Noninvasive Support Research Articles

Incidence and risk factors for early hypoglycemia in very preterm infants: The hyporisk study

To determine incidence, timing and potential risk factors associated with hypoglycemia in the first day of life in very premature infants. Retrospective cohort study including all infants born before 32 weeks of gestation between 1 July 2017 and 31 December 2020 in the Erasmus MC Sophia Children's Hospital (Rotterdam, the Netherlands). Excluded were those who died within 24h after birth or with no glucose data available. We collected maternal and neonatal characteristics from patient files, as well as all routine glucose values for the first 24h. Hypoglycemia was defined as blood glucose value below 2.6mmol/L. Risk factors were selected using univariable and multivariable logistic regression with stepwise backward elimination. Kaplan-Meier survival analysis was performed to examine time-to-event after birth. Of 714 infants included (median gestational age 29.3 weeks, mean weight 1200g), 137 (19%) had at least one episode of hypoglycemia, with a median time-to-event of 126min [95%-CI 105-216]. Relevant independent risk factors for hypoglycemia included two maternal (insulin-dependent diabetes [OR 2.8; 95%-CI 1.3-6.1]; antenatal steroid administration [OR 1.7, 95%-CI 1.1-2.7]), and four neonatal factors (no IV-access in delivery room [OR 6.1, 95% CI-3.2-11.7], gestational age in weeks [OR 1.3, 95% CI-1.2-1.5], small-for-gestational-age [OR 2.6, 95%-CI 1.4-4.8], and no respiratory support (versus non-invasive support) [OR 2.3, 95%-CI 1.0-5.3]). Six risk factors were identified for hypoglycemia in the first 24h of life in very preterm infants, that can be used for development of prediction models, risk-based screening and updating guidelines.

Efficacy of a paper-based interleukin-6 test strip combined with a spectrum-based optical reader for sequential monitoring and early recognition of respiratory failure in elderly pneumonia-a pilot study.

Introduction: Community-acquired pneumonia (CAP) is lethal in elderly individuals who are more vulnerable to respiratory failure and require more emergency ventilation support than younger individuals. Interleukin-6 (IL-6) plays a crucial role and has predictive value in CAP; high serum IL-6 concentrations in adults are associated with high respiratory failure and mortality rates. Early detection of IL-6 concentrations can facilitate the timely stratification of patients at risk of acute respiratory failure. However, conventional enzyme-linked immunosorbent assay (ELISA) IL-6 measurement is laborious and time-consuming. Methods: The IL-6 rapid diagnostic system combined with a lateral flow immunoassay-based (LFA-based) IL-6 test strip and a spectrum-based optical reader is a novel tool developed for rapid and sequential bedside measurements of serum IL-6 concentrations. Here, we evaluated the correlation between the IL-6 rapid diagnostic system and the ELISA and the efficacy of the system in stratifying high-risk elderly patients with CAP. Thirty-six elderly patients (median age: 86.5years; range: 65-97years) with CAP were enrolled. CAP diagnosis was established based on the Infectious Diseases Society of America (IDSA) criteria. The severity of pneumonia was assessed using the CURB-65 score and Pneumonia Severity Index (PSI). IL-6 concentration was measured twice within 24h of admission. Results: The primary endpoint variable was respiratory failure requiring invasive mechanical or non-invasive ventilation support after admission. IL-6 rapid diagnostic readouts correlated with ELISA results (p < 0.0001) for 30 samples. Patients were predominantly male and bedridden (69.4%). Ten patients (27.7%) experienced respiratory failure during admission, and five (13.9%) died of pneumonia. Respiratory failure was associated with a higher mortality rate (p = 0.015). Decreased serum IL-6 concentration within 24h after admission indicated a lower risk of developing respiratory failure in the later admission course (Receiver Operating Characteristic [ROC] curve = 0.696). Conclusion: Sequential IL-6 measurements with the IL-6 rapid diagnostic system might be useful in early clinical risk assessment and severity stratification of elderly patients with pneumonia. This system is a potential point-of-care diagnostic device for sequential serum IL-6 measurements that can be applied in variable healthcare systems.

