5%) and cardiogenic shock (CS) (16.6%). Regarding left ventricular ejection fraction (LVEF) on admission, 69.4% had LVEF<52%, with 32.5% of all patients having LVEF below 30%. The most used ventilation mode as initial mode was volume-controlled mode (VC/AC), used in 71.3% of patients. The mean stay in CCU was 11 (min 1-max 78, SD 12) and of orotracheal intubation was 5 days (min 1-max 64, SD 7). Mean days to weaning from VMI was 2 (min 0-max 8, SD 2). Failure on extubation occurred in 38 patients (19.1%), the most frequent reasons being need for reintubation (12.7%), need for noninvasive MV (8.9%) and self-extubation (2.5%). Only 7 patients (4.5%) required tracheostomy. Regarding complications, 49% developed sepsis, 61.1% had CS, and 7% required renal replacement therapy. In-hospital mortality was 38.2% (60 patients). Conclusions IMV is a technique that is increasingly used in our environment. Patients who require it are usually complex, with multiple comorbidities, with a high percentage of CPA and CS. These patients usually have prolonged stays in the CCU, with an average of more than 10 days, frequent complications and a high in-hospital mortality of almost 40%. It is essential to gather series as large as possible of these patients to improve our knowledge of their management and characteristics.

Use of the combination of spirometry, arterial blood gas analysis and overnight oximetry to predict the outcomes of patients affected by motor neuron disease: The Milan-Torin respiratory score (Mi-To-RS).

The use of multiple tests, including spirometry, arterial blood gas (ABG) analysis and overnight oximetry (OvOx), is highly recommended to monitor the respiratory function of patients with motor neuron disease (MND). In this study, we propose a composite score to simplify the respiratory management of MND patients and better stratify their prognosis. We screened the clinical charts of 471 non-ventilated MND patients referred to the Neuro-rehabilitation Unit of the San Raffaele Scientific Institute of Milan (January 2001-December 2019), collecting spirometric, ABG and OvOx parameters. To evaluate the prognostic role of each measurement, univariate Cox regression for death/tracheostomy was performed, and the variables associated with survival were selected to design a scoring system. Univariate and multivariate Cox regression analyses were then carried out to evaluate the prognostic role of the score. Finally, results were replicated in an independent cohort from the Turin ALS Center. The study population included 450 patients. Six measurements were found to be significantly associated with survival and were selected to design a scoring system (maximum score = 8 points). Kaplan-Meier analysis showed significant stratification of survival and time to non-invasive mechanical ventilation adaptation according to score values, and multivariate analysis confirmed the independent effect of the respiratory score on survival of each cohort. Forced vital capacity, ABG and OvOx parameters provide complementary information for the respiratory management and prognosis of MND patients and the combination of these parameters into a single score might help neurologists predict prognosis and guide decisions on the timing of the implementation of different diagnostic or therapeutic approaches.

Outcome of high-flow nasal cannula (HFNC) therapy in respiratory failure due to lower respiratory tract infections in PICU - a single center experience in Karachi, Pakistan.

Objective: To evaluate the outcome of high-flow nasal cannula (HFNC) therapy by ROX index in critically ill children with acute respiratory failure due to lower respiratory tract infections in pediatric intensive care unit (PICU). Study Design: Analytical, Observational, Cross-sectional study. Setting: The PICU of the Indus Hospital, Karachi, Pakistan. Period: November 2022 to October 2023. Methods: We enrolled children of either gender, aged above 1 month up to 16 years and presenting with acute respiratory insufficiency due to lower respiratory tract infections. The use of HFNC was monitored for 72-hours. HFNC failure was characterized by requiring either noninvasive mechanical ventilation or invasive mechanical ventilation due to an unstable state. Results: In a total of 62 children, 39 (62.9%) were male. The mean age was 27.01±30.96 months. The most common diagnosis at the time of admission were pneumonia, and bronchiolitis noted in 25 (40.3%), and 33 (53.2%) children, respectively. Gradual improvement in ROX index was observed among children with HFNC success while a declining ROX index predicted HFNC failure. Outcome of HFNC was successful in 45 (72.6%) children. Mortality was observed in 12 (19.4%) children. Presence of comorbidity was significantly associated with unsuccessful HFNC outcomes. Conclusion: ROX index was found to be a good predictor of HFNC outcome. Overall, HFNC therapy in PICU demonstrated 72.6% success rate. HFNC outcomes are hampered particularly in cases involving comorbidities highlighting the need for tailored interventions.

