Positive Pressure Ventilation In Patients Research Articles

Pulmonology: What You May Have Missed in 2023.

The field of pulmonology saw significant advances in 2023. The publications highlighted in this article address advances and changes in practice related to asthma, chronic obstructive pulmonary disease (COPD), interstitial lung disease, pleural disorders, and sleep-disordered breathing. One article reviews data examining the efficacy of vaccination against respiratory syncytial virus, a respiratory viral illness that has had devastating effects globally. Four studies evaluate the role of various therapies in COPD, including dupilumab, ensifentrine, pulmonary rehabilitation programs, and lung volume reduction versus endobronchial valves. Another study explores the effect on vascular events of positive-pressure ventilation in patients with sleep-disordered breathing and recent stroke. The use of combination therapy with rituximab and mycophenolate mofetil on progression-free survival in patients with nonspecific interstitial pneumonia is the topic of another study. We also highlight an update of clinical recommendations for the evaluation of patients with pleural disorders and a systematic review analyzing the effectiveness of inhaled corticosteroids as a supplement to dual therapy for COPD.

Airway stenting for liberation from positive pressure ventilation in patients with central airway obstruction presenting with acute respiratory failure

BackgroundCentral airway obstruction (CAO) can lead to acute respiratory failure (RF) necessitating positive pressure ventilation (PPV). The efficacy of airway stenting to aid liberation from PPV in patients with severe acute RF has been scarcely published. We present a systematic review and our recent experience. MethodsA systematic review of PubMed was performed, and a retrospective review of cases performed at our two institutions from 2018 to 2022 in adult patients who needed stent insertion for extrinsic or mixed CAO complicated by RF necessitating PPV. ResultsFifteen studies were identified with a total of 156 patients. The weighted mean of successful liberation from PPV post-stenting was 84.5% and the median survival was 127.9 days. Our retrospective series included a total of 24 patients. The most common etiology was malignant CAO (83%). The types of PPV used included high-flow nasal cannula (HFNC) (21%), non-invasive ventilation (NIV) (17%) and Invasive Mechanical Ventilation (62%). The overall rate of successful liberation from PPV was 79%, with 55% of HFNC and NIV cases being liberated immediately post-procedure. The median survival of the patients with MCAO that were successfully liberated from PPV was 74 days (n = 16, range 3–893 days), and for those with that failed to be liberated from PPV, it was 22 days (n = 4, range 9–26 days). ConclusionIn patients presenting with acute RF from extrinsic or mixed morphology CAO requiring PPV, airway stenting can successfully liberate most from the PPV. This may allow patients to receive pathology-directed treatment and better end-of-life care.

Effects of weights applied to the apex of a bag-valve-mask and pinch strength on tidal volume: a prospective simulation study

A bag-valve-mask (BVM) is a first aid tool that can easily and quickly provide positive-pressure ventilation in patients with breathing difficulties. The most important aspect of BVM bagging is how closely the mask adheres to the patient’s face when the E–C technique is used. In particular, the greater the adhesion force at the apex of the mask, the greater the tidal volume. The purpose of this study was to investigate the effect of various weights applied to the mask’s apex and the pinch strength needed to perform the E–C technique, on tidal volume. In this prospective simulation study, quasi-experimental and equivalent time-series designs were used. A total of 72 undergraduate paramedic student from three universities were recruited using convenience sampling. The tidal volumes according to the weights (0 g, 100 g, 200 g, 300 g) applied to the apical area of the mask, handgrip strength, and pinch strength (tip pinch strength, key pinch strength, and tripod pinch strength) were measured. A linear mixed model analysis was performed. Linear mixed model analyses showed that tidal volume was significantly higher at 200 g (B = 43.38, p = 0.022) and 300 g (B = 38.74, p = 0.017) than at 0 g. Tripod pinch strength (B = 12.88, p = 0.007) had a significant effect on mask adhesion for effective BVM ventilation. Adding weight to the apical area of the mask can help maintain the E–C technique and enable effective ventilation. Future studies are required to develop specific strategies to improve the ventilation skills, which can be an important first-aid activity.