A rare post-COVID neurological complication: Case report of peripheral axonal sensory neuropathy

The present outbreak of Severe Acute Respiratory Syndrome CoronaVirus-2 (SARS-CoV-2), a “novel coronavirus” with neurotropic potential, has presented with multiple cases of neurological manifestations also. SARS-CoV-2 infection is found to be associated with an increased incidence of diverse neurological manifestations such as hyposmia/anosmia, encephalopathy and encephalomyelitis, ischemic stroke and intracerebral hemorrhage, and neuromuscular diseases involving both central and peripheral nervous system. People with these severe complications were most likely elderly with medical comorbidities, especially hypertension and other vascular risk factors. However, in our case a 35-year-old young healthy man developed severe post-COVID neuropathy debilitating his daily activity further requiring rehospitalization. Our patient had developed severe SARS-CoV-2 pneumonia, with a computed tomography severity score of 18/25, needing non-invasive ventilation support, and intensive care unit care for a week, thereafter recovering well without complications and being discharged on room air. He had to be readmitted after 3 days in view of severe bilateral leg pain, being described as “pain crisis.” He was evaluated, a neurologist was involved in the case, with nerve conduction veloci (NCV) lower limbs revealing an axonal sensory neuropathy, which was treated with corticosteroid pulse therapy, gabapentin, and vitamin supplementation to which the patient responded well. Our case presented with pure sensory neuropathy post-COVID which is a rare presentation. The previous reports of treatment of SARS-CoV-2-associated neuropathy have also included corticosteroids and IVIG usually. Our patient improved with pulse therapy of corticosteroid and gabapentin. Thus, awareness and early treatment of peripheral neuropathy after SARS-CoV-2 is needed for good clinical outcomes.

Prognosis of hospitalised adult patients with respiratory syncytial virus infection: a multicentre retrospective cohort study

ObjectivesRespiratory syncytial virus (RSV) is a common agent of viral respiratory infections with significant morbidity and mortality in adults. The objective of this study was to determine risk factors for mortality and invasive mechanical ventilation and to describe the characteristics of patients who received ribavirin. MethodsA retrospective multicentre observational cohort study was conducted in Great Paris area hospitals, including patients hospitalised between 1 January 2015 and 31 December 2019 for documented RSV infection. Data were extracted from the Assistance Publique-Hôpitaux de Paris Health Data Warehouse. The primary endpoint was in-hospital mortality. ResultsOne thousand one hundred sixty-eight patients were hospitalised for RSV infection, including 288 (24.6%) patients who required intensive care unit (ICU) admission. The median (interquartile range) age of patients was 75 (63–85) years, and 54% (n = 631/1168) of them were women. In-hospital mortality was 6.6% (n = 77/1168) in the whole cohort and 12.8% (n = 37/288) in ICU patients. Factors associated with hospital mortality were age >85 years (adjusted odds ratio [aOR] = 6.29, 95% confidence interval [2.47–15.98]), acute respiratory failure (aOR = 2.83 [1.19–6.72]), non-invasive (aOR = 12.60 [1.41–112.36]), and invasive mechanical ventilation support (aOR = 30.13 [3.17–286.27]) and neutropenia (aOR = 13.19 [3.27–53.27]). Factors associated with invasive mechanical ventilation were chronic heart (aOR = 1.98 [1.20–3.26]) or respiratory failure (aOR = 2.83 [1.67–4.80]), and co-infection (aOR = 2.62 [1.60–4.30]). Patients who were treated with ribavirin were significantly younger than others (62 [55–69] vs. 75 [63–86] years; p < 0.001), more frequently males (n = 34/48 [70.8%] vs. n = 503/1120 [44.9%]; p 0.001), and almost exclusively immunocompromised (n = 46/48 [95.8%] vs. n = 299/1120 [26.7%]; p < 0.001). DiscussionThe mortality rate of patients hospitalised with RSV infections was 6.6%. Twenty-five per cent of the patients required ICU admission.

The long-term outcomes of symptomatic congenital lobar emphysema patients.