Trophic Nutrition in ICU Patients Undergoing High-Flow Oxygen Therapy and/or Noninvasive Mechanical Ventilation: The Nutri-Trophic Study.

Enteral nutrition (EN) therapy in ICU patients requiring oxygen therapy with high-flow nasal cannula (HFNC) and/or noninvasive mechanical ventilation (NIMV) is controversial. A prospective, cohort, observational, and multicenter study was conducted in 10 ICUs in Spain to analyze the 90-day mortality, tolerance, side effects, and infectious complications of trophic EN in patients requiring HFNC therapy and/or NIVM. A total of 149 patients were enrolled. The mean age, severity scores, tracheobronchitis, bacteremia, and antimicrobial therapy were significantly higher in deceased than in living patients (p < 0.05), and the mortality rate was 14.8%. A total of 110 patients received oral trophic feedings, 36 patients received nasogastric tube feedings (NGFs), and 3 received mixed feedings. Trophic EN was discontinued in only ten (14.9%) patients because of feeding-related complications. The variables selected for the multivariate logistic regression on feeding discontinuation were SOFA upon admission (OR per unit = 1.461) and urea (OR per mg/dL = 1.029). There were no significant differences in the development of new infections according to the route of EN administration. Early trophic feeding administered to patients with acute respiratory failure requiring noninvasive ventilation is safe and feasible, and is associated with few dietary and infectious complications in a mortality, setting comparable to similar studies.

Predictors of mortality among critical COVID-19 patients admitted to the intensive care unit in the Sulaimani governorate in 2021, Iraq

Background and objective: There are many factors that influence mortality in critically ill patients with COVID-19 infection in the intensive care unit. The aim of this study was to investigate the risk factors that predict the mortalities of critical COVID-19 patients admitted to the intensive care unit in Sulaimani in 2021. Methods: This is an observational retrospective study of critically ill patients with COVID-19 pneumonia admitted to the main intensive care unit of the Sulaimani government between June and December 2020. Overall baseline characteristics are presented based on the patient's survivors versus non-survivors. Mann-Whitney U test was used to compare whether there is a difference between survivors and non-survivors for the independent basic characteristics of the patients. Binary logistic regression was used to identify the predicted factors of survivors. Results: A total of 220 patients were admitted to the intensive care unit, of whom 167 died, with a case fatality rate of 75.9%. The risk factors that predicted mortality in critical COVID-19 patients were an increasing age of more than 59 years (P-value = 0.008), comorbidities (P-value = 0.038), and a lack of use of antiviral drugs (P-value = 0.011). Whereas the factors significantly predicted a reduction in mortality were increasing oxygen saturation (P-value &lt;0.001), systolic blood pressure (P-value = 0.002), non-invasive mechanical ventilation (facemask) (P-value = 0.001), and continuous positive airway pressure (P-value = 0.003). Conclusion: The risk factors that predicted mortality in critical COVID-19 patients were increasing age, comorbidities, and a lack of use of antiviral drugs. Whereas increasing oxygen saturation, systolic blood pressure, non-invasive mechanical ventilation (facemask), and continuous positive airway pressure significantly predicted a reduction in the likelihood of death.

Lactate level is an independent predictor of mortality in patients with hematologic malignancy receiving urgent chemotherapy in intensive care unit