[Predictive value of HACOR score on the clinical outcome of non-invasive positive pressure ventilation in the treatment of chronic obstructive pulmonary disease with pulmonary encephalopathy].

To explore the predictive value of HACOR score [heart rate (H), acidosis (A), consciousness (C), oxygenation (O), and respiratory rate (R)] on the clinical outcome of non-invasive positive pressure ventilation in patients with pulmonary encephalopathy due to chronic obstructive pulmonary disease (COPD). A prospective study was conducted. The patients with COPD combined with pulmonary encephalopathy who were admitted to Henan Provincial People's Hospital from January 1, 2017 to June 1, 2021 and initially received non-invasive positive pressure ventilation were enrolled. Besides non-invasive positive pressure ventilation, standard medical treatments were delivered to these patients according to guidelines. The need for endotracheal intubation was judged as failure of non-invasive ventilation treatment. Early failure was defined as the need for endotracheal intubation within 48 hours of treatment, and late failure was defined as the need for endotracheal intubation 48 hours and later. The HACOR score at different time points after non-invasive ventilation, the length of intensive care unit (ICU) stay, the total length of hospital stay, and the clinical outcome were recorded. The above indexes of patients with non-invasive ventilation were compared between successful and failed groups. The receiver operator characteristic curve (ROC curve) was drawn to evaluate the predictive effect of HACOR score on the failure of non-invasive positive pressure ventilation in the treatment of COPD with pulmonary encephalopathy. A total of 630 patients were evaluated, and 51 patients were enrolled, including 42 males (82.35%) and 9 females (17.65%), with a median age of 70.0 (62.0, 78.0) years old. Among the 51 patients, 36 patients (70.59%) were successfully treated with non-invasive ventilation and discharged from the hospital eventually, and 15 patients (29.41%) failed and switched to invasive ventilation, of which 10 patients (19.61%) were defined early failure, 5 patients (9.80%) were late failure. The length of ICU and the total length of hospital stay of the non-invasive ventilation successful group were significantly longer than those of the non-invasive ventilation failure group [length of ICU stay (days): 13.0 (10.0, 16.0) vs. 5.0 (3.0, 8.0), total length of hospital stay (days): 23.0 (12.0, 28.0) vs. 12.0 (9.0, 15.0), both P < 0.01]. The HACOR score of patients at 1-2 hours in the non-invasive ventilation failure group was significantly higher than that in the successful group [10.47 (6.00, 16.00) vs. 6.00 (3.25, 8.00), P < 0.05]. However, there was no significant difference in HACOR score before non-invasive ventilation and at 3-6 hours between the two groups. The ROC curve showed that the area under the ROC curve (AUC) of 1-2 hour HACOR score after non-invasive ventilation for predicting non-invasive ventilation failure in COPD patients with pulmonary encephalopathy was 0.686, and the 95% confidence interval (95%CI) was 0.504-0.868. When the best cut-off value was 10.50, the sensitivity was 60.03%, the specificity was 86.10%, positive predictive value was 91.23%, and negative predictive value was 47.21%. Non-invasive positive pressure ventilation could prevent 70.59% of COPD patients with pulmonary encephalopathy from intubation. HACOR score was valuable to predict non-invasive positive pressure ventilation failure in pulmonary encephalopathy patients due to COPD.

Pneumoscrotum, a Rare Presentation of Barotrauma Following Noninvasive Positive Pressure Ventilation in Patients with Severe COVID-19 Pneumonia:.

Patients with Coronavirus disease 2019 (COVID-19) pneumonia are at risk of hypoxemic respiratory failure. Hence, many patients may require noninvasive positive pressure ventilation (NIPPV) during their hospital course. Using mechanical ventilation such as bilevel positive airway pressure or a ventilator to provide NIPPV may result in adverse events, including barotrauma. We reported two cases (40- and 43-years-old men) of severe COVID-19 pneumonia and hypoxemic respiratory failure who underwent NIPPV for respiratory support. These cases were complicated with barotrauma in their course of hospital admission that manifested with pneumoscrotum. In the cases of pneumoscrotum, it is crucial to understand its underlying etiology and origin since this clinical finding may be the outcome of life-threatening illnesses requiring urgent treatment.