Surgical (OP) management for symptomatic congenital lobar emphysema (CLE) is the standard of care with nonoperative (NOP) approach applied for asymptomatic cases. The aim of this study is to report the outcomes for NOP approach to the care of symptomatic CLE infants. A retrospective study of CLE patients treated 2000-2021 at a single institution. Patients with CLE and respiratory symptoms were included. Overall, 23 children had symptomatic CLE, and 12 had NOP management. The median age at diagnosis was 38.5 days (50) in the NOP group versus 25 days (20) in the OP group (p = 0.31). There was no significant difference in the location of the involved lobe, term birth, postnatal diagnosis and gender, and both groups required noninvasive support in 33% of the cases. There was a trend towards higher frequency of oxygen support in the OP group preoperatively (89% vs. 42%, p = 0.07). The median length of stay was 14 days in the NOP group compared to a median postsurgery stay of 7.5 days in the OP group. In follow-up, there was no significant difference in respiratory readmission in first year of life, growth delay, treatment with asthma medication or body mass index in the NOP versus OP group. None of the children in the NOP group required surgery during follow-up. A NOP approach for symptomatic CLE infants can have favorable long-term outcomes. Further studies will be required to identify markers to aid in clinical decision-making.

Exhaled Volatile Organic Compounds for Early Prediction of Bronchopulmonary Dysplasia in Infants Born Preterm

To investigate the predictive performances of exhaled breath volatile organic compounds (VOCs) for development of bronchopulmonary dysplasia (BPD) in infants born preterm. Exhaled breath was collected from infants born <30 weeks' gestation at days 3 and 7 of life. Ion-fragments detected by gas-Chromatography-mass-spectrometry analysis were used to derive and internally validate a VOC prediction model for moderate or severe BPD at 36 weeks postmenstrual age. We tested the predictive performance of the National Institute of Child Health and Human Development (NICHD) clinical BPD prediction model with and without VOCs. Breath samples were collected from 117 infants (mean gestation 26.8 [±1.5] weeks). Thirty-three percent of the infants developed moderate or severe BPD. The VOC model showed a c-statistic of 0.89 (95% confidence interval [CI] 0.80-0.97) and 0.92 (95% CI 0.84-0.99)) for the prediction of BPD at days 3 and 7, respectively. Adding the VOCs to the clinical prediction model in non-invasive supported infants resulted in significant improvement in discriminative power on both days (day 3: c-statistic 0.83 versus 0.92, p-value 0.04; day 7: c-statistic 0.82 versus 0.94, p-value 0.03). This study showed that VOC profiles in exhaled breath of preterm infants on non-invasive support in the first week of life differ between those developing and not developing BPD. Adding VOCs to a clinical prediction model significantly improved its discriminative performance.

Characteristics and outcomes of patients with chronic obstructive pulmonary disease admitted to the intensive care unit due to acute hypercapnic respiratory failure.

The study aimed to describe the clinical course, outcomes, and prognostic factors of chronic obstructive pulmonary disease (COPD) patients with acute hypercapnic respiratory failure. This retrospective study involved patients with acute hypercapnic respiratory failure due to COPD of any cause admitted to the intensive care unit (ICU) for non-invasive or invasive mechanical ventilation (IMV) support between December 2015 and February 2020. One hundred patients were evaluated. The main causes of acute hypercapnic respiratory failure were bronchitis, pneumonia, and heart failure. The patients' mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 23.0±7.2, and their IMV rate was 43%. ICU, in-hospital, and 90-day mortality rates were 21%, 29%, and 39%, respectively. Non-survivors had more pneumonia, shock within the first 24 hours of admission, IMV, vasopressor use, and renal replacement therapy, along with higher APACHE II scores, lower admission albumin levels and PaO2/ FiO2 ratios, and longer ICU and hospital stays than survivors. Logistic regression analysis identified APACHE II score (odds ratio [OR], 1.157; 95% confidence interval [CI], 1.017-1.317; P=0.026), admission PaO2/FiO2 ratio (OR, 0.989; 95% CI, 0.978-0.999; P=0.046), and vasopressor use (OR, 8.827; 95% CI, 1.650-47.215; P=0.011) as predictors of ICU mortality. APACHE II score (OR, 1.099; 95% CI, 1.021-1.182; P=0.011) and admission albumin level (OR, 0.169; 95% CI, 0.056-0.514; P=0.002) emerged as predictors of 90-day mortality. APACHE II scores, the PaO2/FiO2 ratio, vasopressor use, and albumin levels are significant short-term mortality predictors in severely ill COPD patients with acute hypercapnic respiratory failure.