BackgroundIntensive care unit (ICU) survival of cancer patients has improved. Urgent chemotherapy has become feasible in critically ill patients with specific organ dysfunction due to hematological malignancies. ObjectiveThe aim of the study was to assess ICU mortality rates and the factors associated with mortality in patients with hematologic malignancies receiving urgent chemotherapy in the ICU. MethodsWe retrospectively included all patients admitted to the ICU who received chemotherapy due to hematologic malignancy in 2012–2022. ResultsOf the 129 patients undergoing chemotherapy in the ICU, 50 (38.7 %) died during the ICU follow-up. The following conditions were significantly more common among nonsurvivors: presence of infection at the time of ICU admission (p < 0.001), the requirement for mechanical ventilation during ICU stay (p < 0.001), the need for noninvasive mechanical ventilation during ICU stay (p = 0.014), vasopressor support (p < 0.001), and sepsis (p < 0.001). Logistic regression analysis revealed that among laboratory parameters on ICU admission, lactate (p = 0.008), albumin (p = 0.022), C-reactive protein (p = 0.046), baseline sequential organ failure assessment (SOFA) score (p < 0.001), newly developed heart failure (p = 0.006), and the requirement for vasopressor agents during ICU stay (p < 0.001) significantly influenced the risk of mortality in the univariate analysis. The multivariate analysis revealed lactate levels (p = 0.047) on ICU admission as an independent predictor of mortality. ConclusionThe development of heart failure and lactate levels on admission were the main predictors of mortality. Additionally, higher SOFA scores revealed that illness severity was closely associated with mortality. Future studies should focus on strategies to further reduce these risks and achieve the best outcomes for these patients.

Durability of Original Monovalent mRNA Vaccine Effectiveness Against COVID-19 Omicron-Associated Hospitalization in Children and Adolescents - United States, 2021-2023.

Pediatric COVID-19 vaccination is effective in preventing COVID-19-related hospitalization, but duration of protection of the original monovalent vaccine during SARS-CoV-2 Omicron predominance merits evaluation, particularly given low coverage with updated COVID-19 vaccines. During December 19, 2021-October 29, 2023, the Overcoming COVID-19 Network evaluated vaccine effectiveness (VE) of ≥2 original monovalent COVID-19 mRNA vaccine doses against COVID-19-related hospitalization and critical illness among U.S. children and adolescents aged 5-18 years, using a case-control design. Too few children and adolescents received bivalent or updated monovalent vaccines to separately evaluate their effectiveness. Most case-patients (persons with a positive SARS-CoV-2 test result) were unvaccinated, despite the high frequency of reported underlying conditions associated with severe COVID-19. VE of the original monovalent vaccine against COVID-19-related hospitalizations was 52% (95% CI=33%-66%) when the most recent dose was administered <120 days before hospitalization and 19% (95% CI=2%-32%) if the interval was 120-364 days. VE of the original monovalent vaccine against COVID-19-related hospitalization was 31% (95% CI=18%-43%) if the last dose was received any time within the previous year. VE against critical COVID-19-related illness, defined as receipt of noninvasive or invasive mechanical ventilation, vasoactive infusions, extracorporeal membrane oxygenation, and illness resulting in death, was 57% (95% CI=21%-76%) when the most recent dose was received <120 days before hospitalization, 25% (95% CI=-9% to 49%) if it was received 120-364 days before hospitalization, and 38% (95% CI=15%-55%) if the last dose was received any time within the previous year. VE was similar after excluding children and adolescents with documented immunocompromising conditions. Because of the low frequency of children who received updated COVID-19 vaccines and waning effectiveness of original monovalent doses, these data support CDC recommendations that all children and adolescents receive updated COVID-19 vaccines to protect against severe COVID-19.

COVID-19 and Clostridioides difficile Coinfection Analysis in the Intensive Care Unit.

Since the emergence of SARS-CoV-2 in late 2019, the global mortality attributable to COVID-19 has reached 6,972,152 deaths according to the World Health Organization (WHO). The association between coinfection with Clostridioides difficile (CDI) and SARS-CoV-2 has limited data in the literature. This retrospective study, conducted at Mureș County Clinical Hospital in Romania, involved 3002 ICU patients. Following stringent inclusion and exclusion criteria, 63 patients were enrolled, with a division into two subgroups-SARS-CoV-2 + CDI patients and CDI patients. Throughout their hospitalization, the patients were closely monitored. Analysis revealed no significant correlation between comorbidities and invasive mechanical ventilation (IMV) or non-invasive mechanical ventilation (NIMV). However, statistically significant associations were noted between renal and hepatic comorbidties (p = 0.009), death and CDI-SARS-CoV-2 coinfection (p = 0.09), flourochinolone treatment and CDI-SARS-CoV-2 infection (p = 0.03), and an association between diabetes mellitus and SARS-CoV-2-CDI infection (p = 0.04), as well as the need for invasive mechanical ventilation (p = 0.04). The patients with CDI treatment were significantly younger and received immuno-modulator or corticotherapy treatment, which was a risk factor for opportunistic agents. Antibiotic and PPI (proton pump inhibitor) treatment were significant risk factors for CDI coinfection, as well as for death, with PPI treatment in combination with antibiotic treatment being a more significant risk factor.