An Analysis of the Effect of Noninvasive Positive Pressure Ventilation on Patients with Respiratory Failure Complicated by Diabetes Mellitus.

Objective To observe the clinical effectiveness of noninvasive positive pressure ventilation in patients with respiratory failure complicated by diabetes. Methods From May 2021 to May 2022, 90 patients with respiratory failure complicated by diabetes treated in our hospital were recruited and randomly assigned to receive either medication (control group) or noninvasive positive pressure ventilation (study group), with 45 patients in each group. The clinical endpoint was therapeutic outcomes. Results Noninvasive positive pressure ventilation resulted in significantly lower Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) scores versus medications (P < 0.05). Patients with noninvasive positive pressure ventilation showed better pulmonary function indices versus those with medications (P > 0.05). There was no significant difference in arterial oxygen (PaO2), carbon dioxide partial pressure (PaCO2), and arterial oxygen pressure/inspired fraction of O2 (PaO2/FiO2) between the two groups prior to the intervention (P > 0.05). However, patients in the study group had significantly elevated PaO2 and PaO2/FiO2 and lower PaCO2 levels than those in the control group (P < 0.05). Following the intervention, noninvasive positive pressure ventilation resulted in significantly lower inflammatory factor levels versus medications (P > 0.05). After the intervention, markedly better glucose control was observed in the study group versus the control group (P < 0.05). The incidence of complications in the control group was 2.38%, which was significantly lower than that of the control group (16.67) (P < 0.05). Conclusion Noninvasive positive pressure ventilation effectively suppresses the inflammatory response, improves the blood gas analysis index, and eliminates the negative emotions of patients, thereby maintaining hemodynamic stability and improving clinical efficacy with a better safety profile. Further studies are recommended prior to clinical promotion.

Factors and Outcomes Associated with Failed Noninvasive Positive Pressure Ventilation in Patients with Acute Respiratory Failure.

BackgroundThe decision guild for non-invasive positive pressure ventilation (NPPV) application in acute respiratory failure (ARF) patients still needs to work out.MethodsAdult patients with acute hypoxemic or hypercapnic respiratory failure were recruited and treated with NPPV or primary invasive mechanical ventilation (IMV). Patients’ characteristic and clinical outcomes were recorded. Logistic regression models were used to estimate the adjusted odds ratio (aOR) and 95% confidence intervals for baseline characteristics and clinical outcomes. Subgroup analyses by reason behind successful NPPV were conducted to ascertain if any difference could influence the outcome.ResultsA total of 4525 ARF patients were recruited in our facility between year 2015 and 2017. After exclusion, 844 IMV patients, 66 patients with failed NPPV, and 74 patients with successful NPPV were enrolled. Statistical analysis showed APACHE II score (aOR = 0.93), time between admission and start NPPV (aOR = 0.92), and P/F ratio (aOR = 1.04) were associated with successful NPPV. When comparing with IMV patients, failed NPPV patients displayed a significantly lower APACHE II score, higher Glasgow Coma Scale, longer length of stay in hospital, longer duration of invasive ventilation, RCW/Home ventilator, and some comorbidities.ConclusionAPACHE II score, time between admission and start NPPV, and PaO2 can be predictors for successful NPPV. The decision of NPPV application is critical as ARF patients with failed NPPV have various worse outcomes than patients receiving primary IMV.