How long is too long: A retrospective study evaluating the impact of the duration of noninvasive oxygenation support strategies (high flow nasal cannula & BiPAP) on mortality in invasive mechanically ventilated patients with COVID-19.

We investigated the association of noninvasive oxygenation support [high flow nasal cannula (HFNC) and BiPAP], timing of invasive mechanical ventilation (IMV), and inpatient mortality among patients hospitalized with COVID-19. Retrospective chart review study of patients hospitalized with COVID-19 (ICD-10 code U07.1) and received IMV from March 2020-October 2021. Charlson comorbidity index (CCI) was calculated; Obesity defined as body mass index (BMI) ≥ 30 kg/m2; morbid obesity was BMI ≥ 40 kg/m2. Clinical parameters/vital signs recorded at time of admission. 709 COVID-19 patients underwent IMV, predominantly admitted from March-May 2020 (45%), average age 62±15 years, 67% male, 37% Hispanic, and 9% from group living settings. 44% had obesity, 11% had morbid obesity, 55% had type II diabetes, 75% had hypertension, and average CCI was 3.65 (SD = 3.11). Crude mortality rate was 56%. Close linear association of age with inpatient-mortality risk was found [OR (95% CI) = 1.35 (1.27-1.44) per 5 years, p<0.0001)]. Patients who died after IMV received noninvasive oxygenation support significantly longer: 5.3 (8.0) vs. 2.7 (SD 4.6) days; longer use was also independently associated with a higher risk of inpatient-mortality: OR = 3.1 (1.8-5.4) for 3-7 days, 7.2 (3.8-13.7) for ≥8 days (reference: 1-2 days) (p<0.0001). The association magnitude varied between age groups: 3-7 days duration (ref: 1-2 days), OR = 4.8 (1.9-12.1) in ≥65 years old vs. 2.1 (1.0-4.6) in <65 years old. Higher mortality risk was associated with higher CCI in patients ≥65 (P = 0.0082); among younger patients, obesity (OR = 1.8 (1.0-3.2) or morbid obesity (OR = 2.8;1.4-5.9) (p<0.05) were associated. No mortality association was found for sex or race. Time spent on noninvasive oxygenation support [as defined by high flow nasal cannula (HFNC) and BiPAP] prior to IMV increased mortality risk. Research for the generalizability of our findings to other respiratory failure patient populations is needed.

Determinants of Noninvasive Ventilation Failure Among Neonates with Respiratory Distress Admitted to the Intensive Care Unit in Addis Ababa, Ethiopia: An Unmatched Case-Control Study Design

Background Respiratory distress contributes significantly to mortality and morbidity in infants. The incidence of noninvasive ventilation failure is remarkably high. There is limited data available regarding noninvasive ventilation failure in Ethiopia. Therefore, this study aimed to identify determinants of noninvasive ventilation failure among neonates with respiratory distress admitted to the intensive care unit in Addis Ababa, Ethiopia in 2022. This study was conducted from November 11, 2021, to January 30, 2022. A total of 237 charts (79 cases and 158 controls) were selected by a simple random sampling technique. Cases were defined as neonates who failed with noninvasive ventilation support while controls were successfully managed with noninvasive ventilation support. The data were abstracted from the facility-based data abstraction form. The data were cleaned, entered into Epidata version 4.4, and exported to SPSS version 25.0 software for analysis. Both binary and multiple logistic regression analyses were used to identify the determinants of noninvasive ventilation failure in neonates with respiratory distress with an adjusted odds ratio (AOR) with a 95% confidence level at P value &lt; .05 used to declare determinants of a noninvasive ventilation failure. The mean birth weights of the neonates were 2.87 ± 0.85 SD kilograms and the mean gestational age was 35.02±2.66 SD. The current study determined that the incidence of noninvasive ventilation failure among neonates with respiratory distress was 20/100 per person-year in 2021. This study identified that determinants of noninvasive ventilation failure among neonates with respiratory distress were: very preterm neonates (AOR = 2.99 [95%CI: 1.11–8.12]); comorbid illness in mothers (AOR = 3.13 [95%CI: 1.55–6.33]), initiation of noninvasive ventilation at admission to the newborn intensive care unit (AOR = 2.63 [95%CI: 1.24–5.59]); oxygen saturation (SpO2) &lt;85 and 85–93 SpO2 (AOR = 3.11 [95%CI: 1.32–7.32]) and (AOR = 2.75 [95%CI: 1.17–6.44]), Apgar score at 5 min &lt;7(AOR = 3.19 [95%CI: 1.48–6.89]), and noninvasive ventilation through a home-made CPAP (AOR = 4.09 [95%CI: 1.82–9.20]), respectively. Conclusion and Recommendation The incidence rate of noninvasive ventilation failure among neonates is very high with identified determinants of noninvasive ventilation failures being comorbidity illness of the mother, Apgar score, Oxygen saturation at admission in %, ventilator modality of homemade CPAP, and initiation time of noninvasive ventilation. Therefore, policymakers and health planners would be better emphatically considering these identified determinants during neonatal training and guideline development for better neonatal noninvasive ventilation outcomes.