Comparison of BAP65, DECAF, PEARL and MEWS Scores in Predicting Respiratory Support Need in Hospitalized ECOPD Patients

OObjective: 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 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 non-invasive or invasive mechanical ventilation support are grouped as ventilatory support group (n = 54). Comparison between receiver operating characteristic (ROC) 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 cut-off value of 1 presented the highest sensitivity and BAP65 score with a cut-of value of 2 presented the highest specificity in predicting ventilatory support need. Multivariable analysis revealed 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 correlation with age, comorbidity index and dyspnea. BAP65 and DECAF scores also showed 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.

Respiratory alkalosis in the acute hypoxemic patient during non-invasive mechanical ventilation: troubleshooting and prognostic relevance

Respiratory alkalosis is one of the four basic disturbances to the acid-base equilibrium. Persistent primary respiratory alkalosis during non-invasive mechanical ventilation in patients with hypoxemic respiratory failure could be a risk factor for NIV failure. A 69-year-old man with acute hypoxemic respiratory failure caused by severe COVID-19 pneumonia demonstrated progressive worsening of gas exchange and clinical conditions. Despite a positive response to noninvasive mechanical ventilation, a therapeutic increase in respiratory support was required.

The Effect of Guided Imagery and Progressive Muscle Relaxation on Sedation in Patients Undergoing Noninvasive Mechanical Ventilation

Mental imagery and relaxation are noninvasive methods and can easily be used by the patient. Accordingly, this study aimed to detect the effect of guided mental imagery (GI) and progressive muscle relaxation (PMR) on sedation in patients undergoing noninvasive mechanical ventilation (NIV). This clinical trial study was carried out in the Shahid Modarres Hospital in 2022 and encompassed 80 patients with COVID-19 undergoing NIV, who were assigned to two intervention and control groups. The sedation survey scale was used to collect the required data. Before the intervention, the two groups completed the questionnaires, and then the relaxation program was presented during four sessions for the intervention group. This study included 80 patients with a mean age (± SD) of 59.59 ± 9.27 years. The Quade nonparametric ANCOVA revealed the significant impact of intervention on the post values of Total score (p-value < 0.001), Tolerance (p-value < 0.001), Calmness (p-value < 0.001), Ventilator synchrony (p-value < 0.001), face relaxation (p-value < 0.001), Consciousness (p-value = 0.009) and Awakeness (p-value = 0.020). The study findings demonstrated the effectiveness of relaxation program in promoting sedation in patients undergoing NIV. Accordingly, intensive care unit (ICU) nurses at our institution are encouraged to use PMR and GI to sedation of patients under NIV.

Severe Community-Acquired Pneumonia: Noninvasive Mechanical Ventilation, Intubation, and HFNT.

Severe acute respiratory failure (ARF) is a major issue in patients with severe community-acquired pneumonia (CAP). Standard oxygen therapy is the first-line therapy for ARF in the less severe cases. However, respiratory supports may be delivered in more severe clinical condition. In cases with life-threatening ARF, invasive mechanical ventilation (IMV) will be required. Noninvasive strategies such as high-flow nasal therapy (HFNT) or noninvasive ventilation (NIV) by either face mask or helmet might cover the gap between standard oxygen and IMV. The objective of all the supporting measures for ARF is to gain time for the antimicrobial treatment to cure the pneumonia. There is uncertainty regarding which patients with severe CAP are most likely to benefit from each noninvasive support strategy. HFNT may be the first-line approach in the majority of patients. While NIV may be relatively contraindicated in patients with excessive secretions, facial hair/structure resulting in air leaks or poor compliance, NIV may be preferable in those with increased work of breathing, respiratory muscle fatigue, and congestive heart failure, in which the positive pressure of NIV may positively impact hemodynamics. A trial of NIV might be considered for select patients with hypoxemic ARF if there are no contraindications, with close monitoring by an experienced clinical team who can intubate patients promptly if they deteriorate. In such cases, individual clinician judgement is key to choose NIV, interface, and settings. Due to the paucity of studies addressing IMV in this population, the protective mechanical ventilation strategies recommended by guidelines for acute respiratory distress syndrome can be reasonably applied in patients with severe CAP.