Physiological effects of high-intensity versus low-intensity noninvasive positive pressure ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease: a randomised controlled trial

BackgroundHigh-intensity noninvasive positive pressure ventilation (NPPV) is a novel ventilatory approach to maximally decreasing elevated arterial carbon dioxide tension (PaCO2) toward normocapnia with stepwise up-titration of pressure support. We tested whether high-intensity NPPV is more effective than low-intensity NPPV at decreasing PaCO2, reducing inspiratory effort, alleviating dyspnoea, improving consciousness, and improving NPPV tolerance in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).MethodsIn this physiological, randomised controlled trial, we assigned 24 AECOPD patients to undergo either high-intensity NPPV (n = 12) or low-intensity NPPV (n = 12). The primary outcome was PaCO2 24 h after randomisation. Secondary outcomes included gas exchange other than PaCO2 24 h after randomisation, inspiratory effort, dyspnoea, consciousness, NPPV tolerance, patient–ventilator asynchrony, cardiac function, ventilator-induced lung injury (VILI), and NPPV-related adverse events.ResultsInspiratory positive airway pressure 24 h after randomisation was significantly higher (28.0 [26.0–28.0] vs. 15.5 [15.0–17.5] cmH2O; p = 0.000) and NPPV duration within the first 24 h was significantly longer (21.8 ± 2.1 vs. 15.3 ± 4.7 h; p = 0.001) in the high-intensity NPPV group. PaCO2 24 h after randomisation decreased to 54.0 ± 11.6 mmHg in the high-intensity NPPV group but only decreased to 67.4 ± 10.6 mmHg in the low-intensity NPPV group (p = 0.008). Inspiratory oesophageal pressure swing, oesophageal pressure–time product (PTPes)/breath, PTPes/min, and PTPes/L were significantly lower in the high-intensity group. Accessory muscle use and dyspnoea score 24 h after randomisation were also significantly lower in that group. No significant between-groups differences were observed in consciousness, NPPV tolerance, patient–ventilator asynchrony, cardiac function, VILI, or NPPV-related adverse events.ConclusionsHigh-intensity NPPV is more effective than low-intensity NPPV at decreasing elevated PaCO2, reducing inspiratory effort, and alleviating dyspnoea in AECOPD patients.Trial registration: ClinicalTrials.gov (NCT04044625; registered 5 August 2019).

Nursing evaluation during treatment with helmet continuous positive airway pressure in patients with respiratory failure due to COVID-19 pneumonia: A case series

BackgroundDuring COVID-19 outbreak, with the increasing number of patients presenting with acute respiratory failure, a large use of non invasive positive pressure ventilation was done in the emergency departments and medical wards despite the lack of recommendations. ObjectivesThis study describes the clinical characteristics of patients presenting to the hospital with acute respiratory failure due to COVID-19 related pneumonia undergoing treatment with helmet continuous positive airway pressure (CPAP) with a strict nursing evaluation and monitoring. MethodsA case series study enrolling adult patients admitted to an emergency department of an Italian hospital with acute respiratory failure due to COVID-19 pneumonia from March 18th to April 18th, 2020, was conducted. Only patients who strictly followed a local CPAP protocol were enrolled. ResultsA total of 52 patients were included in this study. Thirty-eight patients (73%) were judged eligible for endotracheal intubation (ETI). Eighteen (34.6%) were intubated. Sixteen (30.8%) patients died: seven (38.9%) and nine (26.5%) in the eligible-for-ETI and non eligible-for-ETI group, respectively. The median hospital length of stay was different in the ETI and non-ETI group: 26 days (interquartile range [IQR]: 16–37) vs 15 days [IQR 9–17] (p = 0.005). The median invasive mechanical ventilation time was 11 days [IQR 7–21] with an ICU length of stay of 14.5 days [IQR 10–28]. During the CPAP trial, among patients eligible for ETI variations over time for positive end-expiratory pressure (p = 0.003) and respiratory rate (p = 0.059) were found between intubated and non-intubated patients. ConclusionsA short closed monitored CPAP trial could be considered for acute respiratory failure due to COVID-19 pneumonia before considering ETI. A progressive positive end-expiratory pressure titration should target reduction in a patient’s respiratory rate. More studies are needed to evaluate the efficacy and predictors of failure of CPAP and non-invasive positive pressure ventilation in patients with acute respiratory failure due to COVID-19 pneumonia.

Clinical Effect of Non-invasive Positive PressureVentilation in Patients with Severe Pulmonary Infection

Clinical Effect of Non-invasive Positive PressureVentilation in Patients with Severe Pulmonary Infection

Effect of sequential high-flow nasal cannula oxygen therapy and non-invasive positive-pressure ventilation in patients with difficult weaning from mechanical ventilation after extubation on respiratory mechanics.