Anemia as a Significant Predictor of Adverse Outcomes in Hospitalized Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease: Analysis of National (Nationwide) Inpatient Sample Database.

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) has significant health implications. Anemia is usually an unseen comorbidity, which could significantly affect outcomes in AECOPD patients, and there is limited data to support this. We conducted this study to assess the effect of anemia on this patient population. We performed a retrospective cohort study using the National (Nationwide) Inpatient Sample (NIS) data from 2008 to 2014. Patients with AECOPD and anemia with age >40 years were identified using appropriateInternational Classification of Diseases, Ninth Revision (ICD-9) codes, excluding transfer out to other hospitals. We calculated the Charlson Comorbidity Index as a measure of associated comorbidities. We analyzed bivariate group comparisons in patients with and without anemia. Odds ratios were calculated using multivariate logistic and linear regression analysis using SAS version 9.4 (2013; SAS Institute Inc. Cary, North Carolina, United States). Among 3,331,305 patients hospitalized with AECOPD, 567,982 (17.0%) had anemia as a comorbidity. The majority of patients were elderly, women, and white. After adjusting for potential confounders in regression, mortality (adjusted OR (aOR) 1.25, 95%CI: 1.18-1.32), length of hospital stay (β 0.79, 95%Cl 0.76-0.82), and hospitalization cost (β 6873, 95%Cl 6437-7308) were significantly higher in patients with anemia. In addition, patients with anemia required significantly higher blood transfusion (aOR 16.9, 95%CI 16.1-17.8), invasive ventilator support (aOR 1.72, 95%CI 1.64-1.79), and non-invasive ventilator support (aOR 1.21, 95%CI 1.17-1.26). In this first retrospective largest cohort study on this topic, we find anemia is a significant comorbidity associated with adverse outcomes and healthcare burden in hospitalized AECOPD patients. We should focus on close monitoring and management of anemia to improve the outcomes in this population.

Non invasive ventilation and the high-flow nasal circuit

The purpose of this study is to discuss non-invasive ventilation and the High Flow Nasal Circuit (HFNC). The therapy is used by intensivists in Intensive Care Units – ICUs. It is a non-invasive breathing support modality that delivers heated and humidified gas mixtures to bedridden patients through a nasal cannula. The methodology used for the theme occurred in the online databases, Virtual Health Library (VHL) and Scientific Electronic Library Online (SCIELO). For greater reliability of the articles, a bibliographical survey of relevant studies was carried out, using keywords on the subject, and the selected articles had as criteria: clinical studies published in the last ten years. this new technique as a means of non-invasive ventilatory support, aims to provide the patient with greater comfort, improved oxygenation, reduced need for invasive mechanical ventilation and reduced reintubation rates. Because it is a new alternative, new studies must be carried out in the scientific academy.

Non-invasive support for the hypoxaemic patient.