Remarkable clinical improvement with oral nucleoside treatment in a patient with adult-onset TK2 deficiency: A case report

ObjectivesThymidine kinase 2 deficiency (TK2d) is a rare autosomal recessive mitochondrial disorder. It manifests as a continuous clinical spectrum, from fatal infantile mitochondrial DNA depletion syndromes to adult-onset mitochondrial myopathies characterized by ophthalmoplegia-plus phenotypes with early respiratory involvement. Treatment with pyrimidine nucleosides has recently shown striking effects on survival and motor outcomes in the more severe infantile-onset clinical forms. We present the response to treatment in a patient with adult-onset TK2d. MethodsAn adult with ptosis, ophthalmoplegia, facial, neck, and proximal muscle weakness, non-invasive nocturnal mechanical ventilation, and dysphagia due to biallelic pathogenic variants in TK2 received treatment with 260 mg/kg/day of deoxycytidine (dC) and deoxythymidine (dT) under a Compassionate Use Program. Prospective motor and respiratory assessments are presented. ResultsAfter 27 months of follow-up, the North Star Ambulatory Assessment improved by 11 points, he walked 195 m more in the 6 Minute-Walking-Test, ran 10 s faster in the 100-meter time velocity test, and the Forced Vital Capacity stabilized. Growth Differentiation Factor-15 (GDF15) levels, a biomarker of respiratory chain dysfunction, normalized. The only reported side effect was dose-dependent diarrhea. DiscussionTreatment with dC and dT can significantly improve motor performance and stabilize respiratory function safely in patients with adult-onset TK2d.

Positive impact on childrenÓ?s quality of life under non-invasive home mechanical ventilation - PedsQL application in a monocentric cohort

Positive impact on childrenÓ?s quality of life under non-invasive home mechanical ventilation - PedsQL application in a monocentric cohort

Predictors of Mortality and Orotracheal Intubation in Patients with Pulmonary Barotrauma Due to COVID-19: An Italian Multicenter Observational Study during Two Years of the Pandemic.

Introduction: Coronavirus disease 2019 (COVID-19) is a significant and novel cause of acute respiratory distress syndrome (ARDS). During the COVID-19 pandemic, there has been an increase in the incidence of cases involving pneumothorax and pneumomediastinum. However, the risk factors associated with poor outcomes in these patients remain unclear. Methods: This observational study collected clinical and imaging data from COVID-19 patients with PTX and/or PNM across five tertiary hospitals in central Italy between 1 March 2020 and 1 March 2022. This study also calculated the incidence of PTX and PNM and utilized multivariable regression analysis and Kaplan-Meier curve analysis to identify predictor factors for 28-day mortality and 3-day orotracheal intubation after PTX/PNM. This study also considered the impact of the three main variants of concern (VoCs) (alfa, delta, and omicron) circulating during the study period. Results: During the study period, a total of 11,938 patients with COVID-19 were admitted. This study found several factors independently associated with a higher risk of death in COVID-19 patients within 28 days of pulmonary barotrauma. These factors included a SOFA score ≥ 4 (OR 3.22, p = 0.013), vasopressor/inotropic therapy (OR 11.8, p < 0.001), hypercapnia (OR 2.72, p = 0.021), PaO2/FiO2 ratio < 150 mmHg (OR 10.9, p < 0.001), and cardiovascular diseases (OR 7.9, p < 0.001). This study also found that a SOFA score ≥ 4 (OR 3.10, p = 0.015), PCO2 > 45 mmHg (OR 6.0, p = 0.003), and P/F ratio < 150 mmHg (OR 2.9, p < 0.042) were factors independently associated with a higher risk of orotracheal intubation (OTI) within 3 days from PTX/PNM in patients with non-invasive mechanical ventilation. SARS-CoV-2 VoCs were not associated with 28-day mortality or the risk of OTI. The estimated cumulative probability of OTI in patients after pneumothorax was 44.0% on the first day, 67.8% on the second day, and 68.9% on the third day, according to univariable survival analysis. In patients who had pneumomediastinum only, the estimated cumulative probability of OTI was 37.5%, 46.7%, and 57.7% on the first, second, and third days, respectively. The overall incidence of PTX/PNM among hospitalized COVID-19 patients was 1.42%, which increased up to 4.1% in patients receiving invasive mechanical ventilation. Conclusions: This study suggests that a high SOFA score (≥4), the need for vasopressor/inotropic therapy, hypercapnia, and PaO2/FiO2 ratio < 150 mmHg in COVID-19 patients with pulmonary barotrauma are associated with higher rates of intubation, ICU admission, and mortality. Identifying these risk factors early on can help healthcare providers anticipate and manage these patients more effectively and provide timely interventions with appropriate intensive care, ultimately improving their outcomes.