BackgroundPatients with difficult weaning who undergo mechanical ventilation are more likely to be at risk of reintubation and the sequential use of oxygen therapy after extubation is a concern for clinicians. Therefore, the aim of the present study was to compare the effects of transnasal high-flow nasal cannula (HFNC) oxygen therapy and non-invasive positive-pressure ventilation (NIV) on respiratory mechanics in patients with difficult weaning.MethodsThe present study was a single-center, retrospective, observational study. Twenty-nine patients with difficult weaning off invasive mechanical ventilation from the Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, from December 2018 to April 2021, were included. Within 48 h after extubation, alternate respiratory support with HFNC and NIV was provided. Relevant indicators were recorded after each support mode had been maintained for at least 60 min. These included esophageal pressure (Pes), gastric pressure (Pga), transdiaphragmatic pressure (Pdi), pressure-time product of Pes (PTPes), pressure-time product of Pga (PTPga), pressure-time product of Pdi (PTPdi), ratio of the PTPdi to the PTPes (PTPdi/PTPes), and ratio of the Pes to the Pdi (Pes/Pdi), diaphragmatic electromyogram (EMGdi), percentage of esophageal pressure coefficient of variation (CVes%),diaphragmatic electromyogram coefficient of variation (CVEMG),inspiratory time (Ti), expiratory time (Te) and respiratory cycle time (Ttot).ResultsOf the 29 patients included, 22 were males and 7 were females [age: 63.97±15.34 years, Acute Physiological and Chronic Health Estimation II (APACHE II) score: 18.00±5.63]. The CVes% and the Pes/Pdi were significantly higher in patients with NIV than HFNC using 40 L/min, CVes%: 9 (−6, 20) vs. −7 (−23, 6) and Pes/Pdi: 0.17 (−0.1, 0.53), vs. −0.12 (−0.43, 0.08) (P<0.05). The remaining indicators were not statistically different.ConclusionsThe sequential NIV and HFNC can be tolerated in patients with such difficult weaning off mechanical ventilation after extubation, and more patients tend to choose HFNC subjectively. Compared with HFNC, NIV reduces the work of adjunctive respiratory muscle, but the patient’s Pes dispersion is high when NIV is used, and it is necessary to pay attention to patient–ventilator coordination in clinical practice. We recommend alternating HFNC and NIV during the sequential respiratory therapy after extubation.

A Prospective Observational Study of High-Flow Nasal Oxygen Therapy and Noninvasive Positive Pressure Ventilation in Patients with Acute Hypoxemic Respiratory Failure

Background: Treatment for acute hypoxemic respiratory failure (AHRF) includes treating the underlying disease, conventional oxygen therapy (COT), noninvasive ventilation (NIV), high-flow nasal oxygen (HFNO), and invasive mechanical ventilation. Aim: The aim of this study was to compare the use of HFNO and NIV in patients with moderate-to-severe AHRF to the tertiary level intensive care unit (ICU) of a teaching hospital. Methods: All adult patients admitted to the ICU with AHRF and failed COT were included. Administration of HFNO or NIV was protocol-based and targeted improvement in oxygen saturation, respiratory rate, PaO2, and PaCO2. Demographic data, clinical details, vital parameters, and laboratory findings were noted at prespecified intervals. Acute Physiology and Chronic Health Evaluation II at 24 h of ICU admission and daily Sequential Organ Failure Assessment were noted. The primary outcome was failure of treatment modalities defined as need for intubation and invasive ventilation. The secondary outcomes measured at 28 days were differences in ventilator-free days, ICU and hospital length of stay, patient comfort, and mortality. Results: A total of 35 patients were included in the study. Treatment failure was 20.8% (5/24) in the NIV group and 36% (4/11) in the HFNO group (P = 0.32). The number of ventilator-free days at day 28 was 22.67 ± 9.92 and 19.36 ± 12.45 (P = 0.44) in the NIV and HFNO groups, respectively. Mortality at 28 days was 12.5% (3/24) and 27.2% (3/11) in the NIV and HFNO groups, respectively (P = 0.282). Conclusion: Treatment with HFNO is associated with nonsignificant increase in the need for intubation and 28-day mortality compared to NIV. Larger studies are required to assess the utility of HFNO in moderate-to-severe AHRF.