Optimisation of oxygenation strategies in patients with hypoxaemic respiratory failure is a top priority for acute care physicians, as hypoxaemic respiratory failure is one of the leading causes of admission. Various oxygenation methods range from non-invasive face masks to high flow nasal cannulae, which have advantages and disadvantages for this heterogeneous patient group. Focus has turned toward examining the benefits of non-invasive ventilation, as this was heavily researched in resource-limited settings during the COVID-19 pandemic. The oxygenation strategy should be determined on an individualised basis for patients, and with new evidence from the COVID-19 pandemic, providers may now consider placing further emphasis on non-invasive approaches. As non-invasive ventilation continues to be used in increasing frequency, new methods of monitoring patient response, including when to escalate ventilation strategy, will need to be validated.

Systematic review: efficacy of therapies for cholestatic pruritus.

Pruritus is a symptom of several cholestatic liver diseases (CLDs) that can impair health-related quality of life (HRQoL). Despite evidence-based guideline therapy, managing cholestatic pruritus (CP) remains challenging, thus making the need for newer, more effective therapeutic agents more evident. Our study evaluated the efficacy of existing CP therapies. Systematic review. From inception until March 2023, we conducted a comprehensive search of MEDLINE, Cochrane, EMBASE, Scopus, ClinicalTrial.gov, and other sources, including pharmaceutical webpages and conference proceedings published in English that reported on CP interventions. Two reviewers independently conducted screening and full-text review of articles with extraction conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The methodological quality of studies included in our qualitative synthesis was assessed by using the Cochrane ROBINS-I and ROBINS-II tools for interventional studies and the National Heart, Lung, and Blood Institute Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. The primary outcome assessed in our systematic review was the severity of CP after therapy. Of 3293 screened articles, 92 studies were eligible for inclusion in the qualitative synthesis. Some patients' HRQoL improved with evidence-based standard therapy. Others, particularly those with severe and refractory CP, often required conversion to or addition of experimental noninvasive (e.g., ondansetron) or extracorporeal liver support to alleviate CP. In addition, studies investigating a newer class drug, the ileal bile acid transporter inhibitor (IBATi), demonstrate its effectiveness in reducing serum bile acid and alleviating CP with sustained improvement noted in patients with the inherited childhood cholestatic disorders - progressive familial intrahepatic cholestasis and Alagille syndrome. Our findings consolidate data on the efficacy of guideline-based approaches and newer therapies for CP. While the initial findings are promising, additional clinical trials will be needed to determine the full extent of IBATi's efficacy and potential use in treating other common CLDs. These results provide a foundation for future research and highlight the need for continued investigation into the management and treatment of CLDs.

Volume-guarantee vs. pressure-limited ventilation in evolving bronchopulmonary dysplasia.

Extremely premature infants are at high risk for developing bronchopulmonary dysplasia (BPD). While noninvasive support is preferred, they may require ventilator support. Although volume-targeted ventilation (VTV) has been shown to be beneficial in preventing BPD, no data exists to guide ventilator management of infants with evolving BPD. Thus, clinicians employ a host of ventilator strategies, traditionally time-cycled pressure-limited ventilation (PLV) and more recently volume-guarantee ventilation (VGV) (a form of VTV). In this study, we sought to test the hypothesis that use of VGV in evolving BPD is associated with improved clinical and pulmonary outcomes when compared with PLV. Single-center, retrospective cohort review of premature infants born less than 28 weeks inborn to a Level 4 NICU from January 2015 to December 2020. Data abstracted included demographics, maternal and birth data, and ventilator data until death or discharge. Exposure to either VGV or PLV was also examined, including ventilator "dose" (number of time points from DOL 14, 21 and 28 the patient was on that particular ventilator) during the period of evolving BPD. Of a total of 471 patients with ventilation data available on DOL 14, 268 were not ventilated and 203 were ventilated. PLV at DOL 21 and 28 was associated with significantly higher risk of BPD and the composite outcome of BPD or death before 36 weeks compared to VGV. Both increasing VGV and PLV doses were significantly associated with higher odds of BPD and the composite outcome. For each additional time point of VGV and PLV exposure, the predicted length of stay (LOS) increased by 15.3 days (p < 0.001) and 28.8 days (p < 0.001), respectively. Our study demonstrates the association of use of VGV at DOL 21 and 28 with decreased risk of BPD compared to use of PLV. Prospective trials are needed to further delineate the most effective ventilatory modality for this population with "evolving" BPD.