Enlarging bullae and spontaneous pneumothorax associated with CPAP use: A case series of three patients

Objectives Spontaneous pneumothorax among patients with obstructive sleep apnea treated by nocturnal continuous positive airway pressure (CPAP) has not been well documented. Methods We present three cases of patients on chronic CPAP who experienced spontaneous pneumothorax without clear predisposing factors. Their personal and family medical histories, imaging characteristics, and CPAP settings are reviewed. Results In all three cases, the patients had bullae ipsilateral to the pneumothoraces that either formed (n = 1) or grew significantly (n = 2) after CPAP initiation. No other risk factors for pneumothorax or bullae were identified. Conclusions This case series demonstrates a need for further investigation into a possible connection between spontaneous pneumothorax, bullae development, and CPAP use. Keywords: obstructive sleep apnea, continuous positive airway pressure, bullae, complications of noninvasive mechanical ventilation, spontaneous pneumothorax

Analysis of the changes in the management of preterm newborns born in a Spanish third-level hospital in the past 10 years.

Preterm newborns require the use of the best and most current strategies to treat and prevent both acute pathology and associated sequelae. This study aimed to compare the differences in the management of preterm newborns over 10 years in a tertiary hospital in Spain and its impact on height, weight, and neurological development in the medium term. We conducted a retrospective, observational, and analytical study examining the management and clinical variables in preterm newborns under 32 weeks of gestational age who were born in our hospital in 2011 and 2021. Twenty-six newborns were included in the study. Significant differences in magnesium sulfate use, continuous positive airway pressure immediately after birth, and non-invasive mechanical ventilation during hospitalization were observed. Differences were found in the use of parenteral nutrition and the timing of initiation of enteral feeding. We did not observe differences in the neurological or weight evolution in the medium term. Significant differences in managing preterm newborns in these 10 years were observed. Lower mortality and alterations in central nervous system ultrasound and, significantly, less growth retardation during admission in 2021 have been observed; however, it does not manifest with improvement in long-term somatometrics or neurological prognosis.

Early machine learning prediction of hospitalized patients at low risk of respiratory deterioration or mortality in community-acquired pneumonia: Derivation and validation of a multivariable model.

Current prognostic tools for pneumonia predominantly focus on mortality, often neglecting other crucial outcomes such as the need for advanced respiratory support. The objective of this study was to develop and validate a tool that predicts the early risk of non-occurrence of respiratory deterioration or mortality. We conducted a single-center, retrospective cohort study involving hospitalized adult patients with community-acquired pneumonia (CAP) and acute hypoxic respiratory failure from January 2009 to December 2019 (n = 4379). We employed the gradient boosting machine (GBM) learning to create a model that estimates the likelihood of patients requiring advanced respiratory support (high flow nasal cannula [HFNC], non-invasive mechanical ventilation [NIMV], and invasive mechanical ventilation [IMV]) or facing mortality during hospitalization. This model utilized readily available data including demographic, physiologic, and laboratory data, sourced from electronic health records and obtained within the first six hours of admission. Out of the cohort, 890 patients (25.2%) either required advanced respiratory support or died during their hospital stay. Our predictive model displayed superior discrimination and higher sensitivity (cross-validation C-statistic = 0.71; specificity = 0.56; sensitivity = 0.72) compared to the pneumonia severity index (PSI) (C-statistic = 0.65; specificity = 0.91; sensitivity = 0.24; P value < 0.001), while maintaining a negative predictive value (NPV) of approximately 0.85. These data demonstrate that our machine learning model predicted the non-occurrence of respiratory deterioration or mortality among hospitalized CAP patients more accurately than the PSI. The enhanced sensitivity of this model holds potential for reliably excluding low-risk patients from pneumonia clinical trials.