Use of bilevel positive pressure ventilation in patients with bronchiolitis.

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

Possible role of Non-invasive Continuous Positive Pressure Ventilation In Patients With Overlap Syndrome: Obstructive Sleep Apnea And Chronic Obstructive Pulmonary Disease

Background: Overlap syndrome (OS), describes the association and simultaneous presence of OSA and COPD, Overlap syndrome has poor clinical prognosis , including increased risk for cardiovascular morbidity, hospitalization due to COPD acute exacerbation, and all-cause mortality. Efficient CPAP treatment has been related to improved survival and decreased hospitalizations. Patients and methods: This study was carried out at sleep lab of Chest Department on 24 patients splitted into two groups Group 1: patients with overlap syndrome (OS) under medical treatment plus CPAP. Group 2: patients with (OS) under medical treatment only. All patients in the study were subjected to full medical history taking, Quality of sleep by Epworth sleepiness scale (ESS). Clinical examination; (general and local), Spirometry, complete lab investigation, polysomnography and Echocardiography.Results: Statistically significant difference was observed between the two groups as regard AHI, nocturnal desaturation, mean pulmonary artery pressure, number of exacerbations per year and frequency of hospital admissions.Conclusion: Patients with CPAP-treated overlap syndrome for a period of one year experienced improving in nocturnal desaturation, mean pulmonary artery pressure and number of exacerbations.

High-Flow Nasal Cannula versus Noninvasive Positive Pressure Ventilation in Patients with Heart Failure after Extubation: An Observational Cohort Study.

Noninvasive positive pressure ventilation (NPPV) has been widely applied in patients with high-risk extubation failure, including heart failure. High-flow nasal cannula (HFNC) has been demonstrated to benefit patients with heart failure by reducing cardiac preload. This study aimed to compare the effectiveness of HFNC to NPPV for preventing extubation failure in patients with heart failure. This 3-year retrospective and single-center cohort study included patients with heart failure with left ventricular ejection fraction <50% who received prophylactic HFNC or NPPV after scheduled extubation from January 2015 to January 2018 from a medical center with four adult intensive care units. Demographics, comorbidities, diagnosis, and weaning status were collected. The primary outcome was treatment failure within 72 hours after extubation, which was defined as escalation to NPPV or reintubation in the HFNC group and was defined as requiring reintubation in the NPPV group. Secondary outcomes were reintubation within 72 hours, reintubation, duration of stay, and mortality during the intensive care unit and hospital stay. Of the 104 patients analyzed, characteristics of 58 patients in the HFNC group and 46 patients in the NPPV group were compared. The treatment failure within 72 hours in the two groups was not significantly different (25.9% vs 13%, p=0.106). Hypoxemic respiratory failure related treatment failure was significantly higher in the HFNC group. Prophylactic HFNC as first-line therapy had a comparable rate of reintubation within 72 hours to the prophylactic NPPV alone (17.2% vs 13%, p=0.556). Other secondary outcomes were similar between the two groups. Among patients with heart failure, HFNC was not inferior to NPPV for preventing extubation failure and reintubation. However, in case of an impending respiratory failure, selective patients may benefit from rescue NPPV.

Caffeine Citrate for the Prevention of Apnea Associated With Alprostadil Infusions.