Patterns of Respiratory Support by Gestational Age in Very Preterm Infants

Introduction: A detailed understanding of respiratory support patterns in preterm infants is lacking. The aim was to explore and visualize this practice in Sweden. Methods: Preterm infants with gestational ages of 22–31 weeks, admitted to neonatal units reporting daily to the Swedish Neonatal Quality Register and discharged alive in November 2015–April 2022, were included in this descriptive cohort study. Proportions receiving mechanical ventilation, noninvasive support, or supplemental oxygen were calculated and graphically displayed for each gestational week and postnatal day (range 0–97) up to hospital discharge or 36 weeks of postmenstrual age. Results: Respiratory support in 148,515 days of care (3,368 infants; 54% males; median [interquartile range] birthweight = 1,215 [900–1,525] g) was evaluated. Trajectories showed distinct nonlinear patterns for each category of respiratory support, but differences in respiratory support over the gestational age range were linear: the proportion of infants on mechanical ventilation decreased by −11.7 to −7.3% (variability in estimates related to the postnatal day chosen for regression analysis) for each week higher gestational age (r = −0.99 to −0.87, p ≤ 0.001). The corresponding proportions of infants with supplemental oxygen decreased by −12.4% to −4.5% for each week higher gestational age (r = −0.98 to −0.94, p < 0.001). At 36 weeks of postmenstrual age, dependencies on mechanical ventilation, noninvasive support, and supplemental oxygen varied from 3%, 84%, and 94% at 22 weeks to 0%, 3%, and 5% at 31 weeks of gestational age, respectively. Conclusions: Respiratory support patterns in very preterm infants follow nonlinear, gestational age-specific postnatal trajectories in a dose-response-related fashion.

Evaluation of emerging inflammatory markers for predicting oxygen support requirement in COVID-19 patients.

Coronavirus disease 2019 (COVID-19), a highly contagious pathogenic viral infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread rapidly and remains a challenge to global public health. COVID-19 patients manifest various symptoms from mild to severe cases with poor clinical outcomes. Prognostic values of novel markers, including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and C-reactive protein to lymphocyte ratio (CLR) calculated from routine laboratory parameters have recently been reported to predict severe cases; however, whether this investigation can guide oxygen therapy in COVID-19 patients remains unclear. In this study, we assessed the ability of these markers in screening and predicting types of oxygen therapy in COVID-19 patients. The retrospective data of 474 COVID-19 patients were categorized into mild and severe cases and grouped according to the types of oxygen therapy requirement, including noninvasive oxygen support, high-flow nasal cannula and invasive mechanical ventilator. Among the novel markers, the ROC curve analysis indicated a screening cutoff of CRP ≥ 30.0 mg/L, NLR ≥ 3.0 and CLR ≥ 25 in predicting the requirement of any type of oxygen support. The NLR and CLR with increasing cut-off values have discriminative power with high accuracy and specificity for more effective oxygen therapy with a high-flow nasal cannula (NLR ≥ 6.0 and CLR ≥ 60) and mechanical ventilator (NLR ≥ 8.0 and CLR ≥ 80). Our study thus identifies potential markers to differentiate the suitable management of oxygen therapy in COVID-19 patients at an earlier time for improving disease outcomes with limited respiratory support resources.

Four Waves of the COVID-19 Pandemic: Comparison of Clinical and Pregnancy Outcomes.