To evaluate the incidence of apnea and requirement for positive pressure ventilation in patients who received caffeine for prevention while receiving alprostadil compared with those who did not receive caffeine. This was a single-center, retrospective study of patients who received alprostadil over a 7-year time frame. Patients were divided into 2 groups based on whether they received caffeine for prevention of apnea while receiving alprostadil. The incidence of apnea and requirements for positive pressure ventilation were recorded. A total of 64 patients who received alprostadil were included for review. Thirty-two patients received caffeine for the prevention of apnea, and 32 patients received alprostadil only. Alprostadil doses were similar between the 2 groups (0.04-0.05 mcg/kg/min). Seven patients had a documented apneic event; 3 in the group given caffeine and 4 in the control group. One patient in each group required intubation because of apnea. All patients with documented apnea were on low-dose alprostadil therapy (<0.05 mcg/kg/min). Three patients had apnea after dose reductions had been made. Six out of the seven patients experienced apnea within the first 24 hours after the infusion. Only 1 patient experienced multiple apneic events. In this small sample, there was no difference in incidence of apnea between patients on low-dose alprostadil who received caffeine for prevention and those who did not. Despite the use of low-dose alprostadil therapy and dose reductions, the incidence of apnea remains low, and most patients did not have repeated apneic events or require intubation.

Clinical decision support recommending ventilator settings during noninvasive ventilation.

NIV therapy is used to provide positive pressure ventilation for patients. There are protocols describing what ventilator settings to use to initialize NIV; however, the guidelines for titrating ventilator settings are less specific. We developed an advisory system to recommend NIV ventilator setting titration and recorded respiratory therapist agreement rates at the bedside. We developed an algorithm (NIV advisor) to recommend when to change the non-invasive ventilator settings of IPAP, EPAP, and FiO2 based on patient respiratory parameters. The algorithm utilized a multi-target approach; oxygenation, ventilation, and patient effort. The NIV advisor recommended ventilator settings to move the patient's respiratory parameters in a preferred target range. We implemented a pilot study evaluating the usability of the NIV advisor on 10 patients receiving critical care with non-invasive ventilation (NIV). Respiratory therapists were asked their agreement on recommendations from the NIV advisor at the patient's bedside. Bedside respiratory therapists agreed with 91% of the ventilator setting recommendations from the NIV advisor. The POB and VT values were the respiratory parameters that were most often out of the preferred target range. The IPAP ventilator setting was the setting most often considered in need of changing by the NIV advisor. The respiratory therapists agreed with the majority of the recommendations from the NIV advisor. We consider the IPAP recommendations informative in providing the respiratory therapist assistance in targeting preferred POB and Vt values, as these values were frequently out of the target ranges. This pilot implementation was unable to produce the results required to determine the value of the EPAP recommendations. The FiO2 recommendations from the NIV advisor were treated as ancillary information behind the IPAP recommendations.

Noninvasive Positive Pressure Ventilation in Patients with Acute Respiratory Failure Secondary to Acute Exacerbation of Chronic Obstructive Pulmonary Disease.

IntroductionAcute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a leading cause of poor quality of life and mortality in developing countries. Noninvasive positive pressure ventilation (NIPPV) remains the first-line intervention in hospitalized patients with acute respiratory failure (ARF) due to AECOPD. However, NIPPV may fail in some patients. This study was conducted to assess the frequency of NIPPV failure and clinical parameters and outcomes in AECOPD patients with failed NIPPV and their conversion to invasive positive pressure ventilation (IPPV).MethodsThis prospective observational study was conducted in the pulmonology unit of a tertiary care hospital in Pakistan. AECOPD patients with ARF who were candidates of NIPPV were included after securing informed consent. Their demographic characteristics, clinical parameters, and in-hospital outcomes were recorded on a semi-structured proforma. For statistical analysis, SPSS software version 22.0 for Windows (IBM, Armonk, NY) was used.ResultsWith 24 hours of NIPPV, 73 (70.2%) patients improved and the remaining 31 (29.8%) were shifted to IPPV. Patients in the IPPV group had higher systolic blood pressure (BP) [133.8 mmHg (±21.2) vs. 121.1 mmHg (±8.3); probability value (p): <0.000] and lower diastolic BP [68.7 mmHg (±13.4) vs. 76.2 mmHg (±10.8); p: 0.003]. Their pH was more acidic [7.20 (±0.13) vs. 7.42 (±0.01); p: <0.000], heart rates were high [131.1 (±10.5) vs. 100.2 (±7.5); p: <0.000], and the percentage of oxygen saturation was low [90.7 (±3.0) vs. 93.4 (±4.5); p: 0.004]. Patients who were managed on NIPPV throughout their hospital stay required respiratory support for fewer days [3.2 (±1.3) vs. 4.1 (±1.8); p: 0.005], and their hospital stay was shorter [3.5 (±1.2) vs. 5.3 (±2.5) days; p: <0.000]. Mortality rate in the NIPPV group was significantly lower (1.4% vs. 12.9%; p: 0.01).ConclusionsDeranged blood pressure, increased heart rate, acidemia, and a low percentage of oxygen saturation are crucial clinical and biochemical parameters that can predict the success of NIPPV with 24 hours of therapy in patients with AECOPD and secondary ARF. Patients who do not improve with 24 hours of NIPPV therapy usually have poor in-hospital outcomes including mortality.

Use of noninvasive positive pressure ventilation in patients with severe obesity undergoing esophagogastroduodenoscopy: a randomized controlled trial

BackgroundPatients with severe obesity being considered for bariatric surgery often undergo preoperative esophagogastroduodenoscopy (EGD). Severe obesity is a risk factor for oxygen desaturation events during EGD. The use of noninvasive positive pressure ventilation (NIPPV) to reduce desaturation events during EGD among patients with severe obesity has not been studied. ObjectiveTo evaluate the use of NIPPV among patients with severe obesity undergoing EGD. SettingCommunity hospital endoscopy suite. MethodsA randomized controlled trial evaluated the use of NIPPV in patients with severe obesity undergoing EGD. Patients were randomized into treatment (NIPPV) and control (nasal cannula, NIPPV for rescue) groups. Primary endpoints were oxygen desaturation events ≤94% and oxygen desaturation events <90% requiring intervention. A secondary endpoint was the use of NIPPV as a rescue maneuver. ResultsFifty-six patients with a body mass index of 40 to 60 were randomized (n = 28 treatment and n = 28 control). A statistically significant difference was noted between the groups for desaturation events ≤94% (14.3% of treatment and 57.1% of control groups, P = .002). There was also a statistically significant difference in the risk of a desaturation event <90% requiring intervention (3.5% of treatment and 28.6% of control groups, P = .025). All patients in the control group who developed desaturation events requiring intervention were rescued with NIPPV. ConclusionsThis study demonstrated the successful use of NIPPV as an adjunct to decrease the incidence of desaturation events in patients with severe obesity undergoing EGD.

Outcome of early use of non-invasive positive pressure ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease.

Objective:To determine the outcome of early use of non-invasive positive pressure ventilation (NIPPV) in Pakistani patients with acute exacerbation of chronic obstructive pulmonary disease.Methods:This descriptive study was conducted at Shifa International Hospital Islamabad from April 2015 to January 2017. A total of 120 patients with acute exacerbation of chronic obstructive pulmonary disease receiving NIPPV alongside standard therapy were included in the study. The patients were clinically assessed before starting on NIPPV. The parameters of respiratory rate, pH and paCO2 were monitored and NIPPV was given for six hours to evaluate clinical outcomes and analyze the factors predicting failure (requirement of mechanical ventilation and mortality). Frequency and percentages were calculated for qualitative variables while Mean and Standard Deviation for quantitative variables. Chi-square and t-test were used to see differences in pre and post NIPPV arterial blood gases.Results:Patients’ mean age was 58.88±10.09 years. Males were 88 (73.3%) and females were 32 (26.7%). The mean respiratory rate was 24±1.45 per minute before and 17.96±1.35 per minute after NIPPV (p < 0.00001). The mean pH before NIPPV was 7.27±0.04 and afterwards 7.38±0.02 (p < 0.00001). The mean pCO2 was 61.87±9.60 mm of Hg before and 57.46±6.79 mm of Hg after NIPPV (P < 0.0003). Twenty Four (20%) patients required invasive ventilation of which 19 (15.8%) patients could not survive.Conclusions:There was remarkable improvement in the arterial blood gases after NIPPV. However, the high mortality rate and significant number of COPD patients requiring mechanical ventilation necessitates further investigation into our population.