During the last two and a half years, clinical manifestations, disease severity, and pregnancy outcomes have differed among pregnant patients with SARS-CoV-2 infection. These changes were preceded by the presence of new variants of SARS-CoV-2, known in the literature as variants of concern. The aim of this study is to describe the differences between maternal clinical characteristics and perinatal outcomes among pregnant women with COVID-19 during four waves of the COVID-19 epidemic in Serbia. This retrospective study included a series of 192 pregnant patients who were hospitalized due to the severity of their clinical status of SARS-CoV-2 infection. During four outbreaks of COVID-19 infection in Serbia, we compared and analyzed three sets of variables, including signs, symptoms, and characteristics of COVID-19 infection, clinical endpoints, and maternal and newborn parameters. During the dominance of the Delta variant, the duration of hospitalization was the longest (10.67 ± 1.42 days), the frequency of stillbirths was the highest (17.4%), as well as the frequency of progression of COVID infection (28.9%) and the requirement for non-invasive oxygen support (37%). The dominance of the Delta variant was associated with the highest number of prescribed antibiotics (2.35 ± 0.28), the most common presence of nosocomial infections (21.7%), and the highest frequency of corticosteroid therapy use (34.8%). The observed differences during the dominance of four variants of concern are potential pathways for risk stratification and the establishment of timely and proper treatments for pregnant patients. Early identification of the Delta variant, and possibly some new variants with similar features in the future, should be a priority and, perhaps, even an opportunity to introduce more accurate and predictive clinical algorithms for pregnant patients.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Explainable Artificial Intelligence in the Early Diagnosis of Gastrointestinal Disease

This study reviews the recent progress of explainable artificial intelligence for the early diagnosis of gastrointestinal disease (GID). The source of data was eight original studies in PubMed. The search terms were "gastrointestinal" (title) together with "random forest" or "explainable artificial intelligence" (abstract). The eligibility criteria were the dependent variable of GID or a strongly associated disease, the intervention(s) of artificial intelligence, the outcome(s) of accuracy and/or the area under the receiver operating characteristic curve (AUC), the outcome(s) of variable importance and/or the Shapley additive explanations (SHAP), a publication year of 2020 or later, and the publication language of English. The ranges of performance measures were reported to be 0.70-0.98 for accuracy, 0.04-0.25 for sensitivity, and 0.54-0.94 for the AUC. The following factors were discovered to be top-10 predictors of gastrointestinal bleeding in the intensive care unit: mean arterial pressure (max), bicarbonate (min), creatinine (max), PMN, heart rate (mean), Glasgow Coma Scale, age, respiratory rate (mean), prothrombin time (max) and aminotransferase aspartate (max). In a similar vein, the following variables were found to be top-10 predictors for the intake of almond, avocado, broccoli, walnut, whole-grain barley, and/or whole-grain oat: Roseburia undefined, Lachnospira spp., Oscillibacter undefined, Subdoligranulum spp., Streptococcus salivarius subsp. thermophiles, Parabacteroides distasonis, Roseburia spp., Anaerostipes spp., Lachnospiraceae ND3007 group undefined, and Ruminiclostridium spp. Explainable artificial intelligence provides an effective, non-invasive decision support system for the early diagnosis of GID.

Abstract 169: End Tidal CO2 In Multimodal Vest CPR

Introduction: Circumferential constriction vest CPR is more effective at creating forward blood flow than traditional sternal compression only CPR. Active compression-decompression plus the impedance threshold device CPR (ACD-ITD-CPR) incorporates multiple hemodynamic pump mechanisms and also appears more effective. We have developed a new multimodal CPR that combines vest CPR with additional pump mechanisms, one of which is abdominal counterpulsation. Traditional coronary perfusion pressure (CPP) has not been validated during CPR that incorporates compression modalities applied during the relaxation phase. End tidal carbon dioxide (ET-CO2), however, is an indicator of forward blood flow during CPR that is unaffected by relaxation phase compressions. Hypothesis: Multimodal vest CPR that incorporates multiple pump mechanisms may be more effective than standard alternatives as indicated by ET-CO2. Methods: Utilizing a porcine model of ventricular fibrillation, we measured ET-CO2 in: 1) traditional sternal compression CPR (S-CPR), 2) active compression-decompression plus the impedance threshold device CPR (ACD-ITD-CPR) and 3) a new multimodal CPR comprised of circumferential constriction plus abdominal counterpulsation and active sternal decompression (MM-CPR) . After onset of cardiac arrest, 1 min. epochs of each CPR were randomly performed. Results: Seven experiments were performed with a mean number of epochs per experiment of 7. The mean (M + SD) ET-CO2 for S-CPR was 9 + 3 mmHg, for ACD-ITD-CPR 12 + 6, and for MM-CPR 19+8 (P&lt;.05). Conclusions: Multimodal CPR comprising circumferential constriction plus abdominal counterpulsation and active sternal decompression is a promising new type of non-invasive circulatory support.